Response to interferon treatment decreases with epidermal dedifferentiation in condylomas

After interferon (IFN) treatment of patients with condyloma acuminatum, groups clinically proven to be responders or nonresponders were selected, and cellular parameters that might influence the clinical response were studied in pretreatment biopsies by reverse transcription polymerase chain reaction (RT-PCR). The nonresponders were found to express higher amounts of cellular proliferative markers, such as proliferating cell nuclear antigen (PCNA), cyclin A, and cdc 2 kinase, but lower levels of growth suppressor genes (TGF-beta 1, TGF-beta 2 and p53) before IFN treatment. The responders retained the epidermal keratinization, except for some signs of hyperproliferation (K6, K16 cytokeratins). In addition, the nonresponders showed a shift in the keratinization pattern to a mucosal or fetal type, as evidenced by high expression of the K18, K6, K16 and K13 cytokeratins but decreased K5, K14 and K10 levels before treatment. The expression of the human papillomavirus (HPV) genes is consistent with these differentiation patterns. The crucial conclusion to be drawn from this study is that those condylomas whose pretreatment phenotype most closely resembles that of normal epidermis respond to IFN treatment, whereas those more akin to nonkeratinizing epithelia fail to respond, i.e. the resistance of condylomas to IFN treatment is correlated with dedifferentiation.

[Two cases of giant condyloma of the penis treated with penis-sparing methods]

Herein, we report two cases of giant condyloma of the penis treated with penis-sparing methods. In the first case, the papillomatous tumor disappeared with topical use of fluorouracil ointment. In the second case, the tumor was treated with topical use of fluorouracil or bleomycin hydrochloride, followed by the resection of tumor. Giant condylomas reported in the recent 13 years are reviewed and methods of treatment discussed.

Audits of the treatment of genital warts: closing the feedback loop

An initial audit of the treatment of patients presenting to the GUM Department at Leeds General Infirmary with a first episode of anogenital warts was reported in 1993. Treatment was found to be unselective and poorly monitored and the results of treatment were disappointing. As a consequence, guidelines for the management of new patients presenting with genital warts were devised. In order to establish whether these guidelines had produced any improvements in outcome, a second audit was performed looking at the results of treatment in patients with new genital warts who attended 6 months or more after the new guidelines were introduced. Progress was documented for 6 months after presentation. There was a significant fall in the numbers of patients receiving podophyllin 25% solution as first-line treatment, and corresponding increases in the initial use of cryotherapy, trichloracetic acid and, in men, podophyllotoxin solution. (Podophyllotoxin was not licensed for use in women at the time of the second audit.) There were significant improvements in the outcome of treatment. Originally 44% of men had warts despite receiving treatment for 3 months, and 32% were still attending for treatment 6 months after presentation. After the introduction of treatment guidelines, these figures had fallen to 8% and 3% respectively. In the first audit 38% of women still had warts after 3 months' treatment but in the second audit this figure was reduced to 18%. At 6 months, the percentage of women still attending for treatment was halved from 12% in the first audit to 6% in the second audit. The mean number of clinic visits fell from 5 to 3 in men and from 9 to 6 in women. The treatment protocols have been modified and now include the use of podophyllotoxin cream and solution in both men and women.

Perianal condylomata acuminata

Anal and perianal condylomata acuminata are warts caused by infection with the human papillomavirus (HPV). The annual incidence of genital warts seems to have increased during the past few decades. Approximately 1.5 million consultations per year take place in the United States with this condition (1). Papillomavirus is a sexually transmitted disease, and is associated with several other venereal infections as well as with intraepithelial neoplasia and invasive squamous carcinoma. Only certain genotypes of HPV are carcinogenic, and can be precisely identified by in situ hybridisation techniques. There are many therapeutic alternatives, possibly reflecting the wide variability in treatment response.

The cost of treating genital warts

BACKGROUND

Genital warts is a common sexually transmitted disease treated by a variety of medical specialists. Standard therapies offer symptomatic relief but cannot ensure lasting remission. Using the clinical literature, claims databases, and a panel of experienced practitioners, the relative efficacy, cost, and cost effectiveness of five common treatments for genital warts were assessed in this study.

METHODS

We reviewed the clinical literature for the following genital wart therapies: podofilox, podophyllin, trichloroacetic acid, cryotherapy, and laser therapy, focusing on their relative efficacy. Physicians experienced in treating genital warts defined standard treatment protocols for men and women patients with moderate wart burdens. Using national claims data and protocols developed by physicians, we derived three economic models based on provider charges, third-party payments, and a resource-based relative value scale, respectively.

RESULTS

The literature review demonstrated highly variable success and recurrence rates among treatment methods and failed to show that one treatment provides consistently superior efficacy. In the economic models, treating women generally proved more costly than treating men per episode of care. This was due to the need for more extensive follow-up visits in the treatment of women. Total costs were highest for cryotherapy and lowest for a patient-applied therapy that reduced the need for follow-up visits.

CONCLUSIONS

Clinicians should consider both clinical and cost issues when choosing the appropriate treatment for patients with genital warts.

Patients with genital warts: how are they managed by general practitioners?

This study was carried out to assess the management by general practitioners of patients with genital warts. An anonymized postal questionnaire was sent to 2060 general practitioners in the north west of England; 1260 (61.2%) completed questionnaires were returned. A total of 76.69% of GPs saw one or more cases per quarter. Of 468 (37.1%) GPs who managed patients in-house, 393 (83.9%) used podophyllin of concentration between 0.5 and 50%; 169 (43%) did not specify the podophyllin concentration and 112(23.9%) used podophyllotoxin. Of 395 GPs (31.3%) prescribing patient self-treatment, 259 (65.6%) prescribed podophyllin, but 60.23% did not specify the concentration; 134(33.9%) prescribed podophyllotoxin. Screening for selected sexually transmitted infections (STIs) was performed by 258/618 (41.7%) GPs. Only 74 (11.97%) screened for Chlamydia trachomatis and Neisseria gonorrhoeae and Trichomonas vaginalis. Partner notification was advised by 1138 (90.3%) and condom use by 1027 (81.5%). Only 333 (26.4%) referred all patients to GUM departments. Many GPs manage patients in-house, most using podophyllin solutions which vary in concentration, are non-standardized and potentially hazardous. Most GPs who instigate patient self-treatment prescribe podophyllin which is not licensed for this usage. Podophyllotoxin 0.5% is a safe, effective alternative. Few non-referring GPs screened for the 3 common STIs, thus putting patients at risk of complications such as pelvic inflammatory disease. Non-referral of patients with genital warts to GUM departments may have costly medical and financial consequences.

The psychosocial impact of human papillomavirus infection: implications for health care providers

The American Social Health Association (ASHA) surveyed people with human papillomavirus (HPV) about their experiences with the disease and its effect on their lives. A sample of 837 was chosen from the subscribers to HPV News, ASHA's quarterly journal for people with HPV. Of the sample, 489 returned completed surveys, which addressed medical history, health care experiences, personal impact, and demographic information. Data analysis was descriptive. Data illustrated that the psychosocial impact of HPV can be serious. More than three-quarters of respondents reported feelings of depression and anger, and two-thirds feelings of shame. Sexual enjoyment and activity were also negatively affected by HPV. Additionally, respondents expressed dissatisfaction with the diagnosing health care providers' counselling on emotional and sexual issues. These results may be instructive to those delivering health services by providing insight into the significant personal impact of HPV on those infected.

[Anorectal diseases in patients with human immunodeficiency virus (HIV) infection]

BACKGROUND

The incidence of VIH-related disease has arisen dramatically in the last decade. Many of these patients will present with specific anorectal complaints.

PURPOSE

This review paper was performed to discuss the diagnostic and therapeutic implications of anorectal diseases in patients with VIH infection.

RESULTS

A detailed sexual history is important in order to document the mode of transmission. The nature of the anorectal complaint is then evaluated and classified as infectious, neoplastic or idiopathic. Treatment should be planned accordingly.

CONCLUSIONS

In the 1990's it's important that the physician who cares for patients with anorectal complaints be familiar with VIH-related diseases and their treatment plans.

Pseudobowenoid change of the vulva: a histologic variant of untreated condylata acuminatum

Vulvar condylomata are distinguished from vulvar intraepithelial neoplasia by orderly maturation, a low mitotic index, and the absence of nuclear atypia in the lower epithelial layers. Podophyllin therapy might produce changes in condylomata mimicking vulvar intraepithelial neoplasia but can be distinguished, particularly with a recent history of podophyllin use. This report describes five patients with vulvar condylomata that morphologically resemble both podophyllin effect and vulvar intraepithelial neoplasia. The mean age was 30.5 years. All lesions exhibited superficial keratinocytes in various stages of apoptosis, with a spectrum of nuclear degenerative changes characterized by absence of the nuclear membrane and dispersed nuclear chromatin. The characteristic finding was a perichromatin halo delineated by a rim of dense cytoplasm, beyond which a second zone of uniform clearing was observed, similar to changes noted in vulvar intraepithelial neoplasia. There was an absence, however, of either nuclear atypia in the lower cell layers or apoptosis and mitotic arrest observed in vulvar intraepithelial neoplasia and podophyllin therapy. Two (50%) of four lesions tested positive for human papillomavirus nuclei acids, one by polymerase chain reaction and the other by DNA-DNA in situ hybridization. No common human papillomavirus types were found. Pseudobowenoid change might represents a distinct type of vulvar condyloma, perhaps related to an unusual human papillomavirus.

Combined therapy trial with interferon alpha-2a and ablative therapy in the treatment of anogenital warts

OBJECTIVE

To determine whether the combination of systemically administered interferon alpha-2a and ablative surgery for the treatment of genital and/or perianal warts produces a 30% or greater improvement in lasting response rate compared with a control group receiving a combination of placebo and ablative therapy.

DESIGN

Randomised, triple-blind, placebo-controlled trial using 1 or 3 MIU of interferon alpha-2a or placebo administered subcutaneously three times weekly for 10 weeks in combination with ablative surgery.

SETTING

International, multicentre study in 10 genitourinary medicine clinics.

PATIENTS

Two hundred and fifty patients with anogenital warts.

MAIN OUTCOME MEASURES

Lasting response at week 38.

RESULTS

Standard efficacy analysis at week 38 showed a lasting response in 51% (35/68) of 3 MIU interferon-treated patients, 48% (30/63) of 1 MIU interferon-treated patients and 43% (29/67) of placebo-treated patients.

CONCLUSIONS

With the doses and regime described, treatment with interferon alpha-2a in combination with ablative therapy is not significantly superior in the treatment of anogenital warts than placebo and ablative therapy.

Randomised double-blind trial of recombinant interferon-beta for condyloma acuminatum

OBJECTIVE

To evaluate the safety and efficacy of two intralesional doses of recombinant human interferon-beta (r-hIFN-beta: Rebif, Ares Serono), given 3 times a week for 3 weeks, in the treatment of condyloma acuminatum.

DESIGN

A randomised, double-blind, within-patient, placebo-controlled study.

SUBJECTS

25 patients (24 males, 1 female) with a history of condyloma acuminatum. Twenty had failed previous treatment for condyloma acuminatum. In each patient, 3 distinct lesions were selected for treatment. Each selected lesion was randomly assigned to receive intralesionally one of the following: r-hIFN-beta 33,000 IU/day, r-hIFN-beta 1 x 10(6) IU/day, or matching placebo.

SETTING

Institut Alfred Fournier, Paris, France.

OUTCOME MEASURES

Response was evaluated colposcopically at the end of treatment (day 22) and 5 weeks later (month 2). Complete response (CR) was defined as disappearance of the treated lesion. Partial response (PR) was defined as at least a 50% reduction in size, but not disappearance of the treated lesion.

RESULTS

The higher dose of 1 x 10(6) IU achieved significantly more complete and partial remissions than placebo, both by the end of treatment, and 5 weeks later.

CONCLUSIONS

r-hIFN-beta appears to be safe and effective when administered intralesionally to patients with condyloma acuminatum. Most of the treated patients had failed previous treatments and were therefore a resistant population.

Comparative study of systemic interferon alfa-2a with oral isotretinoin and oral isotretinoin alone in the treatment of recurrent condylomata accuminata

OBJECTIVES

We attempted to test the hypothesis that the combination of systemic interferon alfa-2a and oral isotretinoin is more effective than isotretinoin alone in the treatment of recurrent condylomata accuminata.

STUDY DESIGN

Fifty seven women with recurrent condylomata accuminata were randomly assigned in two groups. Group A (n = 24) received isotretinoin alone (Roaccutan, Roche) 1 mg/kgr orally daily for 3 months or until a remission was achieved; Group B (n = 33) received Interferon alfa-2a (Roferon-A, Roche) 3 million units subcutaneously three times for 8 weeks plus isotretinoin 1 mg/Kg orally for 3 months or until a remission was achieved.

RESULTS

There was no statistically significance in remission rates between the two groups (18/24 vs 28/33, p > 0.1). However the duration of treatment was statistically significantly shorter in Group B (1.9 vs 2.5 months, p < 0.01). Side effects were minimal.

Genital warts: a study of patient anxiety and information needs

Infection with genital warts is one of the most commonly seen infections in genitourinary medicine (GUM) clinics. A study of 50 women with a first-time diagnosis of genital warts was undertaken to determine the patients' levels of knowledge and anxiety in relation to their diagnosis. The findings revealed that 42 (84%) of these women were aware of their possible diagnosis before attending the clinic. Just over a half of them received this information from their GPs. Eight (35%) patients lacked and fundamental knowledge about the mode of transmission of genital warts and the need for prophylactic use of condoms. Seventeen (74%) of the women did not know or were unsure about the methods of treatment. High levels of anxiety were reported by the patients on their first clinic attendance. To increase knowledge and lessen anxiety in this client group, the author recommends reciprocal liaison between GPs, their practice nurses and GUM clinics.

Cytological evaluation and molecular human papillomavirus test of cervical scrapings from women treated for condyloma

The incidence of cervical carcinoma has decreased by about half since cytological screening was introduced in Sweden in the 1960s. This is an encouraging but not altogether satisfactory development. Human papillomaviruses (HPVs) are known to be potential agents in the etiology of cervical cancer. Therefore, an additional HPV test might well improve the detection rate of high-grade cervical intraepithelial neoplasia (CIN). The purpose of this investigation was to compare the correlation of cytology and HPV testing in a pilot study of 94 women recruited from a clinic for sexually transmitted diseases after condyloma treatment and to check earlier established molecular biological assays. Cervical scrapings, taken for simultaneous Pap smear and molecular HPV DNA testing, were assessed by the polymerase chain reaction. Of the 94 women tested, 47 (50%) had normal cytology and negative HPV DNA; 36 (38%) had normal cytology but positive HPV DNA, 26 (72%) of whom harbored high-risk HPVs; 1 (1%) had abnormal cytology but negative HPV DNA, and 10 (11%) had abnormal cytology and positive HPV DNA, 5 (50%) of whom harbored high-risk HPVs. It is concluded that an HPV test would add greater specificity and possibly also greater sensitivity to cytology for detecting or predicting high-grade CIN. This information may be of value when designing future gynecological screening programs.

Autoimplantation technique in the treatment of anogenital warts: a clinico-immunological study

An autoimplantation technique was adopted in the treatment of 50 cases of anogenital warts and was compared with the conventionally used podophyllin regimen in a matched group of 50 patients. They were assessed with 15 untreated subjects in a control group for the rate of clinical cure after 6 weeks, recurrence after 1 year follow up and for humoral and cell mediated immune responses before and after treatment. In the podophyllin group, 70% of patients were cured after 6 weeks while in autoimplantation, only 44% of patients were cured, and none in the control group had natural remission of warts without any treatment. After 1 year all the cured cases (100%) that completed follow up had recurrence of warts with podophyllin treatment, while none had recurrence of lesions in the autoimplantation group. Results of the humoral and cell mediated immune (CMI) response studies revealed that autoimplantation technique significantly augmented both humoral and CMI responses while there was not significant change in the immune status after podophyllin treatment (P > 0.001).

Interferon response depends on viral transcription in human papillomavirus-containing lesions

Human papillomaviruses (HPVs) express various proteins which have been proven to interact with some cellular functions playing a role in cell cycle progression and differentiation. Therefore, these viral gene products might be candidates for interfering with IFN-mediated antiproliferative actions. Condyloma biopsies from patients subsequently demonstrated to be responsive or non-responsive to IFN treatment were investigated. mRNA levels of HPV genes and IFN-responsive genes were determined by RT-PCR and correlated with IFN responsiveness. Patients clinically nonresponsive to IFN demonstrated a characteristic HPV transcriptional activity differing from responder patients. Nonresponders expressed mostly early E7 mRNAs; responders demonstrated higher expression of the late L1 gene. This differential transcription of infecting HPV also correlated with the extent of IFN mediated antiproliferative effect. A hypothesis for further study is that HPV E7 may inhibit IFN responsiveness, while HPV L1 may promote IFN responsiveness.

Anorectal disorders. Five common causes of pain, itching, and bleeding

Hemorrhoids are a common source of anorectal symptoms, which are determined by their size. A helpful measure in small hemorrhoids is a high-fiber diet; in moderate lesions, ligature therapy is effective. Surgery should be reserved for large hemorrhoids. Anal fissures, probably caused by trauma to the anal canal during defecation, may persist because of a cycle of hard stools, pain, and reflex spasm. A high-fiber diet and sitz baths relieve acute fissures. Lateral partial internal sphincterotomy is usually effective when they become chronic. Perianal abscess is often caused by acute infection of the anal glands; fistula is the result of chronic infection. Swelling and induration may be present. Pain is throbbing and continuous, and perianal examination may require use of an anesthetic. Incision and drainage with follow-up to ensure resolution of infection is required. Pruritus ani may result from several contributing conditions or may be idiopathic. Restoration of dry, intact perianal skin is the treatment goal. Patients should be taught gentle hygiene and drying methods and advised to avoid caffeine or other dietary items that seem to exacerbate symptoms. Condylomata acuminata cause bleeding and pain if allowed to progress. Biopsy should be considered in patients at risk of dysplasia. Repeated application of caustic topical agents may help small lesions. Large, extensive, and persistent lesions require surgical ablation.

Anal and penile condylomas in HIV-negative and HIV-positive men: clinical, histological and virological characteristics correlated to therapeutic outcome

Clinical, histological and HPV DNA hybridization findings were analyzed for 73 homosexual and 38 heterosexual men attending for anal warts; therapy results were evaluated retrospectively for 76 of these patients. Concurrent anal and penile warts occurred most commonly in the heterosexual men (p < 0.001). While perianal warts were most common in heterosexuals (p < 0.05), intraanal warts were most common in homosexuals (p < 0.001). Altogether 23 homosexual men were HIV-infected; 13 HIV-positive men followed regarding therapeutic outcome were immunologically relatively intact with mean CD4 counts of 524/mm3. Of 136 biopsy specimens 70% revealed benign hyperplasia, 27% AIN I, 2% AIN II and none AIN III. Of ISH positive samples 94% contained HPV 6/11 and 6% HPV 16/18/31/33. Anal warts were cured after an average of 2.5 (mean 1-10) therapy sessions in 64% of heterosexual, in 84% of HIV-negative homosexual and in 62% of HIV-positive homosexual men. The mean number of therapy sessions against anal warts was highest (p < 0.001) and the time for accomplishing cure for anal and penile warts was longest (p < 0.001) in the heterosexual study group.

Current therapy for recurrent and extensive anal warts

PURPOSE

This study was undertaken to review the literature regarding the current therapy for recurrent and extensive anal warts.

METHODS

The available treatments for condyloma acuminatum are reviewed with particular regard to their efficacy for recurrent or extensive anal lesions. Topical agents, surgical methods, and the use of interferon are discussed. Treatment of anal warts in the immunocompromised patient is also addressed.

CONCLUSIONS

Although small lesions may be responsive to repeated applications of topical agents, more extensive lesions require surgical or combination treatment. Intralesional interferon may be a useful adjunct to surgical methods to decrease recurrence.

Noncervical human papillomavirus genital infections

The incidence of human papillomavirus infection is increasing. More than 60 types of human papillomavirus have been isolated; some types are known to have malignant potential. Differential diagnosis of the lesions includes condyloma latum, seborrheic keratoses, nevi, pearly penile papules and neoplasms. The goal in treating noncervical human papillomavirus infection is the elimination of lesions; eradication of the virus is not yet possible. Current forms of treatment include cryotherapy, podophyllum resin, podophilox, trichloroacetic acid, laser ablation, loop electrosurgical excision procedure (LEEP), fluorouracil and alpha interferon. Success in treating condyloma may be increased if the area is first soaked with 5 percent acetic acid to more clearly show the extent of the local infection. Recurrence is a problem no matter what form of therapy is used.