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Zhu P, Qi R, Yang Y, Huo W, Zhang Y, He L, Wang G, Xu J, Zhang F, Yang R, Tu P, Ma L, Liu Q, Li Y, Gu H, Cheng B, Chen X, Chen A, Xiao S, Jin H, Zhang J, Li S, Yao Z, Pan W, Yang H, Shen Z, Cheng H, Song P, Fu L, Chen H, Geng S, Zeng K, Wang J, Tao J, Chen Y, Wang X, Gao X. Clinical guideline for the diagnosis and treatment of cutaneous warts (2022). J Evid Based Med 2022; 15:284-301. [PMID: 36117295 PMCID: PMC9825897 DOI: 10.1111/jebm.12494] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/26/2022] [Indexed: 01/11/2023]
Abstract
AIM Cutaneous warts caused by human papillomavirus are benign proliferative lesions that occur at any ages in human lives. Updated, comprehensive and systematic evidence-based guidelines to guide clinical practice are urgently needed. METHODS We collaborated with multidisciplinary experts to formulate this guideline based on evidences of already published literature, focusing on 13 clinical questions elected by a panel of experts. We adopted Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to form classification of recommendations as well as the improved Delphi method to retain respective recommendations with a consensus degree of over 80%. RESULTS Our guideline covered aspects of the diagnosis and treatment of cutaneous warts such as diagnostic gold standard, transmission routes, laboratory tests, treatment principle, clinical cure criterion, definitions, and treatments of common warts, flat warts, plantar warts, condyloma acuminatum, and epidermodysplasia verruciformis. Recommendations about special population such as children and pregnant women are also listed. In total, 49 recommendations have been obtained. CONCLUSIONS It is a comprehensive and systematic evidence-based guideline and we hope this guideline could systematically and effectively guide the clinical practice of cutaneous warts and improve the overall levels of medical services.
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Affiliation(s)
- Peiyao Zhu
- Department of DermatologyThe First Hospital of China Medical UniversityHeping DistrictShenyangP.R. China
- NHC Key Laboratory of Immunodermatology, China Medical UniversityHeping DistrictShenyangP.R. China
- Key Laboratory of Immunodermatology, China Medical UniversityMinistry of EducationHeping DistrictShenyangP.R. China
- National and Local Joint Engineering Research Center of Immunodermatological TheranosticsHeping DistrictShenyangP.R. China
| | - Rui‐Qun Qi
- Department of DermatologyThe First Hospital of China Medical UniversityHeping DistrictShenyangP.R. China
- NHC Key Laboratory of Immunodermatology, China Medical UniversityHeping DistrictShenyangP.R. China
- Key Laboratory of Immunodermatology, China Medical UniversityMinistry of EducationHeping DistrictShenyangP.R. China
- National and Local Joint Engineering Research Center of Immunodermatological TheranosticsHeping DistrictShenyangP.R. China
| | - Yang Yang
- Department of DermatologyThe First Hospital of China Medical UniversityHeping DistrictShenyangP.R. China
- NHC Key Laboratory of Immunodermatology, China Medical UniversityHeping DistrictShenyangP.R. China
- Key Laboratory of Immunodermatology, China Medical UniversityMinistry of EducationHeping DistrictShenyangP.R. China
- National and Local Joint Engineering Research Center of Immunodermatological TheranosticsHeping DistrictShenyangP.R. China
| | - Wei Huo
- Department of DermatologyThe First Hospital of China Medical UniversityHeping DistrictShenyangP.R. China
- NHC Key Laboratory of Immunodermatology, China Medical UniversityHeping DistrictShenyangP.R. China
- Key Laboratory of Immunodermatology, China Medical UniversityMinistry of EducationHeping DistrictShenyangP.R. China
- National and Local Joint Engineering Research Center of Immunodermatological TheranosticsHeping DistrictShenyangP.R. China
| | - Yuqing Zhang
- Department of Clinical Epidemiology and Evidence‐Based MedicineThe First Hospital of China Medical UniversityHeping DistrictShenyangP.R. China
| | - Li He
- Department of DermatologyFirst Affiliated Hospital of Kunming Medical UniversityKunmingP.R. China
| | - Gang Wang
- Department of DermatologyXijing HospitalFourth Military Medical UniversityXi'an, ShaanxiP. R. China
| | - Jinhua Xu
- Department of DermatologyHuashan HospitalFudan UniversityShanghaiP.R. China
| | - Furen Zhang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and VenereologyShandong First Medical University & Shandong Academy of Medical SciencesJinanP.R. China
| | - Rongya Yang
- Department of DermatologyGeneral Hospital of Beijing Military Command of PLADongcheng DistrictBeijingP.R. China
| | - Ping Tu
- Department of Dermatology and VenerologyPeking University First HospitalBeijingP.R. China
| | - Lin Ma
- Department of DermatologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingP.R. China
| | - Quanzhong Liu
- Department of DermatologyTianjin Medical University General HospitalTianjinP.R. China
| | - Yuzhen Li
- Department of DermatologySecond Affiliated Hospital of Harbin Medical UniversityHarbinP.R. China
| | - Heng Gu
- Institute of DermatologyChinese Academy of Medical Sciences and Peking Union Medical CollegeNanjingP.R. China
| | - Bo Cheng
- Department of DermatologyThe First Affiliated Hospital of Fujian Medical UniversityFuzhouP.R. China
| | - Xiang Chen
- Department of DermatologyXiangya HospitalCentral South UniversityChangshaP.R. China
| | - Aijun Chen
- Department of DermatologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingP.R. China
| | - Shengxiang Xiao
- Department of DermatologyThe Second Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anP.R. China
| | - Hongzhong Jin
- Department of DermatologyPeking Union Medical College HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeDongcheng DistrictBeijingP.R. China
| | - Junling Zhang
- Department of DermatologyTianjin Academy of Traditional Chinese Medicine Affiliated HospitalTianjinP.R. China
| | - Shanshan Li
- Department of DermatologyThe First Hospital of Jilin UniversityChangchunJilin ProvinceP.R. China
| | - Zhirong Yao
- Department of DermatologyXinhua HospitalShanghai Jiao Tong University School of MedicineShanghaiP.R. China
| | - Weihua Pan
- Department of DermatologyShanghai Key Laboratory of Molecular Medical MycologySecond Affiliated Hospital of Naval Medical UniversityShanghaiP.R. China
| | - Huilan Yang
- Department of DermatologyGeneral Hospital of Southern Theatre Command of PLAGuangzhouP.R. China
| | - Zhu Shen
- Department of DermatologyInstitute of Dermatology and VenereologySichuan Academy of Medical Sciences and Sichuan Provincial People's HospitalChengduP.R. China
| | - Hao Cheng
- Department of Dermatology and VenereologySir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhouP.R. China
| | - Ping Song
- Department of DermatologyGuang'anmen HospitalChina Academy of Chinese Medical SciencesBeijingP.R. China
| | - Lingyu Fu
- Department of Clinical Epidemiology and Evidence‐Based MedicineThe First Hospital of China Medical UniversityHeping DistrictShenyangP.R. China
| | - Hongxiang Chen
- Department of DermatologyUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhanP.R. China
| | - Songmei Geng
- Department of DermatologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiP.R. China
| | - Kang Zeng
- Department of DermatologyNanfang HospitalSouthern Medical UniversityGuangzhouP.R. China
| | - Jianjian Wang
- Evidence‐Based Medicine CenterSchool of Basic Medical SciencesLanzhou UniversityLanzhouP.R. China
| | - Juan Tao
- Department of DermatologyUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhanP.R. China
| | - Yaolong Chen
- Evidence‐Based Medicine CenterSchool of Basic Medical SciencesLanzhou UniversityLanzhouP.R. China
- World Health Organization Collaborating Center for Guideline Implementation and Knowledge TranslationLanzhouP.R. China
- GIN AsiaLanzhouP.R. China
| | - Xiuli Wang
- Institute of PhotomedicineShanghai Skin Disease HospitalSchool of MedicineTongji UniversityShanghaiP.R. China
| | - Xing‐Hua Gao
- Department of DermatologyThe First Hospital of China Medical UniversityHeping DistrictShenyangP.R. China
- NHC Key Laboratory of Immunodermatology, China Medical UniversityHeping DistrictShenyangP.R. China
- Key Laboratory of Immunodermatology, China Medical UniversityMinistry of EducationHeping DistrictShenyangP.R. China
- National and Local Joint Engineering Research Center of Immunodermatological TheranosticsHeping DistrictShenyangP.R. China
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Cubilla AL, Velazquez EF, Young RH. Epithelial Lesions Associated with Invasive Penile Squamous Cell Carcinoma: A Pathologic Study of 288 Cases. Int J Surg Pathol 2016; 12:351-64. [PMID: 15494861 DOI: 10.1177/106689690401200408] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A heterogeneous spectrum of epithelial alterations and atypical lesions affect the squamous epithelium of penile mucosal anatomical compartments. Analogous to other genital sites, the terminology utilized to define the lesions is variable. The few pathologic studies of penile precancerous lesions are mostly related to carcinoma in situ and human papilloma virus (HPV), and the information on low-grade atypical lesions is limited. The objective of this study was to comprehensively describe the morphologic features of all epithelial alterations, benign and atypical, low grade and high grade, associated with invasive squamous cell carcinoma of the penis and to investigate their relation with each other and with subtypes of invasive carcinoma. We also propose herein a simple and reproducible nomenclature for penile precancerous abnormalities until more biological, molecular, or epidemiologic information on the lesions is available. Two hundred and eighty-eight penectomy and circumcision specimens with invasive squamous cell carcinoma were pathologically evaluated. Carcinomas were classified as usual, verrucous, papillary not otherwise specified, warty (condylomatous), basaloid, and mixed. Associated lesions were classified as squamous hyperplasia and squamous intraepithelial lesions of low and high grade (LGSIL and HGSIL). In LGSIL, atypia was confined to the lower third, and in HGSIL, atypical cells affected at least two thirds of the squamous epithelium. Subtypes of SIL were squamous, warty, basaloid, warty-basaloid, and papillary. Squamous hyperplasia, the most common lesion, was found in 83% of the cases, followed by LGSIL (59%) and HGSIL (44%). In 62% of the cases more than 1 associated lesion was present per specimen. A sequence from squamous hyperplasia to low-grade to high-grade SIL was seen frequently. Squamous hyperplasia was more commonly associated with usual squamous, papillary, and verrucous than with warty and basaloid invasive carcinomas. LGSIL was associated with all types of squamous cell carcinoma but was rarely present adjacent to basaloid or verrucous tumors. HGSIL was present in two thirds of invasive warty, basaloid, and mixed warty-basaloid tumors, in about half of usual squamous cell carcinomas, and was absent in papillary and verrucous carcinomas. Correlation of special types of invasive carcinomas with subtypes of SIL revealed morphologic correspondence of invasive tumor and the associated intraepithelial lesion. Squamous LGSIL was preferentially associated with verrucous, papillary, and usual squamous cell carcinomas; warty LGSIL, with invasive warty and mixed wartybasaloid carcinomas. High-grade SIL of the squamous type was frequently found in squamous cell carcinoma of usual type but was rarely present with warty or basaloid carcinomas. Basaloid HGSIL was associated with basaloid carcinoma, and HGSIL of warty type, with either warty or mixed warty-basaloid carcinomas. The high frequency of squamous hyperplasia and LGSIL and preferential association with usual, verrucous, and papillary carcinomas plus the subtle morphologic differences of the 2 lesions suggest that, despite its benign appearance, squamous hyperplasia is a precursor of the aforementioned carcinomas. The association and histologic similarities between high-grade SIL of the basaloid, warty, or mixed forms with their invasive counterparts indicate these lesions are their likely precursors.
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Affiliation(s)
- Antonio L Cubilla
- Instituto de Patologia e Investigacion, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, Paraguay
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Ying Z, Li X, Dang H. 5-aminolevulinic acid-based photodynamic therapy for the treatment of condylomata acuminata in Chinese patients: a meta-analysis. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2013; 29:149-59. [PMID: 23651275 DOI: 10.1111/phpp.12043] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/15/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Zuolin Ying
- Department of Dermatology, Shanghai First People's Hospital; School of Medicine, Shanghai Jiao Tong University; Shanghai; China
| | - Xiaojie Li
- Department of Dermatology, Shanghai First People's Hospital; School of Medicine, Shanghai Jiao Tong University; Shanghai; China
| | - Hong Dang
- Department of Dermatology, Shanghai First People's Hospital; School of Medicine, Shanghai Jiao Tong University; Shanghai; China
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Liang J, Lu XN, Tang H, Zhang Z, Fan J, Xu JH. Evaluation of photodynamic therapy using topical aminolevulinic acid hydrochloride in the treatment of condylomata acuminata: a comparative, randomized clinical trial. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2010; 25:293-7. [PMID: 19906163 DOI: 10.1111/j.1600-0781.2009.00467.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the safety and efficacy of photodynamic therapy (PDT) with topical application of 20% wt/vol aminolevulinic acid hydrochloride (ALA) in the treatment of condylomata acuminata (CA). STUDY DESIGN Patients with CA were randomly allocated into the ALA-PDT group and the CO(2) laser group in an allocation ratio of 3 : 1. The treatment was repeated weekly if necessary, but no more than 3 times. The primary efficacy endpoint was the wart clearance rate 1 week after the last treatment. The recurrence rate was evaluated at weeks 4, 8 and 12 after the treatment ended. The clinical response to therapy and adverse effects were recorded. RESULTS A total of 91 patients with CA were enrolled in the clinical trial. Of these 90 (98.9%) patients completed the trial (67 in the ALA-PDT group, and 23 in CO(2) laser group). By 1 week after the last treatment, the complete clearance rate was 95.93% in the ALA-PDT group and 100% in CO(2) laser group (P>0.05). The clearance rate of CA at male urethral orifice was 100% in the ALA-PDT group and 100% in the CO(2) laser group (P>0.05). The overall recurrence rate calculated by the end of the entire follow-up period was significantly lower in the ALA-PDT group than that in the CO(2) laser group (9.38% vs 17.39%, P<0.05). Moreover, there was no systemic adverse event in either group. The proportion of patients with adverse effects in the ALA-PDT group (8.82%) was also significantly lower than that in the CO(2) laser group (100%, P<0.05). The side-effects in patients treated with ALA-PDT mainly included mild burning and/or stinging restricted to the illuminated area. CONCLUSION The results confirmed that topical application of ALA-PDT is a simpler and as effective therapy with a lower incidence of adverse effects in the treatment of CA compared with conventional CO(2) laser therapy.
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Affiliation(s)
- Jun Liang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
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ROSS E, ROMERO R, KOLLIAS N, CRUM C, ANDERSON R. Selectivity of protoporphyrin IX fluorescence for condylomata after topical application of 5-aminolaevulinic acid: implications for photodynamic treatment. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1997.19442059.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chen K, Chang BZ, Ju M, Zhang XH, Gu H. Comparative study of photodynamic therapy vs. CO2laser vaporization in treatment of condylomata acuminata, a randomized clinical trial. Br J Dermatol 2007; 156:516-20. [PMID: 17300242 DOI: 10.1111/j.1365-2133.2006.07648.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Most conventional therapies for condylomata acuminata (CA) are traumatic and have high recurrence rates. OBJECTIVES To investigate the efficacy and safety of topical application of 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) for the treatment of CA. METHODS Sixty-five patients with CA were allocated into the treatment (ALA-PDT) group and treated with 20% ALA solution under occlusive dressing for 3 h followed by irradiation with the helium-neon laser at a dose of 100 J cm(-2) and a power of 100 mW. Another 21 CA patients were allocated into the control group and treated with the CO(2) laser. The treatment was to be repeated 1 week later if the lesion was not completely removed after the first treatment. RESULTS After one treatment, the complete removal rate was 95% in the ALA-PDT group and 100% in the control group. After two treatments with ALA-PDT, the complete removal rate in the treatment group was 100%. The recurrence rate for ALA-PDT group was 6.3% which was significantly lower than that in control group (19.1%, P < 0.05). Moreover, the proportion of patients with adverse effects in the ALA-PDT group (13.9%) was also significantly lower than that in control group (100%, P < 0.05). The side-effects in patients treated with ALA-PDT mainly included mild burning and/or stinging restricted to the illuminated area. CONCLUSIONS The present study shows that topical application of ALA-PDT is a simpler, more effective and safer therapy with a lower recurrence for treatment of CA compared with conventional CO(2) laser therapy.
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Affiliation(s)
- K Chen
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
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Kumar B, Gupta S. The acetowhite test in genital human papillomavirus infection in men: what does it add? J Eur Acad Dermatol Venereol 2001; 15:27-9. [PMID: 11451317 DOI: 10.1046/j.1468-3083.2001.00196.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Many genital human papillomavirus (HPV) infections are clinically invisible epithelial lesions. They remain so for a considerable time before some develop into clinically apparent lesions. The inapparent and asymptomatic nature of these lesions poses a problem in the detection and management of genital HPV infection. Without reliable, and readily available diagnostic methods, no definite therapeutic approach can be recommended or followed. The acetowhite test has been recommended to help determine the extent of the affected area. OBJECTIVE To evaluate the acetowhite test in detecting inapparent subclinical HPV involvement in male patients with clinically apparent warts. METHODS Two hundred and two uncircumcised patients with genital warts were included. Patients with concomitant inflammatory lesions were excluded. The warts and adjacent normal skin/mucosa of normal appearance were wrapped in gauze soaked in 5% acetic acid for about 3-5 min. The area was subsequently examined with a hand lens (x 8). RESULTS All of the 116 hyperplastic warts became acetowhite, as well as a narrow rim of surrounding skin. Few flat warts in dry areas only became dull white and none pure white. No whiteness was observed in the surrounding area. Only 15 of 26 flat warts in moist areas became acetowhite. One (eroded lesion) of 13 verruca vulgaris type lesions and none of the pigmented papules gave positive results to the acetowhite test. CONCLUSIONS The sensitivity of the acetowhite test for hyperplastic warts is very high, but for other types of warts is low. Detection of subclinical HPV-infected areas is difficult; the acetowhite test did not assist in the identification of additional areas of infection in our patients.
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Affiliation(s)
- B Kumar
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Aynaud O, Piron D, Bijaoui G, Casanova JM. Developmental factors of urethral human papillomavirus lesions: correlation with circumcision. BJU Int 1999; 84:57-60. [PMID: 10444125 DOI: 10.1046/j.1464-410x.1999.00104.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the relationship between circumcision and urethral human papillomavirus (HPV) lesions, and the influence of urethritis on the development of urethral HPV infections on inducing squamous metaplasia of the urethral epithelium. PATIENTS AND METHODS The study included 210 heterosexual, HIV-negative men (median age 29 years) who all had female partners with genital HPV infection. The patients were divided into three groups according to clinical findings, i.e. 97 patients with no clinical HPV lesions on peniscopy and urethroscopy, 70 patients with balanopreputial lesions but no urethral lesions, and 43 patients with urethral HPV lesions, including 17 who had associated penile lesions. They all underwent meatopeniscopy for HPV screening, urethral biopsy for histological analysis, and bacterial cultures were taken. The results in each subgroup were compared between circumcised and uncircumcised men. RESULTS There was no significant difference in the incidence of HPV infection (58% vs 42%, odds ratio, OR, 1.8; 95% confidence interval, CI, 0.98-3.62) between uncircumcised and circumcised men, but this relationship differed with the developmental site of HPV lesions (shaft-foreskin, P<0.02; urethra, not significant). There was also a significant difference in the prevalence of urethritis between uncircumcised and circumcised men (34.5% vs 19%, OR 2.35, 95% CI 1. 08-5.11), and between HPV-infected and uninfected men (41.5% vs 18%, OR 3.17, 95% CI 1.71-5.83). This positive relationship of the prevalence of urethritis for both factors (circumcision and HPV) depended on the type of organism (sexually transmitted disease, not significant; common organism, P<0.02). The frequency of urethritis was related to the site of HPV lesions; urethritis was present in 36% of the patients with preputial HPV lesions, compared with 51% of those with urethral HPV lesions. Chlamydia trachomatis was detected in 1% of the patients without and in 7% of those with HPV lesions. In 68% of the patients, histological analysis of the urethral mucosa showed a squamous metaplasia of the urethral epithelium associated with urethritis. CONCLUSIONS Being uncircumcised did not seem to increase the risk of HPV urethral infection in young men. Genital bacterial infections and urethral HPV lesions appear to be linked. Urethritis can induce squamous metaplasia of the urethral epithelium, which appears to favour the colonization of the anterior urethra by HPVs.
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Affiliation(s)
- O Aynaud
- Collège Européen et Francophone d'Urologie Libérale, Paris, France
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ROSS E, ROMERO R, KOLLIAS N, CRUM C, ANDERSON R. Selectivity of protoporphyrin IX fluorescence for condylomata after topical application of 5-aminolaevulinic acid: implications for photodynamic treatment. Br J Dermatol 1997. [DOI: 10.1111/j.1365-2133.1997.tb01110.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Human papillomaviruses (HPVs) cause benign tumors (i.e., warts) and are occasionally responsible for malignant tumors such as squamous-cell carcinomas. Therapy for most warts is commonly via surgical or cytodestructive methods. Presently, only one antiviral/immunomodulatory drug is available for wart therapy; this agent, interferon alpha (IFN alpha), is approved only for genital warts (condylomata acuminata) and is expensive, relatively difficult to use, associated with systemic side effects, and somewhat slow acting. Two new antiviral/immunomodulatory drugs, imiquimod and cidofovir, have been proved to be effective and able to overcome many of the shortcomings of IFN alpha. While these two agents are pending approval, other treatments are being evaluated, such as antisense oligonucleotides and therapeutic HPV vaccines. In contrast to surgical and cytodestructive therapies, the goal of these new antiviral/immunomodulatory agents is not just to remove the tumor but also to reduce sufficiently the amount of latent and subclinical HIV so as to reduce the rate of recurrence.
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Affiliation(s)
- G E Baker
- Department of Dermatology, Microbiology/Immunology, University of Texas Medical Branch, Galveston, USA
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Schell BJ, Rosen T. Evaluation of acetowhitening in Bowen's disease. THE JOURNAL OF DERMATOLOGIC SURGERY AND ONCOLOGY 1994; 20:740-2. [PMID: 7962934 DOI: 10.1111/j.1524-4725.1994.tb03196.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND From a clinical standpoint, the lesions of Bowen's disease (squamous cell carcinoma in situ) are generally sharply demarcated. Following excision, however, contiguous extension and/or small foci of Bowen's disease are occasionally found, located outside the clinically apparent margins. Acetowhitening has been suggested as a means of delineating the extent of involvement and identifying subclinical lesions of condyloma acuminata. More recently, acetowhitening has offn similarly reported to be of potential value in the presurgical evaluation of Bowen's disease. OBJECTIVE The purpose of this investigation was to further evaluate the use and reliability of acetowhitening both to delineate margins of Bowen's disease and to identify subclinical foci of involvement. METHODS Eight patients with histologically confirmed Bowen's disease were studied. Six percent acetic acid was applied to the lesions and the surrounding skin. Histologic examination of acetowhite lesions and adjacent acetowhite skin as well as adjacent, nonwhitened normal appearing skin was performed. RESULTS Our results were inconsistent, and included both false positives and false negatives. CONCLUSIONS Acetowhitening is unreliable in identification of Bowen's disease. Clinically normal, acetowhite-negative skin adjacent to a lesion of Bowen's disease may be involved.
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Affiliation(s)
- B J Schell
- Department of Dermatology, Baylor College of Medicine, Houston, TX 77030
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Wikström A, von Krogh G, Hedblad MA, Syrjänen S. Papillomavirus-associated balanoposthitis. Genitourin Med 1994; 70:175-81. [PMID: 8039781 PMCID: PMC1195226 DOI: 10.1136/sti.70.3.175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To assess whether there might be an association between genital papillomavirus infection (GPVI) and balanoposthitis. DESIGN Retrospective HPV DNA examination of biopsy specimens from 23 men suffering from balanoposthitis and exhibiting acetowhite lesions that were penoscopically and histologically concurrent with HPV infection. SETTING The STD clinics at Karolinska Hospital and South Hospital, Stockholm, Sweden. PARTICIPANTS Randomly selected men attending with long-lasting and/or recurrent penile symptoms and exhibiting a clinical picture of balanoposthitis, who revealed a penoscopical and histopathological picture of epidermal lesions that were concordant with accepted criteria for typical or conspicuous GPVI. Asymptomatic controls were selected retrospectively on the basis of identical penoscopy and histology criteria. RESULTS A history of previous condylomata was obtained in eight (35%) of 23 men. At penoscopic evaluation tiny condylomatous lesions were observed in five (22%) patients. The in situ hybridisation (ISH) assay using specific probes for the HPV types 6/11, 16/18, 31/33 and 42 was positive in 13/23 (56%) of the patient samples, but in only 26% of the 19 control samples. In patient biopsies the oncogenic HPV types 16/18 and/or 31/33 were found in 7/13 samples, whereas HPV 6/11 and/or 42 were present in another six cases. PCR performed on the ten ISH negative patient biopsies, were negative in all cases. CONCLUSION Symptoms included redness, itching, burning, tenderness, dyspareunia, fissuring and in two cases penile oedema and inguinal adenopathy. All patients fulfilled penoscopical and histopathological criteria for HPV infection. We demonstrate some tentative evidence that HPV might be associated with long-lasting balanoposthitis, although our data still are circumstantial for a causative association. The results also elucidate the diversity in clinical presentation of GPVI.
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Affiliation(s)
- A Wikström
- Department of Dermatovenereology, Karolinska Hospital, Stockholm, Sweden
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Aziz DC, Ferré F, Robitaille J, Ferenczy A. Human papillomavirus testing in the clinical laboratory. Part II: vaginal, vulvar, perineal, and penile squamous lesions. J Gynecol Surg 1994; 9:9-15. [PMID: 10150115 DOI: 10.1089/gyn.1993.9.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The accurate diagnosis of HPV-related diseases of the lower genital tract requires expertise, and sometimes even the expert may face a dilemma as to the precise nature of the biopsies submitted from colposcopically suspicious HPV-related lesions. We have evaluated the role of viral testing using dot blot hybridization (ViraType) and PCR in the diagnosis of histologically typical (42 cases) and equivocal (30 cases) squamous intraepithelial lesions of the vagina (7), vulva (30), perianal epithelium (3), penis (31), and scrotum (1). The viral kits were used according to the manufacturer's instructions in a routine laboratory setting, and the probes available were HPV 6/11, 16, 18, and 31, 33, 35 (the 30s group). HPV DNA was found in 45 of 72 (62%) of all lesions. PCR was more sensitive (58%) than ViraType (39%) for detecting HPV DNA sequences (p less than 0.02), particularly in equivocal lesions (EQHPV), 14 of 30 (47%) by PCR vs 4 of 30 (13%) by ViraType (p less than 0.004). The majority of lesions contained oncogenic type viruses irrespective of their histologic presentation, namely, type 16. Only condylomata acuminata were predominantly HPV 6 or 11 positive. Viral testing may play a role in the quality control of the diagnostic expertise of routine laboratories as well as ascertaining the HPV-relatedness of histologically equivocal lesions of the anogenital tract. In view of the relatively high false-negative rates for detecting HPV DNA by ViraType and PCR, only a positive test may be meaningful unless other HPV types are added.
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Affiliation(s)
- D C Aziz
- OncQuest, Division of Specialty Laboratories, Inc., Santa Monica, California
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Hippeläinen MI, Syrjänen S, Hippeläinen MJ, Saarikoski S, Syrjänen K. Diagnosis of genital human papillomavirus (HPV) lesions in the male: correlation of peniscopy, histology and in situ hybridisation. Genitourin Med 1993; 69:346-51. [PMID: 8244350 PMCID: PMC1195115 DOI: 10.1136/sti.69.5.346] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To assess the diagnostic criteria of genital HPV lesions in male sexual partners of HPV infected women. METHODS Peniscopically directed biopsy specimens (from 693 lesions in 300 men) were examined on light microscopy and in situ hybridisation (ISH) for HPV types 6,11,16,18,31,33 and 42. The predictive value of different histological criteria for ISH positivity was also evaluated using stepwise logistic regression analysis. RESULTS Flat HPV lesions were most accurately predicted by the punctuation pattern on peniscopy, giving the concordance between peniscopy and histology between peniscopy and histology of 79.5% (66/83) and that between peniscopy and ISH of 56.6% (47/83). Diffuse acetowhite pattern disclosed a typical HPV lesion in only 17.8% (13/73), and HPV DNA was found in 11.0% (8/73) of cases. Of the 114 biopsy specimens from peniscopically healthy areas adjacent (0.5-1 cm) to the lesions, 93.0% (106/114) were normal on light microscopy, and HPV DNA was found in only 2.6%. Penile intraepithelial neoplasia (PIN) lesions were most frequently ISH positive, 81.1% (30/37), 50% showing HPV 16 and/or 18 DNA. Lesions classified as HPV-suspicious or nonspecific on light microscopy were HPV DNA-positive in 16.9% (11/65) and 8.1% (13/160), the frequency of high-risk HPV types being 3.1% and 1.3%, respectively. In logistic regression analysis, koilocytosis was the most powerful predictor of ISH-positivity in the flat lesions (without PIN), the risk ratio being 3.7. CONCLUSION No conclusive peniscopic criteria for male HPV infections could be established, making histological evaluation mandatory. Care should be exercised in interpreting as HPV lesions the cases devoid of koilocytosis, HPV typing being essential in confirming the diagnosis in doubtful cases.
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Affiliation(s)
- M I Hippeläinen
- Department of Gynaecology and Obstetrics, University of Kuopio, Finland
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15
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Rymark P, Forslund O, Hansson BG, Lindholm K. Genital HPV infection not a local but a regional infection: experience from a female teenage group. Genitourin Med 1993; 69:18-22. [PMID: 8383095 PMCID: PMC1195003 DOI: 10.1136/sti.69.1.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To investigate the prevalence of human papillomavirus (HPV) infections in a group of female teenagers, and to analyse to what extent HPV DNA was also detectable, in urethra and cervix samples among the patients with macroscopic genital warts compared with those without. DESIGN The patients were interviewed about their sexual habits and history of venereal diseases. They underwent a gynaecological health control examination, including macroscopic inspection for genital warts and collection of a cytological vaginal smear (Pap smear). Cell samples were also taken from endocervix and urethra and from vulva lesions, when found. These samples were tested for HPV DNA of the types 6, 11, 16, 18 and 33 using the polymerase chain reaction (PCR) technique. SETTING An adolescence out-patient clinic in Malmö, Sweden. SUBJECTS Forty-nine female teenagers consulting for gynaecological complaints, some of them for genital warts. RESULTS Twenty patients had present and four had a history of genital warts (group A). The other 25 patients had no visible lesions (group B). In the first group (A) 18 of the 24 patients were positive for HPV DNA in one or more of the three locations studied. More patients were positive in urethra (17) than in cervix (15). In group B four of the 25 patients were positive for HPV DNA in urethra, three of these also in cervix. In the two groups 11 and four patients, respectively, showed pathological Pap smears. CONCLUSIONS The finding of HPV DNA in urethra, both from women with and without visible genital warts, indicates that there is a high probability that the infection is also present in cervix, suggesting that the genital HPV infections are multifocal. Thus, patients with genital warts are most likely to have cervical HPV infections and will more often have pathological Pap smears than patients without warts.
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Affiliation(s)
- P Rymark
- Department of Obstetrics and Gynaecology, University of Lund, Malmö General Hospital, Sweden
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16
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Burmer GC, True LD, Krieger JN. Squamous cell carcinoma of the scrotum associated with human papillomaviruses. J Urol 1993; 149:374-7. [PMID: 8381191 DOI: 10.1016/s0022-5347(17)36089-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A 53-year-old man presented with recurrent squamous cell carcinoma, and dysplasia of the scrotum and penis. Risk factors included psoralen and ultraviolet radiation therapy for psoriasis, and x-ray therapy for primary lymphoma of the groin. Three different human papillomavirus types were documented using the polymerase chain reaction in distinct anatomical areas. The scrotal carcinoma was associated with human papillomavirus type 18, while regions of dysplasia contained either type 18, 16 or 6/11. Diagnosis of squamous dysplasia and carcinoma of the scrotum in men with psoriasis is complicated by chronic active inflammation, and molecular biological methods may be necessary to detect human papillomavirus infected cells.
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Affiliation(s)
- G C Burmer
- Department of Pathology, School of Medicine, University of Washington, Seattle
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Affiliation(s)
- M R Ling
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
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Wikström A, Hedblad MA, Johansson B, Kalantari M, Syrjänen S, Lindberg M, von Krogh G. The acetic acid test in evaluation of subclinical genital papillomavirus infection: a comparative study on penoscopy, histopathology, virology and scanning electron microscopy findings. Genitourin Med 1992; 68:90-9. [PMID: 1316310 PMCID: PMC1194819 DOI: 10.1136/sti.68.2.90] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate colposcopic criteria in acetowhite lesions of the penis ("penoscopy") for the diagnosis of subclinical genitoanal papillomavirus infection (GPVI) compared with histopathological criteria of HPV involvement and to various hybridisation assays for HPV DNA detection, and to depict typical lesions by scanning electron microscopy. DESIGN The study included 101 randomly selected male partners of females with known GPVI, or with penile symptoms such as itching, burning and dyspareunia who did not exhibit overt genital warts but appeared to be afflicted with acetowhite penile lesions after topical application of 5% acqueous acetic acid. Lesions were judged by penoscopy as either typical, conspicuous or nontypical for underlying HPV infection. Biopsy specimens from 91 men were examined by light microscopy and by either Southern blot (SB), polymerase chain reaction (PCR) and/or in situ hybridisation (ISH) assays for the presence of HPV DNA of the HPV types 6, 11, 16, 18, 31, 33 and 42 (Group A). From another ten men lesions clinically typical for GPVI were also examined topographically by scanning electronic microscopy (Group B). SETTING The STD out-patient clinic of the Department of Dermatovenereology of Karolinska Hospital, Stockholm, Sweden. RESULTS Group A Seventy eight (86%) of the biopsied lesions met the penoscopy criteria of being either typical of or conspicuous for GVPI. The agreement between penoscopy and histopathology was fairly good, as HPV diagnosis was made by both methods in 56 (62%) of the cases. The reliability of applying strict colposcopic hallmarks was further substantiated by the finding that 55 (60%) of the biopsy specimens taken from penoscopically typical/conspicuous lesions contained HPV DNA. However, there are diagnostic pitfalls for the acetic acid test. Coexistence of an eczematoid reaction with changes indicative of HPV influence was detected in six (7%) of the cases, while an inflammatory response only occurred in 17 (19%) of the specimens. Additional histopathological diagnoses (normal epithelium, lichen sclerosus et atrophicus, balanitis circinata parakeratotica, verruca plana) were established in another eight (9%) of the cases. Among the HPV DNA positive cases, all of the HPV types tested for were detected with the exception of HPV 18. A severe penile intraepithelial neoplasia (PIN III) was revealed in five (5%) of biopsies; HPV 16 was present in two and HPV 42 in one of these biopsy specimens. GROUP B Scanning electron microscopy depiction harmonised with the penoscopy findings showing that subclinical GPVI characteristically exhibits a well demarcated, slightly elevated border and that the central area of lesions often displays a "groove" in which the epithelium appears to be thin with protrusions from beneath that probably represent capillaries. CONCLUSION Use of the acetic acid test for evaluation of GPVI should be combined with a colposcopic evaluation based on strict topographic hallmarks, followed by a directed biopsy for light microscopic evaluation. We found that the positive predictive value of colposcopy was as high when correlated with histopathological findings (72%) as when virological methods were used, whether HPV DNA hybridisation testing was performed with the well established SB and ISH assays (45%), or by applying the newly introduced and highly sensitive PCR assay as well (71%). False positivity from the acetic acid test occurs and is mainly due to inflammatory conditions but also to the presence of other conditions. Epithelial fissures are evidently associated with some subclinical GPVI lesions and may potentially represent loci minores for infectious stimuli and perhaps facilitate the transmission of some blood-borne STDs. We prose that the term "papillomavirus balanoposthitis" should be used for penile HPV infection associated with inflammatory responses. Our study indicates that PIN III frequently occurs in a subclinical form and may be associated with not only previously identified "high-risk" HPV types such as type 16, but also with the HPV type 42 that has not previously been considered as oncogenic.
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Affiliation(s)
- A Wikström
- Department of Dermatovenereology, Karolinska Hospital, Stockholm, Sweden
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Abstract
OBJECTIVE To review the role of human papillomavirus (HPV) as a causative agent of cancer of the cervix. DATA SOURCES, data synthesis, study selection: Medical journals, recently published text books related to cancer of the cervix and HPV and Papillomavirus Reports were examined to review the pathology of cervical cancer and its precursor lesions, its epidemiology in Australia and overseas, methods of detection of HPV (in particular molecular biology techniques used to diagnose HPV) and evidence linking HPV with genital neoplasia. CONCLUSION While there is compelling evidence strongly linking certain HPV types with genital cancer, a causative role is yet to be proven and the aetiology is most likely multifactorial. Detection and typing of high risk genotypes of HPV in the genital tract as a diagnostic exercise to identify those women most at risk of developing genital neoplasia is not currently recommended.
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von Krogh G. Genitoanal papillomavirus infection: diagnostic and therapeutic objectives in the light of current epidemiological observations. Int J STD AIDS 1991; 2:391-404. [PMID: 1782228 DOI: 10.1177/095646249100200601] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
During the past decade a wide span of heterogeneity has been demonstrated for human papillomaviruses (HPVs), and some basic properties of the HPV genome have been revealed. The use of hybridization assays for HPV DNA detection in infected epithelia, and the recent introduction of synthetic HPV peptides for detection of type-specific circulating antibodies, have resulted in a major rethinking of HPV epidemiology. Recent data indicate that various HPVs may be transmitted perinatally during early infancy and that a long latency with periodic reactivation seems to be quite common. The present review attempts to assess recent epidemiological data with the concept of genitoanal papillomavirus infection (GPVI) as a predominantly sexually transmitted disease. Some diagnostic and therapeutic aspects are outlined with a pragmatic approach to the clinical relevance of GPVI.
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von Krogh G, Wikström A. Efficacy of chemical and/or surgical therapy against condylomata acuminata: a retrospective evaluation. Int J STD AIDS 1991; 2:333-8. [PMID: 1958717 DOI: 10.1177/095646249100200504] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In order to estimate treatment resistance of condylomas, standardized records of 230 males aged 17-80 years (mean 27) attending at an STD clinic were analysed retrospectively. Anal warts occurred in 38 (17%) men; in 19 (50%) intranal warts were extensive enough to require further referral to the Department of Surgery. Urinary meatal warts occurred in 30 men; 9 of them (30%) were referred to the Department of Urology. The remaining 202 (88%) men were treated in the STD clinic with simple surgery and/or home-treatment with 0.5% podophyllotoxin-ethanol twice a day for one or more 3 day sessions. After a follow-up of at least one year, 46 (23%) patients still had condylomas. However, 77 (49%) of the remaining 156 men were cured after a single therapeutic session, and after 1-4 sessions the cumulative cure rate was 77%.
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Affiliation(s)
- G von Krogh
- Department of Dermatovenereology, Karolinska Hospital, Stockholm, Sweden
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