Genital and perianal warts: new treatment opportunities for human papillomavirus infection

Trends and strategies to combat viral infections: A review on FDA approved antiviral drugs

The infectious microscopic viruses invade living cells to reproduce themselves, and causes chronic infections such as HIV/AIDS, hepatitis B and C, flu, etc. in humans which may lead to death if not treated. Different strategies have been utilized to develop new and superior antiviral drugs to counter the viral infections. The FDA approval of HIV nucleoside reverse transcriptase inhibitor, zidovudine in 1987 boosted the development of antiviral agents against different viruses. Currently, there are a number of combination drugs developed against various viral infections to arrest the activity of same or different viral macromolecules at multiple stages of its life cycle; among which majority are targeted to interfere with the replication of viral genome. Besides these, other type of antiviral molecules includes entry inhibitors, integrase inhibitors, protease inhibitors, interferons, immunomodulators, etc. The antiviral drugs can be toxic to human cells, particularly in case of administration of combination drugs, and on the other hand viruses can grow resistant to the antiviral drugs. Furthermore, emergence of new viruses like Ebola, coronaviruses (SARS-CoV, SARS-CoV-2) emphasizes the need for more innovative strategies to develop better antiviral drugs to fight the existing and the emerging viral infections. Hence, we reviewed the strategic enhancements in developing antiviral drugs for the treatment of different viral infections over the years.

Optical techniques for the diagnosis and treatment of lesions induced by the human papillomavirus - A resource letter

Human papillomaviruses (HPV) are the most common sexually-transmitted virus, and carcinogenic HPV strains are reported to be responsible for virtually all cases of cervical cancer and its precursor, the cervical intraepithelial neoplasia (CIN). About 30% of the sexually active population are considered to be affected by HPV. Around 600 million people are estimated to be infected worldwide. Diseases related to HPV cause significant impact from both the personal welfare point of view and public healthcare perspective. This resource letter collects relevant information regarding HPV-induced lesions and discusses both diagnosis and treatment, with particular attention to optical techniques and the challenges involved to the implementation of those approaches.

Approved Antiviral Drugs over the Past 50 Years

Since the first antiviral drug, idoxuridine, was approved in 1963, 90 antiviral drugs categorized into 13 functional groups have been formally approved for the treatment of the following 9 human infectious diseases: (i) HIV infections (protease inhibitors, integrase inhibitors, entry inhibitors, nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and acyclic nucleoside phosphonate analogues), (ii) hepatitis B virus (HBV) infections (lamivudine, interferons, nucleoside analogues, and acyclic nucleoside phosphonate analogues), (iii) hepatitis C virus (HCV) infections (ribavirin, interferons, NS3/4A protease inhibitors, NS5A inhibitors, and NS5B polymerase inhibitors), (iv) herpesvirus infections (5-substituted 2'-deoxyuridine analogues, entry inhibitors, nucleoside analogues, pyrophosphate analogues, and acyclic guanosine analogues), (v) influenza virus infections (ribavirin, matrix 2 protein inhibitors, RNA polymerase inhibitors, and neuraminidase inhibitors), (vi) human cytomegalovirus infections (acyclic guanosine analogues, acyclic nucleoside phosphonate analogues, pyrophosphate analogues, and oligonucleotides), (vii) varicella-zoster virus infections (acyclic guanosine analogues, nucleoside analogues, 5-substituted 2'-deoxyuridine analogues, and antibodies), (viii) respiratory syncytial virus infections (ribavirin and antibodies), and (ix) external anogenital warts caused by human papillomavirus infections (imiquimod, sinecatechins, and podofilox). Here, we present for the first time a comprehensive overview of antiviral drugs approved over the past 50 years, shedding light on the development of effective antiviral treatments against current and emerging infectious diseases worldwide.

A comparison of a 5% potassium hydroxide solution with a 5-fluorouracil and salicylic acid combination in the treatment of patients with anogenital warts: a randomized, open-label clinical trial

Anogenital warts are caused by human papillomavirus (HPV), over 30 types of which are infectious for the anogenital tract. Without treatment, warts may regress spontaneously, remain unchanged, or increase in number and size. This study compared the efficacy of a topical 5% potassium hydroxide (KOH) solution with that of a topical 0.5% 5-fluorouracil (5-FU) and 10% salicylic acid (SA) combination in the treatment of anogenital warts. Sixty patients were randomly assigned to receive topical KOH or 5-FU + SA. Both groups demonstrated a significant decrease in numbers of lesions (P < 0.05), but this difference was not significant at week 12 (P > 0.05). The mean number of lesions decreased from baseline to week 12 from 17.03 ± 12.64 to 3.73 ± 7.30 and from 16.13 ± 12.97 to 3.10 ± 4.90 in the KOH and 5-FU + SA groups, respectively (P < 0.001). Excellent clearance was achieved by 70.0 and 76.7% of patients in the KOH and 5-FU + SA groups, respectively. Marked improvement was seen in 13.3 and 20.0% of patients in the KOH and 5-FU + SA groups, respectively. At week 16, relapse was observed in two patients in the KOH group and three in the 5-FU + SA group (P > 0.05). No serious adverse events were reported. Neither treatment was more efficacious. Safety and ease of application are important goals in treatments for anogenital warts. A 5% KOH solution is a promising alternative treatment because it is effective and inexpensive and causes minimal side effects.

A randomized trial of efficacy of beta-sitosterol and its glucoside as adjuvant to cryotherapy in the treatment of anogenital warts

INTRODUCTION

All available treatments for anogenital warts have substantial failure rates. An immunomodulating treatment that enhances the patient's own immunity could be valuable as an adjuvant to conventional methods.

METHODS

About 123 patients were enrolled in this study and were randomized either to undergo only cryotherapy every 3 weeks (n = 60 patients) or to undergo cryotherapy and to receive a mixture containing 20 mg sterol and 0.2 mg sterolin (BSS-BSSG mixture), known for its immunomodulating properties (n = 63).

RESULTS

A complete response after 3 months was demonstrated by 18.3% of the patients in the first group and 30.2% of the second group, while 61.7% of the first group and 79.4% of the second group were lesion free at the end of the 6-month follow-up period. Cox regression analysis of the time until response showed a significant advantage to the mixture treatment group (hazard ratio 2.76, 95% confidence interval 1.61-5.67).

LIMITATIONS

The study was not placebo controlled.

CONCLUSION

The BSS-BSSG mixture gave promising results as an adjuvant to cryotherapy and may be used in patients with refractory warts.

Treatment of HPV with hypnosis--psychodynamic considerations of psychoneuroimmunology: a brief communication

There is increasing evidence that the hypnotic cure of warts (infection by the human papilloma virus or HPV) results from activation of an immune response, but whether this is cellular or systemic is unknown. The hypnosis can be by direct suggestion or analytical hypnotherapy when indicated. The evidence is reviewed, and 4 clinical cases suggesting cellular immune response are presented.

[New surgical approaches for the treatment of anogenital HPV infections]

HPV infections in the anogenital region may have very heterogeneous clinical features. Most often typical papillomatous condylomata acuminata are observed that usually present no differential diagnostic difficulty. In contrast, the clinical findings of higher grade intraepithelial dysplasias with flat papules and erythematous/ eczematous lesions are often quite inconspicuous and hardly characteristic. The goal of therapy is to prevent further progression to carcinoma, removal of bothersome tumors and avoidance of complications. Surgical methods are preferentially employed for extensive lesions, unfavorable locations and higher grade dysplasia. Options include removal with scissors or scalpel, laser therapy and electrocautery. For purely intraepithelial alterations, superficial ablative techniques are usually preferable over excision. Further developments such as argon plasma coagulation reduce the risk of unwanted deep thermal destruction with the accompanying complications. The risks for the surgeon and the surgical team during treatment should also not be neglected. With consideration of all relevant aspects, the combination of different methods may reduce the risk of complications and frequency of recurrences. Due to the high recurrence rate independent of the selected therapy, consistent follow-up after primary therapy is crucial for the long-term success.

Immunostimulation to reduce recurrence after surgery for anal condyloma acuminata: a prospective randomized controlled trial

AIM

Human papillomavirus is the most common cause of sexually transmitted disease. It is associated with immunosuppression and shows a marked tendency to recur. We investigated a natural immunostimulant aimed to reduce recurrence.

METHOD

A randomized controlled study was carried out including 261 patients allocated to surgical excision alone (control group; n = 122) and surgical excision plus postoperative immunostimulation for 30 days with a natural product (STET; study group; n = 139). Patients with HIV positivity were excluded. All patients gave fully informed consent.

RESULTS

The patients were followed for 6 months after surgery. Recurrence occurred in 7.2% (10/139) in the study group and in 27.1% (33/122) in the control group (P < 0.0001). There were no significant differences in the sex, sexual orientation, number of lesions, time to diagnosis and treatment or localization of lesions in the two groups.

CONCLUSIONS

Immunostimulation using a natural product significantly reduced the incidence of recurrence of anal condylomata in patients undergoing surgical excision.

Efficacy of hypnosis in the treatment of human papillomavirus (HPV) in women: rural and urban samples

This article investigates the effect of hypnosis on immunity and whether this is the key mechanism in the hypnotic treatment of the genital infection caused by human papillomavirus (HPV). HPV is the most common sexually transmitted disease and can lead to cervical and other cancers. Current medical treatments are aimed at tissue assault (acids, freezing, surgery). Medical wart clearance rates are only 30% to 70% and recurrence is common. Our research contrasted hypnosis-only with medical-only therapies, using both urban hospital and rural community samples. Both hypnosis and medical therapy resulted in a statistically significant (p < .04) reduction in areas and numbers of lesions. Yet, at the 12-week follow-up, complete clearance rates were 5 to 1 in favor of hypnosis.

Ultrasonic technology: a new treatment option for anal condylomata acuminata

PURPOSE

Treatment options for anal and perianal warts caused by human papillomavirus include topical application of cytotoxic substances or immunomodulators and ablative procedures. The objective of this prospective study was the evaluation of the ultrasound-driven Harmonic Scalpel (Ethicon Endo-Surgery, Norderstedt, Germany) for resection of anal and perianal condylomata acuminata.

METHODS

Eight men and three women (age range, 26-72 years) with anal and perianal condylomata acuminata were treated by a Harmonic Scalpel blade operating at a vibration frequency of 55.5 kHz and within a temperature range of 65 degrees C to 120 degrees C. Nine patients were treatment naïve, and two patients had recurrent disease. Follow-up ranged from 4 to 26 months.

RESULTS

Seven patients had perianal condylomata, two patients had exclusively intra-anal, and two patients had perianal and intra-anal warts. All condylomata were excised in a single-step procedure with complete clearing without injury of subepidermal layers. We observed no intraoperative or postoperative complications. No recurrences occurred during follow-up.

CONCLUSIONS

The Harmonic Scalpel has been an effective and safe method for the treatment of anal perianal human papillomavirus condylomata without recurrent warts. Subepidermal skin levels remained uninjured; thus, no complications or unsatisfactory cosmesis occurred.

Local And Systemic Human Papillomavirus Type 6b-Specific Cellular Immune Responses in Patients with Recurrent Genital Warts

Anogenital warts are a common clinical manifestation of genital infection with human papillomavirus type 6b (HPV-6b). Accumulating data indicate that an effective cellular immune response is required for the control of HPV infections. However, in a minority of patients there is a high rate of recurrence of wart lesions. We report the characterization of both local and systemic HPV-specific cellular immune responses in three patients with a history of recurrent genital warts. Although the patients had chronic recurrent wart lesions, we have shown that each had both detectable intralesional and peripheral HPV-specific T lymphocytes. Interestingly, the lesion-infiltrating T cells were specific for only one HPV antigen, focusing on only a few epitopes. Conversely, the T cells derived from peripheral blood recognized a broader range of HPV antigens. The characteristics of the HPV-specific cellular immunity that we have shown in these patients may be indicative of a failure to mount an effective response against the virus. This would be consistent with the chronic nature of the disease in these specific individuals. These observations could be relevant to the design and immunomonitoring of immunotherapeutic vaccines for persistent HPV infections.

Long-term follow-up of endoscopic therapy of anal canal condylomata acuminata with podophyllotoxin

BACKGROUND

Condylomata acuminata of the anal canal, a common sexually transmitted disease, are difficult-to-treat lesions with a high recurrence rate after initial successful treatment.

OBJECTIVE

Our aim was to evaluate by anoscopy the efficacy of podophyllotoxin 0.5% solution topically applied for the treatment of anal warts.

METHODS

We prospectively studied consecutive patients with condylomata acuminata of the anal canal that spared the rectum. They were treated with 0.5% podophyllotoxin solution topically applied on the warts, by anoscopy. Podophyllotoxin solution was administered on days 1, 2 and 3 every week (a treatment cycle) for a maximum of 4 weeks. Patients whose warts were not completely eradicated were classified as failures. Follow-up anoscopy was performed monthly for the first 6 months and every 6 months thereafter. Those who relapsed during the follow-up period were retreated.

RESULTS

Twenty-two immunocompetent patients entered the study. The primary clearance rate was 22.7, 54.5, 68.1 and 86.3% after 1, 2, 3 and 4 treatment cycles, respectively. During the follow-up period (46, 12-60 months), seven patients (36.8%) relapsed. Four of them were successfully retreated. Thus, a complete cure was achieved in 16 out of 22 patients (72.7%). Adverse side-effects were mild. They included proctalgia in six (27.2%), bleeding in four (17.2%), and both proctalgia and bleeding in two (9%) patients.

CONCLUSIONS

Endoscopic topical application of 0.5% podophyllotoxin solution is an effective and well-tolerated method for the treatment of condylomata acuminata of the anal canal.

An armamentarium of wart treatments

Patients and clinicians experience the frustration of cutaneous viral warts caused by infection with the human papilloma virus (HPV).Warts appear in various forms on different sites of the body and include common warts (verruca vulgaris), plane or flat warts, myrmecia, plantar warts, coalesced mosaic warts, filiform warts, periungual warts, anogenital warts (venereal or condyloma acuminata), oral warts and respiratory papillomas. Cervical infection with HPV is now known to cause cervical cancer if untreated. A review of the medical literature reveals a huge armamentarium of wart monotherapies and combination therapies. Official evidence-based guidelines exist for the treatment of warts, but very few of the reported treatments have been tested by rigorous blinded, randomized controlled trials.Therefore, official recommendations do not often include treatments with reportedly high success rates, but they should not be ignored when considering treatment options. It is the purpose of this review to provide a comprehensive overview of the wart treatment literature to expand awareness of the options available to practitioners faced with patients presenting with problematic warts.

Cancer risk among patients with condylomata acuminata

Condylomata acuminata have been shown to increase the risk of anogenital cancers. However, previous studies have been of limited sample size and/or short follow-up duration, which prevent precise estimates of long-term excess risk, especially for specific cancer sites. We estimated the risk of specific cancers in a large cohort of hospitalized patients with condylomata acuminata, as recorded in the Swedish Inpatient Register between 1965 and 1999. Altogether, 10,971 patients (1,685 men and 9,286 women) were followed through 1999 for a median of 13 years. The standardized incidence ratio (SIR)--the ratio of the observed number of cancers to the number expected on the basis of the incidence in the Swedish population at large--was used as a measure of relative risk. After excluding the first-year of follow-up, we observed 43 cases of anogenital cancer in women, and 7 cases in men. Risks were elevated for cancers of the vulva (N = 13, SIR = 10.2, 95% confidence interval (CI) = 5.4-17.4), vagina (N = 4, SIR = 12.0, 95% CI = 3.3-30.7) and penis (N = 5, SIR = 21.9, 95% CI = 7.1-51.2). There was a moderate excess risk of cervical cancer in situ (N = 259, SIR = 1.9, 95% CI = 1.7-2.1), but not invasive cervical cancer. Excess risks of esophageal, buccal cavity, nonmelanoma skin, lung and bladder cancers, and Hodgkin and non-Hodgkin lymphoma, were also observed in both men and women. In conclusion, condylomata acuminata are strongly associated with increased risk of cancers of the vulva, vagina, penis and anus, as well as some nonanogenital malignancies, but not invasive cervical cancer.

Oral and local anesthesia in the nonsurgical radiofrequency-energy treatment of stress urinary incontinence

STUDY OBJECTIVE

To demonstrate the feasibility, safety, and patient comfort associated with nonsurgical radiofrequency-energy (RF) tissue micro-remodeling in women with stress urinary incontinence (SUI) given oral and local anesthesia.

DESIGN

Prospective, open-label pilot clinical trial (Canadian Task Force classification II-2).

SETTING

Department of urology in a major academic teaching hospital in Mexico City, Mexico.

PATIENTS

Sixteen women with SUI and hypermobility (based on history and physical examination) with no history of previous definitive incontinence therapy.

INTERVENTIONS

Nonsurgical, transurethral, outpatient RF tissue micro-remodeling with women given oral plus local anesthesia.

MEASUREMENTS AND MAIN RESULTS

The women had a mean age of 49.7 years (range 30-76 years) and a mean duration of incontinence of 7.6 years (range 1-30 years). The nonsurgical RF micro-remodeling treatment, which was previously demonstrated to be of significant benefit when administered under intravenous (IV) sedation in an outpatient surgicenter setting, was successfully completed in all 16 women. Either the treating physician or the patient had the option to convert to IV sedation during the procedure if there was too much discomfort; however, this did not occur in any of the 16 patients. Thus neither the treating physician nor any patient determined that conversion to IV conscious sedation was required for treatment completion. The first six patients received an oral sedative and oral analgesic as well as a local periurethral anesthetic block with 10 mL of 2% lidocaine. The final 10 patients (63%) received only one oral sedative or analgesic and a total of 10mL lidocaine local anesthetic. Two women who received the maximum oral regimen (both oral sedation and analgesics) experienced nausea and emesis when drinking immediately after treatment, and one of these women also experienced urinary retention, which resolved after 24 hours of catheterization. Immediately before discharge, subjects classified their pain on a scale from zero ("no pain") to 10 ("terrible pain"). Mean score was 1.8, and 38% of subjects selected "zero."

CONCLUSION

This pilot trial demonstrated the feasibility, safety, and patient comfort associated with performing a novel new successful technique of nonsurgical RF of the urethra for treatment of SUI, which was previously studied under IV sedation in an outpatient surgery center, on women in an office-based setting using oral plus local anesthesia.

HPV infection in adolescents: natural history, complications, and indicators for viral typing

Human papillomavirus (HPV) is the most common sexually transmitted disease in both men and women. Prevalence rates are the highest for adolescents. Despite the high prevalence rates, sequelae of genital warts, dysplasia, and cancer are rare developments. Knowledge about the natural history, virology, and cancerous transformation has lead to improved viral detection, including the use of HPV DNA detection tests, screening efforts for HPV-related precancerous and cancerous lesions, and clinical interventions and treatments, including both therapeutic and prophylactic vaccinations.

Genital infection with human papillomavirus in adolescents

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections in adolescents. Such infection is associated with substantial health risks and is unpredictable in its resolution. Genital warts are the most common clinical manifestations of genital HPV infections. Most genital warts are caused by low risk HPV types (notably HPV-6 and -11). The majority of genital HPV infections are latent or subclinical. Although the outcome of a genital HPV infection is variable, the infection is usually transient and complete resolution is common. However, persistent infections with high-risk HPV types (notably HPV-16 and -18) are associated with the development of cervical intraepithelial dysplasia (CIN), which may progress to cervical cancer. Genital warts, generally diagnosed in the clinic, can be treated with imiquimod, podofilox, podophyllin, liquid nitrogen, bichloroacetic or trichloroacetic acid, or surgery. Cervical cytology screening is an ideal screening test for subclinical HPV infection with resultant CIN. Annual cervical cytology screening should begin approximately 3 years after initiation of sexual intercourse but no later than age 21 years. Because of the high rate of regression of low-grade squamous intraepithelial lesions (LSIL) in adolescents, the cytologic study should be repeated within 6 to 12 months. Colposcopy should be reserved for persistent LSIL. Patients with high-grade squamous intraepithelial lesions (HSIL) should be referred for colposcopy and biopsy. Confirmed HSIL should be treated with cryotherapy, laser therapy, or loop electrosurgical excisional procedure. The use of therapeutic vaccines is still experimental. HPV infection can be prevented, to a certain extent, by delaying the initiation of sexual activity, limiting the number of sexual partners, and using latex condoms. Several viruslike particle candidate vaccines are under development for the prevention of HPV. These vaccines have been proven safe, well tolerated, highly immunogenic, and highly efficacious. Such vaccines are urgently needed and ultimately may be an important preventive measure.

Kontrollierte schichtweise Abtragung anogenitaler Warzen mittels Argon-Plasma-Koagulation. Controlled layered removal of anogenital warts by argon-plasma coagulation

BACKGROUND

According to guidelines of the German STD Association, appropriate treatment of extensive anogenital warts with comparable recurrence rates includes cryotherapy, surgical excision, electrosurgery, CO2- and Nd:YAG-laser vaporisation. All these procedures are associated with varying degrees of risk for bleeding, release of potentially infectious aerosol, deep thermal destruction, slow wound healing, and scarring.

METHODS

Using argon-plasma coagulation anogenital warts can be removed in layers in a controlled manner. High frequency current flows through the argon plasma to the tissue, allowing well-controlled, superficial tissue destruction.

RESULTS

From January 2001 to March 2003, 54 patients with extensive genital, anal or anogenital warts were treated. After one treatment, 66% of the pa- tients remained disease-free in the following 4 months. Thirteen patients (24%) showed early recurrence after 4 weeks, five patients (9%) at a later date. In these patients, further treatment, in 9 cases combined with topical imiquimod cream, were necessary for complete remission.

CONCLUSION

Compared to other therapeutic procedures, argon-plasma coagulation is a better controlled, quick and low-risk option for the treatment of anogenital warts. Depending on the type of involvement and individual risk factors, postoperative treatment with topical imiquimod cream may be useful.