anogeneital warts

Management Of

Anogenital Warts

(Condyloma Acuminata)

ByDr. Yehia El Garem, M.D.

Lecturer of Andrology & Dermatology

Alexandria University

Human Papilloma Virus (HPV)

Double-stranded DNA viruses.

Papillomaviruses.

Sexual transmission

Non -sexual transmission (autoinoculation)

IP averages 3 to 4 months, with a range from 1 month 2 years.

Low risk HPV: 6, 11

42, 43, 44

High risk HPV: 16, 18

31, 33, 35, 39, 45, 55, 58.

HPV Genotypes Causing Condyloma

Acuminata

Condyloma Acuminata Clinical Types

External Warts Internal Warts

Single, multiple papules or plaque

Flat , verrucous, pedunculated Reddish or brown smooth

raised papules Dome-shaped lesions on

keratinized skin

Affect mucous membranes Discomfort, pain, bleeding,

difficult intercourse.

Giant Condyloma

(Buschke Lowenstein)

Diagnosis Clinical picture Acetic acid 3-5%: (false +ve, false –

ve) Pap smear HPV typingConsider biopsy if: Diagnosis is uncertain Lesions are unresponsive to or worsen during therapy Warts are pigmented, indurated, fixed, or ulcerated Individual warts are larger than 1 cm

Histopathology

Pap Smear for Cervical Intraepithelial Neoplasia

(CIN)

Pap Smear for Cervical Intraepithelial Neoplasia

(CIN)

Subclinical Genital HPV Infection (Without Exophytic

Warts)(Condyloma Plana)

Manifestations of infection in the absence of genital warts.

Infection is detected on the cervix by Pap test, or biopsy.

Appearance of white areas after application of acetic acid.

Subclinical Infection

Subclinical Infection

Differential Diagnosis

• Dome-shaped or hairlike projections on the corona or shaft adjacent to the corona on 10% of male patients. Normal.

Pearly White Papules

Differential Diagnosis

Molluscum Contagiosum

Shining, pearly white umbilicated papules A semisolid white material can be

expressed from the central umbilication .

On less keratinized surfaces: tend to be broader based, flatter topped, and less friable than warts.

On keratinized skin: the papules are copper colored and surmounted by scale.

Inguinal adenopathy is often present . Condyloma Lata

Differential Diagnosis

Differential Diagnosis

Multiple papules with smooth or verrucous surface

Usually pigmented HPV 16 presents in

most cases

Bowenoid Papulosis

Recommended Regimens for External Genital Warts

• Patient-Applied:

•Podofilox 0.5% solution or gel: Antimitotic drug that destroys wart Twice a day for 3 days, followed by 4 days of no therapy/

four cycles. The total wart area treated should not exceed 10 cm2/

podofilox limited to 0.5 mL per day. Most patients experience mild/moderate pain or local

irritation after treatment.

Recommended Regimens for External Genital Warts

Imiquimod 5% cream:

Topically active immune enhancer that stimulates production of interferon and other cytokines

Three times a week for up to 16 weeks. The treatment area should be washed with soap and

water 6--10 hours after the application. Moderate erythema, erosions and tenderness.

Recommended Regimens for External Genital Warts

• Provider-Administered:

Cryotherapy with liquid nitrogen or cryoprobe.

• Causes epidermal necrosis

• Repeat applications every 1--2 weeks.    

Recommended Regimens for External Genital Warts

Podophyllin resin 10%-25% in a compound tincture of benzoin:

Cytotoxic, antimitotic A small amount should be applied to each wart and

allowed to air dry. The treatment can be repeated weekly, if necessary. To avoid the possibility of complications application

be limited to <0.5 mL or an area of <10 cm2 of warts per session.

The preparation should be thoroughly washed off 1-4 hours after application to reduce local irritation.

Recommended Regimens for External Genital Warts

• Trichloroacetic acid (TCA) 80%--90%.

Destroy warts by chemical coagulation of the protein A small amount should be applied only to warts and

allowed to dry white "frosting" develops. The treated area should washed by sodium bicarbonate to

remove unreacted acid. This treatment can be repeated weekly, if necessary.

Intense burning sensation, ulceration.

Recommended Regimens for External Genital Warts

Surgical removalElectrocautery. Care must be taken to control the depth of

electrocautery to prevent scarring. Tangential excision with a pair of fine

scissors or a scalpel or by curettage.Carbon dioxide LASER

Factors that may influence selection of treatment

Wart size Wart number Anatomic site of wart Wart morphology Patient preference Cost of treatment Adverse effects Provider experience

LocationTherapeutic modalities

Vaginal, cervical

CryotherapyElectrosurgery, LASER

TCA

Urethral meatus

Cryotherapy

Electrosurgery, LASER

Podophyllin 25%

Anal Cryotherapy

TCA 80-90%

Imiquimod 5%

Treatment Of Subclinical Infection

The diagnosis of subclinical genital HPV infection is often not definitive, and no therapy has been identified that eradicates infection.

In the absence of coexistent SIL, treatment is not recommended for subclinical genital HPV

In the presence of coexistent SIL, management should be based on histopathologic findings.

PregnancyThe physiologically impaired immune status of the

mother enhances the grow of genital warts.

The choice of therapy must not endanger the fetus.

Do not use imiquimod, podophyllin, or podofilox in pregnant women because of potential risk to the fetus.

Physician-applied topical treatment with TCA,

freezing with liquid nitrogen, or electrocautery

Patient Education: General Information

Reassure the patient that HPV is a common viral infection and that is not a result of poor hygiene.

Inform the patient that warts may disappear by themselves or may recur after treatment.

Explain that HPV infection may or may not persist

Explain that the goal of treatment is to get rid of the warts, not to eliminate the HPV infection.

Discuss and explain available treatments: Explain each treatment and its limitations and side effects.

Explain that healing after wart treatment takes time, and that abstinence or condom use are needed until the area is completely healed.

Explain that the patient sexual partner is almost certainly infected with HPV (and may even have transmitted it to the patient).

Stress the importance of female patients and female sexual partners having regular Pap smears because HPV can cause cervical cancer.

Explain to the patient and his or her sexual partner that genital warts do not necessarily imply infidelity, because it is usually not possible to determine when the virus was initially acquired.