Warts and HPV infection

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Cause

  • Human Papillomavirus virus (HPV) 
  • Ninety percent of anogenital warts are caused by HPV 6 and 11, and most HPV infection is asymptomatic.
  • About 80% of HPV infections resolve within 12-24 months via immune clearance.
  • The quadrivalent and nonavalent vaccines (Gardasil and Gardasil9) provide excellent
    protection against HPV 6 and 11, but needs to be given prior to commencement of sexual activity to be most effective.
  • Condoms offer some protection against HPV infection, but this is limited as infection is usually multi-focal and often involves surfaces not covered by condoms.
  • The rate of transmission from mother to baby is estimated to be between 1:80 to 1:1500 affected women, and is thought to occur through direct contact in the birth canal. 

Clinical presentation

  • Warty growths with little discomfort (can be sometimes itchy)
  • Psychological distress can be significant
  • PR bleeding after passage of stools with anal lesions
  • HPV infections in young children can include conjunctival, mucosal and pharyngeal disease, the most severe of which is juvenile-onset respiratory papillomatosis (JRP). 
    • Rates of JRP are significantly higher in women diagnosed with anogenital warts in pregnancy, however, JRP is a rare disease with an estimated incidence of around 4 per 100 000 in children. 
  • Malignancy is associated with persistent oncogenic genotypes (cervical, vulval, vaginal, penile, anal, oropharynx) 

Diagnosis

  • Diagnosis of warts is by visual inspection. However, biopsy should be considered for
    • atypical looking warts,
    • those not responding to standard treatment, and
    • cervical warts

Management

  • Choice of treatment depends on the number, size, and degree of keratinization of the warts, their distribution and the area affected, patient preference and pregnancy status.
  • Treatment of warts ameliorates symptoms but is not curative.
  • Asymptomatic infection cannot be treated. 

Condition

Recommended

Comments

Warts which are soft, vulvar or perianal, on mucosal surfaces, on or under the prepuce or on the perianal area

Imiquimod 5% cream in sachets or pump, 1/3 to 1 sachet 3 times a week for 4–16 weeks

OR

Podophyllotoxin 0.5% solution (Condyline paint) or 0.15% cream (Wartec cream) twice daily for 3 consecutive days then none for 4 days. Use for 4 weeks, then review.
 

Imiquimod: Always give patients an instruction sheet and warn regarding potential local irritation. Review every 4 weeks.

Do not use imiquimod:

  • in pregnancy (Category B) or for lactating women
  • in patients under 18 (no studies done)
  • in patients with co-existing dermatitis
  • on vaginal or cervical warts, and intra-anal warts at the dentate line. Warts involving the squamous epithelium of the distal anal canal can be treated with imiquimod

Podophyllotoxin: Warn patients regarding potential local irritation.

  • Contraindicated in pregnancy
  • Do not use on vaginal or cervical warts. 
  • Take care when treating anal warts because solution can be difficult to apply accurately. Consider partner-applied application or use podophyllotoxin cream instead
  • Do not use on areas of skin affected by dermatitis

Keratinized warts, or those which are of long standing

Cryocautery, applied by liquid nitrogen cryospray or by cryoprobe

 

Is well tolerated and very unlikely to result in scarring. The only contraindication is cryoglobulinaemia.
The application of 5% lignocaine ointment or EMLA cream before treatment may help diminish discomfort.

Combined therapies may be used e.g., imiquimod to de-bulk a large area of warts prior to cryotherapy, or vice versa

Warts

Trichloroacetic acid 85% solution

Applied by a clinician.

A small amount of TCA is applied to the wart, and then a small amount of 5 % xylocaine ointment is applied. The patient is then advised to wash the area with saline solution and keep the area dry. This treatment can be repeated weekly.

Large warts where other treatments have failed or are not tolerated.

Surgical ablation – by laser, diathermy or excision under general anaesthesia

surgery will not remove HPV which can result in recurrent warts after surgery

Long term complications are very rare and include hypo or hyper pigmentation and vulvodynia after surgery for extensive warts

Warts in pregnancy

Expectant management 

OR

Cryocautery 
OR
Trichloroacetic acid

OR

Surgical ablation

 

Expectant management is reasonable as the warts will usually improve spontaneously following pregnancy, and treatment does not alter risk of neonatal transmission.

It is common for genital warts to recur or increase in size or number during pregnancy, and to resolve post-delivery. 

Podophyllin, podophyllotoxin, interferon and 5 FU are contraindicated in pregnancy.
Imiquimod is not recommended due to limited safety information.

Surgical ablation is reserved for large obstructive lesions and should be deferred until the third trimester to minimize recurrence. There is a risk of preterm labour. 
There is no strong evidence that Caesarean Section reduces the incidence of transmission, therefore this is only recommended if lesions are obstructive or causing extensive cervical disease. 

Treatment of the warts does not alter viral shedding or potential vertical transmission 

 


Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.


Last Updated Feb 2021