Position statement for the diagnosis and management of anogenital warts

Comparison of topical potassium hydroxide 5% solution with cryotherapy in the treatment of patients with genital warts: A randomized controlled clinical trial

BACKGROUND

Given the therapeutic challenge of wart treatment and the need for an ideal treatment that is effective, noninvasive, cost-effective, and has minimal side effects, this study aims to compare the local impact of a 5% potassium hydroxide (KOH) solution with cryotherapy, the current standard treatment for genital warts.

METHODS

Two groups, each consisting of 49 patients: the first group was treated with a daily topical application of 5% KOH solution using a swab, while the second group underwent cryotherapy in two 5-20 s freeze-thaw cycles. Before treatment, patient demographic data and number of lesions were recorded. Follow-up visits were conducted at four-week intervals for 12 weeks, during which the number of lesions, time to complete recovery, and skin-related side effects were examined and recorded, ensuring comprehensive data collection.

RESULTS

A total of 98 patients (average age: 28.40 ± 7.34 years), 55 cases (55.1%) being female and 43 cases (43.9%) being male. Importantly, there was no significant difference in terms of gender (p = .684), education (p = .533), and marital status (p = .703) between the two study groups. Further, no significant difference in previous infection history (p = .493) and partner infection (p = .098) was identified. There was no significant difference in terms of treatment response (p = .510) and relapse (p < .999) between the two KOH and cryotherapy study groups.

CONCLUSION

The study found no significant differences in treatment response, relapse rates, or side effects between using 5% potassium hydroxide solution and cryotherapy for genital wart treatment. These findings suggest that both modalities offer comparable efficacy and safety profiles, providing clinicians with valuable options in tailoring treatment approaches for patients with genital warts.

Human Papilloma Virus Infection in Men: A Specific Human Virome or a Specific Pathology?

BACKGROUND

Human papillomavirus (HPV) infections in men remain under-researched despite their critical role in disease transmission and the increasing incidence of HPV-related cancers. This study investigates the clinical and molecular characteristics of anogenital HPV infections in men, emphasizing genotype prevalence, diagnostic methods, and lesion variability.

METHODS

A cross-sectional study was conducted on 70 men aged 18-65 years with clinically diagnosed anogenital HPV infection. Lesions were characterized by morphology and location. HPV DNA was analyzed using INNO-LiPA (INNOvative Line Probe Assay), Hybrid Capture II (HC II), and polymerase chain reaction (PCR) assays to determine genotype distribution. Associations between clinical features and HPV genotypes were assessed using multivariate statistical analyses.

RESULTS

Lesions varied in morphology, with verrucous (52.86%) and papular (30%) types being the most common. Localization patterns showed predominance on the penis radix (34.29%) and shaft (27.14%). Molecular testing revealed HPV DNA in 88.57% of the cases using INNO-LiPA, compared to 45% and 40% with HC II and PCR, respectively. Low-risk (LR) genotypes, particularly HPV6, dominated single infections, comprising 68.57% of the cases, while high-risk (HR) genotypes accounted for 20%. Mixed LR and HR infections were observed in 14.29% of the lesions, with greater diversity noted in distal genital regions. Notably, condyloma plana and lesions on the inner prepuce exhibited a higher prevalence of HR and mixed infections. Age and lesion duration showed trends toward older patients and longer disease duration in cases involving perianal and extragenital condylomas, though these findings were not statistically significant. No direct correlation between lesion type or localization and specific genotypes was identified, underscoring the heterogeneity of HPV clinical manifestations in men.

CONCLUSIONS

Anogenital HPV infections in men exhibit significant heterogeneity in lesion morphology, localization, and genotype distribution. HR HPV genotypes were detected in a notable proportion of benign lesions, underscoring their potential role in disease progression. INNO-LiPA proved superior in diagnostic accuracy, highlighting the need for standardized and cost-effective diagnostic approaches for men. Further research is crucial to elucidate HPV's clinical impact in men and inform prevention and treatment strategies.

A Fentanyl Hapten-Displaying Lipid Nanoparticle Vaccine that Non-Covalently Encapsulates a TLR7/8 Agonist and T-Helper Epitope Induces Protective Anti-Fentanyl Immunity

Opioid use disorder - particularly involving fentanyl - has precipitated a public health crisis characterized by a significant increase in addiction and overdose-related deaths. Fentanyl-specific immunotherapy, which aims at inducing fentanyl-specific antibodies capable of binding fentanyl molecules in the bloodstream, preventing their entry in the central nervous system, is therefore gaining momentum. Conventional opioid designs rely on the covalent conjugation of fentanyl analogues to immunogenic carrier proteins that hold the inherent capacity of mounting immunodominant responses. Here, we present an alternative fentanyl vaccine design that utilizes a non-covalent assembly of lipid nanoparticles (LNPs) to deliver fentanyl haptens in conjunction with a CD4+ T-helper peptide epitope and an imidazoquinoline TLR7/8 agonist. Our results demonstrate that a single intramuscular administration of the LNP-based nanovaccine elicits fentanyl-specific antibodies, significantly mitigating the effects of opioid overdose in preclinical mouse models. Furthermore, we analyzed the immunobiological behavior of the vaccine in vivo in mouse models, providing evidence that covalent attachment of a fentanyl hapten to a carrier proteins or peptide epitope is not necessary for inducing an effective immune response. However, co-delivery - specifically, the physical assembly of all immune cues into an LNP - remains essential for inducing hapten-specific immunity.

Human papillomavirus-associated cancers, precancers, and genital warts in Denmark, 2000-2022 - Current burden of disease and population impact of multi-cohort HPV vaccination

OBJECTIVES

We present incidence trends of cancer and precancer at human papillomavirus(HPV)-associated sites, and genital warts, including the current burden of HPV-associated disease in Denmark, a country with multi-cohort HPV vaccination.

METHOD

Cases were identified from high-quality nationwide registries (2000-2022). The age-specific incidence rate, age-standardized incidence rate (ASR) and estimated annual percentage change (EAPC) were calculated according to sex and calendar year. The current burden (2020-2022) of HPV-associated disease was estimated as the average annual number of each lesion multiplied by the disease-specific HPV-attributable fraction.

RESULTS

ASRs of cervical precancer and genital warts declined markedly in the post-HPV vaccination period - for genital warts corresponding to an EAPC of -13.7 % (-15.0;-12.4)(women) and -8.8 % (-9.4;-8.2)(men), respectively. ASRs of HPV-associated cancer sites increased continuously in men (EAPC: 2.8 % (2.2;3.5)), and the same was observed for non-cervical HPV-associated cancer sites in women (EAPC: 2.5 % (2.0;3.0)). Cervical cancer, however, decreased in the post-HPV vaccination period (EAPC: -2.7 % (-3.8;-1.5)). Age-specific incidence rates of HPV-associated cancer sites decreased slightly in younger women and were stable in younger men, while incidence rates in older men approached or even surpassed that of older women. Data on the current burden showed that cervical precancer and genital warts are still the major contributors to HPV-associated disease, and oropharyngeal cancer now accounts for more annual cases on a population level than cervical cancer.

CONCLUSION

Danish data show decreased incidence of cervical lesions and genital warts in the post-vaccine era. Despite population impact of HPV vaccination, HPV-associated disease remains a public health issue and increasingly among men.

Surgical treatment of perineal giant condylomata acuminata (Buschke Lowenstein tumor): Case series from a developing country

INTRODUCTION

Giant condylomata acuminatum (GCA) also referred to as Buschke-Lowenstein tumor (BLT) is a rare tumor primarily associated with low-risk HPV 6 and 11, which is believed to be a slow growing intermediate tumor with low potential to transform into invasive cancer.

CASE PRESENTATION

We presented our experience with three cases of BLT (one woman and two men).

CLINICAL DISCUSSION

The three patients had surgical excision and two of them had reconstruction of the surgical defect with good clinical outcome.

CONCLUSION

We highlighted the importance of early identification of symptoms, treatment options and risk of recurrence as well as primary preventive strategies.

Case Report: Concomitant presence of two STIs in a male patient

Background

The spirochaete Treponema pallidum subsp. pallidum, which causes the infectious disease syphilis, can be spread through sexual contact or perinatal transmission. In recent years, cases of syphilis have increased, especially among individuals engaging in behaviour that makes them more vulnerable (condomless sex and multiple sexual partners). Condylomata acuminata (external genital warts) is one of the most common viral sexually transmitted infections (STIs). Individuals who are behaviourally vulnerable are also highly prone to two or more STIs. Our case exemplifies the occurrence of two STIs in a young man who was behaviourally vulnerable to acquiring STIs.

Case

We report a case of a 21-year-old year old heterosexual man presenting with concomitant primary syphilis and genital warts. He presented with a painless genital ulcer and warty growths on his glans penis. Examination showed a painless indurated ulcer and multiple genital warts. Serology was positive for quantitative Venereal disease research laboratory test (1:16 titre). The patient was diagnosed with two concomitant STIs. He was treated as per the latest Centers for Disease Control and Prevention (CDC) guidelines for primary syphilis and podophyllin resin for genital warts. After four weeks, the genital ulcer showed complete healing and there was a significant reduction of genital warts.

Conclusions

Individuals with multiple sexual partners engaging in sexual activity without the use of prevention tools are at a greater chance of acquiring two or more STIs. To reduce concomitant transmission, preventive measures against genital ulcer diseases like syphilis, herpes, and chancroid, such as early identification and treatment, and condom distribution, must be strengthened as part of national STI prevention. Patients with two or more STIs should be followed regularly to assess the progress of infection and should be offered timely medical treatment.

Study on the detection rate, genetic polymorphism, viral load, persistent infection capacity, and pathogenicity of human papillomavirus type 81

Human papillomavirus (HPV) type 81 has recently become one of the most common low-risk HPV types; however, literature focusing on it is limited. This study aimed to analyze the reasons for the increased detection rate of HPV81 and investigate its evolving pathogenicity. We analyzed the detection rates and trends of HPV81 in 229 061 exfoliated cervical cell samples collected from 2014 to 2023; collected samples of HPV81 single infections from two different time periods; and analyzed the allele frequencies, positive selection, viral load, persistent infection capacity, and pathogenicity of E6 and E7 genotypes. We found that the detection rate of HPV81 ranked first among the low-risk types in exfoliated cervical cells and exhibited a significantly increasing trend (p < 0.001). The frequency of the E6 prototype allele of HPV81 (n = 317) was significantly increased (p = 0.018) and demonstrated the strongest adaptive capacity. The viral load and persistent infection capacity of the E6 prototype were significantly higher than those of the mutants, thus serving as key drivers for increasing the detection rate of HPV81 and enhancing its pathogenicity. The viral load was positively correlated with persistent infection capacity and pathogenicity. Persistent infection was a crucial factor in the pathogenicity of HPV81. Successful adaptive evolution of HPV81 is accompanied by enhanced pathogenicity.

Combination of biopsy forceps excision and ALA-PDT for the treatment of cervical condylomata acuminata

BACKGROUND

Human papilloma virus (HPV) infection and cervical condyloma acuminatum (CA) often co-exist. Although there are many methods to treat cervical CA, high recurrence rate and cervical scars are still troublesome. Biopsy forceps excision combined with 5-aminolevulinic acid photodynamic therapy (ALA-PDT) is a feasible approach for cervical CA, but its efficacy and limitation need to be evaluated.

METHODS

This retrospective study consisted of 49 patients aged 18-50 years with a histologically or colposcopic confirmed cervical CA and with HPV infection. Patients were treated with biopsy forceps excision and ALA-PDT. The efficacy was evaluated through HPV typing and colposcopy directed biopsy.

RESULTS

Three months after the combination treatment the total lesion remission rate was 93.88 % (46/49) and the HPV clearance rate was 83.67 % (41/49). One patients showed some residual lesions and two patients showed new lesions. Recurrence rate was 4.34 % at 6 months follow-up. There was no significant difference in HPV clearance rate at 3 and 6 months follow-up. Univariate analysis showed that the combination treatment was less effective for patients who had size of visible lesion > 1.5 cm2. Adverse effects were minimal and no structural complications were reported. The main side effects were abdominal pain and increased vaginal secretions.

CONCLUSION

Combination of biopsy forceps excision and ALA-PDT is safe and effective for eliminating cervical condylomata lesion and eradicating HPV infection. Colposcopic evaluation is recommended before and after treatment.

Prevalence and Epidemiological Characteristics of Anogenital Warts Among Recently Diagnosed HIV-Positive Women on Antiretroviral Therapy in Lagos, Nigeria

Background Anogenital warts (AGWs) are a prevalent condition resulting from human papillomavirus (HPV) infection, which is the most frequently encountered sexually transmitted infection (STI) on a global scale. Women who are HIV-positive experience a disproportionately high burden of AGWs compared to other populations. It is imperative to comprehend the epidemiological factors linked to the disease within this particular at-risk population. Objectives The objective of the study was to ascertain the prevalence of AGWs and its demographic and socio-biological epidemiological features among recently diagnosed HIV-positive women (HPW) in Lagos, Nigeria. Materials and methods The research was a descriptive cross-sectional study conducted among a sample of 420 recently diagnosed HPW. The study was conducted at the HIV clinic of a tertiary health institution located in Lagos, Nigeria. The participants clinically diagnosed with AGWs were classified as the study group, while individuals without AGWs were classified as the comparison group. Interviewer-administered pretested questionnaires were utilized to gather pertinent demographic and socio-biological epidemiological data from the participants involved in the study. The data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, USA). Results The prevalence of AGWs among recently diagnosed HPW was found to be 8.5% (34/402). These warts were frequently observed on the vulvar labia (35.3%, 12/34), vaginal walls (14.7%, 5/34), and perianal region (14.7%, 5/34). It is worth noting that over a third of cases (35.3%, 12/34) involved multiple areas within the anogenital region. The diagnosis of AGWs was found to have significant associations with occupation (p=0.005), marital status (p<0.001), and educational status (p=0.028). The majority of HPW diagnosed with AGWs were unemployed (32.4%, 11/34), single (47.1%, 16/34), and did not have tertiary education (94.1%, 32/34). The utilization of oral contraceptive pills (OCPs), smoking, low CD4 count, and high viral load were the significant socio-biological factors associated with the diagnosis of AGWs (p<0.001, respectively). Conclusion The study found that the prevalence of AGW among HPW was 8.5% (34/402). Several epidemiological factors, including occupation, marital status, education, CD4 count, viral load, history of OCP use, and smoking, were found to be significantly associated with the diagnosis of AGW. There is a need to conduct more comprehensive studies to thoroughly assess the impact of these epidemiological factors.

Condyloma acuminatum recurrence can be reduced by lesional autotransplantation.. [DOI: 10.21203/rs.3.rs-3920846/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background Condyloma acuminatum (CA), also known as a genital wart (GW), is a sexually transmitted disease caused by human papillomavirus (HPV). HPV lesions, recurrence tendency, and risk of malignant formation are primarily dependent on the person’s immunity level. GW recurrence is a major challenge in CA treatment.The aim of this study was to explore how lesional autotransplantation (LT) can be used to treat coronary anemia and decrease its recurrence. Methods We treated CA through the preparation and implantation of tissue from nine CA patients in our dermatology clinic. Transplantation of small pieces of HPV lesions to the subcutaneous fat of the inguinal region was carried out with the help of a simple surgical method under local anesthesia. Patients were followed up for six to eight months. We searched PubMed and the Web of Science for treatment options for CA to compare our treatment method recurrence rate with existing treatment options. Results During three months of follow-up, seven patients experienced no recurrence of condyloma lesions, while two patients experienced recurrence of small lesions of condyloma acuminatum. The recurrence rate of CA once treated by autotransplantation was relatively low compared to that of other CA treatment options. Conclusions Transplantation of HPV lesions to the inguinal area reduces the recurrence rate in sexually active individuals. The 2/9 recurrence after implantation could be due to poor hygiene, sexual relationships or immune factors.

[Anogenital warts-An update]

With a prevalence of around 1% in the sexually active population anogenital warts are the most frequent human papillomavirus (HPV)-related disease. In the vast majority of cases the underlying cause of the infection is due to HPV types 6 and 11. The diagnosis can usually be clinically established but in certain cases a histopathological work-up can be useful. Buschke-Lowenstein tumors represent such a scenario. The current therapeutic armamentarium for anogenital warts ranges from surgical ablative procedures up to local immunomodulatory treatment. All procedures have different advantages and disadvantages and are relatively time-consuming and sometimes also unpleasant for the patient. Anogenital warts are also a possible expression of an incomplete immunological control of HPV. Therefore, it should be emphasized that for certain affected individuals, especially immunosuppressed patients, special attention should be given to ensuring that screening investigations for HPV-associated dysplasia is carried out according to the respective valid guidelines. The primary prophylaxis by vaccination of girls and boys prior to first HPV exposure represents a very effective option to drastically reduce the prevalence of anogenital warts and other HPV-related diseases.

Benign Colorectal Disorders

Benign conditions of the colon and rectum are a heterogeneous group of conditions that range from inflammatory to infectious to pelvic floor health conditions that affect large segments of the US population. These conditions include diverticular disease, hemorrhoids, and anorectal lesions. The initial presentation of these very common conditions often occurs in the outpatient primary care setting, and most can be managed by the primary care clinician. This article will provide an overview on the prevalence, diagnosis, and management of some of the most common benign colorectal disorders; these are broadly divided into diverticular disease, hemorrhoids, and anorectal conditions.

Topical proactive therapy in dermatology. A scoping review

The term 'proactive therapy' refers to a long-term management of clinically intact skin in previously disease-affected areas. This method was initially implemented in atopic dermatitis to maintain the remission and decrease the risk of exacerbations. Proactive therapy aims to limit the need for reactive treatment and improve the patients' quality of life. A proactive approach is likely to be adopted for other relapsing and inflammatory skin conditions in the future. This scoping review aims to identify dermatological conditions to be treated with the proactive approach, evaluate the available evidence for its efficacy and safety, as well as highlight the research gaps.

Condyloma acuminatum mimicking cervical cancer in a pregnant woman and treatment with cryotherapy: A case report

RATIONALE

Condyloma acuminata and anogenital warts are protruding papillomatous lesions caused by human papillomavirus. In pregnant women, condyloma acuminata over the cervical region may grow rapidly, mimicking cervical cancer.

PATIENT CONCERNS

A pregnant woman at 14 weeks of gestation with condyloma acuminatum mimicking cervical cancer was referred to our hospital for further management.

DIAGNOSIS

Condyloma acuminata.

INTERVENTIONS

Tumor biopsy was performed twice, and the pathology confirmed condyloma acuminatum. Immunohistochemistry revealed focal positivity for p16 and Ki-67. Cryotherapy was performed and regular follow-up was performed at 2-week intervals. A small residual condyloma acuminata was found and treated with cryotherapy.

OUTCOME

During the follow-up period, no recurrence of condyloma acuminata was noted. She delivered a baby at 37 weeks of gestation via cesarean section, without complications.

LESSONS

Condyloma acuminata of the cervix may grow faster during pregnancy, mimicking cervical cancer. Multiple factors must be considered when treating condyloma acuminata during pregnancy. Cryotherapy is proposed as a 1st-line treatment in all trimesters because of its safety, convenience, and cost-effectiveness. Serial follow-up at 2-week intervals to observe post-cryotherapy conditions is recommended.

Treatment of Condylomata Acuminata Using a New Non-Vapor-Generating Focused Ultrasound Method following Imiquimod 5% Cream

Condylomata acuminata is the most common sexually transmitted disease in the world. Physical treatments include excision, cryotherapy, electrocautery and ablative CO₂, and Nd:YAG laser ablation, while topical treatments include imiquimod immunotherapy and antimitotic podophyllotoxin or sinecatechins. Efficacies of all methods are low, and recurrences are very common. A new combined method is presented as a single case in a 25-year-old male patient diagnosed with numerous condylomas on the penis, scrotum, and lower abdomen. The treatment consisted of a 7-week topical monotherapy using 5% imiquimod cream followed by local treatment with 20 MHz high-intensity focused ultrasound on remaining recalcitrant lesions. Results showed resolution of approximately 70% of the condylomas after imiquimod treatment, and full resolution of all recalcitrant condylomas treated subsequently with high-intensity focused ultrasound. The method is concluded to be safe and effective and, furthermore, presents a new physical method that does not generate airborne infectious human papillomavirus particles that pose a health risk for the medical team performing therapy. Further studies in larger populations are recommended to confirm the combined efficacy of the proposed method.

Asian guidelines for condyloma acuminatum

The present guidelines aim to provide comprehensive information on genital condyloma acuminata, including the epidemiology, clinical features, diagnosis and management. The guidelines provide evidence-based recommendations on the diagnosis, prevention and treatment of genital condyloma acuminata in adults in Asia, including patients with HIV co-infection.

METHODOLOGY

A PubMed search was performed, using the keywords "condyloma acuminata", "anal wart", "anogenital wart", "genital wart" and "genital HPV". A total of 3031 results were found in publications during last six years. A careful review of the titles and abstracts was done to find all the studies pertaining to epidemiology, clinical features, diagnosis, treatment and prevention of condyloma acuminata.

DIAGNOSIS

Various diagnostic procedures described are: 1. PCR (LE: 2b). 2. Serology (LE: 2b). 3. In-situ hybridization (LE: 3).

PREVENTION

1. Vaccination (LE: 1a): Quadrivalent vaccine reduced the frequency of anogenital warts in both vaccinated and unvaccinated contacts. According to the update Advisory Committee on Immunization Practices (ACIP) recommendations, the following protocol is recommended: (a). HPV vaccination at age 11 or 12 years for both males and females. (b). Catch-up vaccination for all persons through age 26 years. (c). Shared clinical decision-making regarding potential HPV vaccination for persons aged 27-45 years, who are at risk of new HPV infection. 2. Male circumcision (LE: 2a): conflicting evidence.

HIV AND CONDYLOMA ACUMINATA

In HIV-affected individuals, the course of HPV is more aggressive, with a greater risk of treatment resistance, increased chances of intraepithelial neoplasia as well as cancers.

TREATMENT

Physician administered. 1. Photodynamic therapy (LE: 1a). 2. Laser (LE: 2b). 3. Surgery (LE: 1a). 4. Electrosurgery (LE: 2c). 5. Cryotherapy (LE: 1b). 6. Immunotherapy (LE: 1b). 7. Podophyllin (LE: 1b). Provider administered. 1. Imiquimod 5%(LE: 1a). 2. Podophyllotoxin (LE: 1b). 3. Sinecatechins (LE: 1a). 4. Cidofovir (LE: 3). 5. 5- Fluorouracil (LE: 1a). 6. Interferon (LE: 1a).

Successful Treatment of Condyloma Acuminata Using Office-Made Topical 60% Betel Leaf Extract

BACKGROUND: Condyloma acuminata (CA), also known as anogenital warts, is a predominantly sexually transmitted disease caused by the Human Papillomavirus (HPV). The most common strains of HPV that causes anogenital warts are Type 6 and 11. This vdisease affects the mucous membrane as well as skin of the external genitalia and perianal areas. There are several therapeutic modalities for CA such as destructive and surgical therapies; however, these therapies can pose side-effects mostly tissue destruction. Alternative modalities such as using betel leaf can be atreatment option for CA. CASE REPORT: In this paper, we report a 31-year-old female with CA who experienced clinical improvement after 3 weeks of office-made 60% topical betel leaf extract therapy, prompting more thorough research on the possible use of herbal treatments for treating CA. CONCLUSION: Office-made betel leaf extract therapy is a promising topical therapy for CA and is relatively simple to prepare. The plant has various mechanisms such as anti-proliferative and cytotoxic properties that can be studied further to prove its efficacy in the treatment of CA to prevent adverse events caused by other conventional destructive treatment modalities.

A comparative study of intralesional bleomycin versus cryotherapy in the treatment of condyloma accuminata

Bleomycin is an antineoplastic agent, which is used off label for various dermatologic conditions. There are numerous reports on the use of intralesional bleomycin (ILB) for the treatment of common warts. However, reports on the efficacy of bleomycin in the treatment of anogenital warts (AGWs) are still limited. The aim is to compare the efficacy/tolerability and recurrence rates of AGW treatment with ILB versus cryotherapy. In this prospective study, 50 patients with AGWs were assigned either to receive triple freeze-thaw cycle of cryotherapy or to receive 1.5 mg/mL ILB for a maximum of four sessions with 3-week intervals. Clinical efficacy was determined by the percentage of the patients with complete clearance. The patients with complete clearance were visited by passing 3 months from the last treatment session to evaluate any recurrence. Of 44 patients completing the study, 16 of 21 (76.19%) patients in the ILB group and 15 of 23 (65.22%) patients in the cryotherapy group showed complete resolution (p value = .425). Moreover, recurrence occurred after 3 months in 18.75% and 46.66% of the ILB and the cryotherapy groups' patients, respectively (p value = .096). The most common local adverse events in both treatment groups were pain, dyspigmentation, and ulceration/erosion, while the delayed ulceration and secondary infection were only observed in the bleomycin group. Intralesional bleomycin is as effective as cryotherapy in the treatment of AGWs, but it is more invasive and associated with post-treatment pain, the delayed ulceration, and cutaneous infection. Intralesional bleomycin is not accompanied with the major risk of necrosis or fibrosis, so the use of ILB in the anogenital area is likely to be safe.This clinical trial was registered in Iranian Registry of Clinical Trials site with code: IRCT20190519043631N1.

Topical medication as an initial therapeutic option for protruding and non-protruding condylomata acuminata of the distal urethra

Genital warts (also known as condylomata acuminata) caused by the human papillomavirus (HPV) represent one of the most common sexually transmitted infections. Although they are usually found in the outer genital region, a small proportion of men can present with (often unrecognised) intraurethral warts, generally limited to the distal urethra and urethral meatus. This poses a treatment challenge not adequately addressed by the current guidelines. Here, we present two cases of low-risk HPV-positive patients with protruding and non-protruding condylomata acuminata of the distal urethra, which were treated successfully by using two different topical regimens (ie, a combination of policresulen and imiquimod for one patient and 5-fluorouracil monotherapy for the other). Although this type of management results in lower rates of tissue destruction and complications and may be given preference as an initial therapeutic option, additional prospective comparative clinical studies are needed to elucidate its potential in similar cases.

Preclinical study of a novel therapeutic vaccine for recurrent respiratory papillomatosis

Activation of antigen-specific T-lymphocyte responses may be needed to cure disorders caused by chronic infection with low-risk human papillomavirus (lrHPV). Safe and effective adjuvant therapies for such disorders are needed. The safety and efficacy of a novel gorilla adenovirus vaccine expressing a protein designed to elicit immune responses directed against HPV6 and HPV11, PRGN-2012, was studied using in vitro stimulation of T lymphocytes from patients with recurrent respiratory papillomatosis, in vivo vaccination studies, and therapeutic studies in mice bearing tumors expressing lrHPV antigen. PRGN-2012 treatment induces lrHPV antigen-specific responses in patient T lymphocytes. Vaccination of wild-type mice induces E6-specific T-lymphocyte responses without toxicity. In vivo therapeutic vaccination of mice bearing established HPV6 E6 expressing tumors results in HPV6 E6-specific CD8+ T-lymphocyte immunity of sufficient magnitude to induce tumor growth delay. The clinical study of PRGN-2012 in patients with disorders caused by chronic infection with lrHPV is warranted.

What Proportion of the Spanish Dermatology Caseload Corresponds to Primarily Sexually Transmitted Infections and Other Anogenital Dermatoses? Results From the DIADERM National Random Survey

BACKGROUND AND OBJECTIVE

Predominantly sexually transmitted infections (PSTIs) and infestations and other anogenital dermatoses are covered in the training of specialists in dermatology and venereology in Spain. This study aimed to analyze the proportion of the dermatology caseload these diseases account for within the Spanish national health service and private practices.

MATERIAL AND METHODS

Observational cross-sectional study of 2 periods. We described the diagnoses made in outpatient dermatology clinics obtained through the anonymous DIADERM survey of a representative random sample of dermatologists. Codes of the International Classification of Diseases, Tenth Revision, were used to select all 36 relevant diagnoses in the 2 periods. The diagnoses were classified into 12 groups.

RESULTS

Only 3.16% of diagnoses corresponded to PSTIs and other anogenital dermatoses. The most common diagnostic group was anogenital human papillomavirus infection, followed by molluscum contagiosum infestation, and inflammatory anogenital dermatoses. Lesions with these diagnoses were usually the main reasons for first visits in the national health service. In private practice, the diagnoses usually came after referrals from other physicians.

CONCLUSIONS

PSTIs and other anogenital dermatoses account for a very small proportion of the dermatology caseload in Spain, even considering that diagnoses of molluscum contagiosum inflate the overall estimate of such conditions. The failure to include centers specializing in PSTIs in the DIADERM random sample of dermatologists partly explains the survey's underestimation of these diseases in the specialty. A clear effort to promote use of specialized clinics should be made.

The effect of anxiety, psychopathological symptoms and personality traits on response to treatment in male patients with anogenital warts: a prospective study

BACKGROUND

In the era of precision medicine, identification of possible predictive factors of clinical response to treatment is fundamental. This need is particularly strong for anogenital warts (AGW), because there are several treatment modalities with different clearance and recurrence rates. However, data regarding the effect of mental health parameters on response to treatment in patients with AGW are lacking.

OBJECTIVES

The purpose of the present study was to evaluate the association between patients' mental health parameters and AGW treatment outcomes.

METHODS

This was a single-centre, prospective study that included newly diagnosed male patients with AGW. At their initial visit, all patients completed the State-Trait Anxiety Inventory (STAI), the Symptom Checklist-90-Revised (SCL-90-R) and the Eysenck Personality Questionnaire (EPQ) questionnaires, which evaluate anxiety, psychopathological manifestations and personality traits, respectively. All patients received cryotherapy until clearance of lesions and were followed up for 18 months for detection of recurrences.

RESULTS

The study included 167 male patients. The mean number of days for AGW clearance was 89 ± 65. During the 18-month follow-up, 28% of participants showed a recurrence, after a mean number of 150 ± 132 days. No statistically significant association was detected between questionnaires scores and (a) time needed for AGW clearance, (b) time until 1st recurrence and (c) number of recurrences.

CONCLUSION

If confirmed, our findings indicate that we may not need to modify our AGW treatment plan according to a patient's mental health profile.

Correlation of the ALA-PDT Treatment Efficacy and the HPV Genotype Profile of Genital Warts after Cryotherapy Failure and Podophyllotoxin Therapy in Male Patients

Background: Genital warts are the manifestation of the human papillomavirus (HPV) infection, which may last for weeks or months before the clinical presentation. The primary aim of the study was the correlation of the DNA HPV genotypes eradication with the treatment response in male patients with persistent genital warts. Methods: Twenty-one male patients (age range: 22–58) after failure of cryotherapy and podophyllotoxin treatment were enrolled in the study. Genetic tests (Real Time - PCR method) analyzed the presence of DNA-HPV before and 6 months after four sessions (4 weeks apart) of photodynamic therapy with 5-aminolaevulinic acid (ALA-PDT). The treatment efficacy was evaluated before each PDT session and at the end of the study. Results: The single HPV DNA type was present in 15/21 of the patients (13/15 HPV6). The high-risk HPV types were found in 8/21 subjects, of which 6/8 had several types. Six months after four sessions of PDT, complete response was found in 16/21 (76.19%; p = 0.0007) of patients, and DNA HPV clearance was found in 66.67% (p = 0.03). The eradication rate differed among patients with primary low-risk and high-risk HPV types—76.92% (10/13; p = 0.0003) and 50% (4/8; p = 0.05) respectively. Conclusion: ALA-PDT is an effective treatment even after the failure of previous modalities. The persistence of clinical lesions and high oncological risk HPV types should be an indication for treatment prolongation.

Topical and Systemic Retinoids for the Treatment of Genital Warts: A Systematic Review and Meta-Analysis

BACKGROUND

Genital warts, caused by the human papillomavirus, are a common sexually transmitted disease. The warts can regress spontaneously or exhibit a persistent clinical course. Various therapeutic modalities are available, yet none is curative, and there may be recurrences. Retinoids are considered the mainstay of therapy in many dermatologic diseases. Data on their use for genital warts are limited.

OBJECTIVE

To systematically review the published evidence on the efficacy and safety of retinoids for the treatment of genital warts.

METHODS

A systematic review and meta-analysis of all publications evaluating topical or systemic retinoids for the treatment of genital warts was performed. The primary outcome was complete response (CR); the secondary outcomes were recurrence rate and adverse events.

RESULTS

Six publications were evaluated, three randomized controlled trials and three prospective cohort studies, including a total of 141 patients with genital warts treated exclusively with retinoids (90% with isotretinoin). CR rates were 100% for systemic etretinate (3 out of 3 patients, 95% CI 28-81%) and 56% for isotretinoin (95% CI 28-81%; I2 = 84%). Topical etretinate did not induce CR. The most common side effect of topical agents was irritant contact dermatitis (36%) and that of systemic agents mucocutaneous disorders (80%). The relapse rate was 12% for oral isotretinoin and was unavailable for the other modalities.

CONCLUSIONS

Current data suggest that unlike topical retinoids, systemic retinoids are an effective and safe treatment for genital warts. Further studies are required to determine their specific role and the most effective regimen for each derivative.

A Multicentre, Randomised Clinical Trial to Compare a Topical Nitrizinc® Complex Solution Versus Cryotherapy for the Treatment of Anogenital Warts

INTRODUCTION

Anogenital warts (AGW) are a relevant clinical issue in the field of sexually transmitted disease, and to date no treatment provides a satisfactory clearance rate. Treatment can be both medical and surgical, and be provided by a healthcare provider or by the patient. Cryotherapy (CRYO) is among the most common treatments for AGW. Nitrizinc® Complex solution (NZCS) is a solution containing organic acids, nitric acid and zinc and copper salts that is applied topically to warts, producing mummification of the damaged tissue. It is considered to be an effective and well-tolerated treatment for genital and common warts. The aim of our study was to compare NZCS to CRYO in the treatment of AGW.

METHODS

We performed a prospective, multicentre, single-blind, randomised, superiority clinical study involving 120 patients, aged 18-55 years, diagnosed with a first episode of AGW, with each patient having from three to ten AGW. The patients were treated either with NZCS or CRYO for a maximum of four treatments. Primary endpoints were: (1) comparison of the clinical efficacy of CRYO and NZCS, based on response to treatment (clearance of AGW) within four treatment sessions; and (2) tolerability, assessed via a short questionnaire at the end of each treatment session. Secondary endpoints were: (1) number of treatments needed for clearance; and (2) recurrence at 1 and 3e months after confirmed clearance. The results were analysed on an intention-to-treat basis.

RESULTS

A complete response was achieved in 89.7% of the NZCS group and in 75.4% of the CRYO group (p = 0.0443). NZCS was found to be better tolerated. There was no difference between the NZCS and CRYO treatment arms in the number of sessions needed to clear the lesions. Recurrence occurred after 1 month in 18.4% of the NZCS group and 38.1% of the CRYO group (p = 0.0356), and after 3 months in 25 and 40.6% of these groups, respectively (p = 0.1479).

CONCLUSIONS

Nitrizinc® Complex solution can be considered to be as effective as CRYO for the treatment of small (< 5 mm) external AGW, with a better tolerability profile and lower rate of recurrence.

TRIAL REGISTRATION

ISRCTN identifier, ISRCTN36102369.

Condylomata acuminata of the neovagina in a transgender woman treated with trichloroacetic acid

Condylomata acuminata (genital warts) have been identified in transgender women after gender affirmation surgery. We describe a case of a 57-year-old transgender woman with biopsy-proven neovaginal condylomata acuminata following gender-affirmation vaginoplasty using the penile skin inversion technique. The patient was successfully treated with trichloroacetic acid. To our knowledge, this is the first case report demonstrating successful treatment of neovaginal condyloma with trichloroacetic acid. We provide a review of the relevant literature and highlight the evidence for the clinical utility of trichloroacetic acid in transgender women with condyloma of the neovagina.

Human papillomavirus genotype distribution in genital warts among women in Harare-Zimbabwe

This study aimed to determine the prevalence of HPV genotypes in genital warts among women in Harare, Zimbabwe. Women aged 18-45 years attending gynaecology and genitourinary clinics with a clinical diagnosis of genital-warts were recruited. HPV-DNA was extracted from tissue biopsies. HPV-DNA testing and typing was done by Southern Dot Blot Hybridisation. A hundred samples from 100 women were analysed. Median age of participants was 30.3 years (range 18-45 years). Seventy-eight percent of participants were HIV infected. HPV prevalence was 98%. Low risk genotypes predominated at 86% prevalence. The most prevalent genotypes were 11 (47%), 6 (42%) and 16 (14%). This is the first study on HPV genotype distribution among women with genital warts in Zimbabwe. The high prevalence of HR-HPV 16 in clinically benign lesions shows that warts should have histological analysis to exclude pre-malignancy and malignancy.Impact statementWhat is already known on this subject? Genital warts (GWs), also known as condylomata acuminata (EAC), are a clinical manifestation of persistent infection with 'low risk' or non-oncogenic HPV genotypes. HPV 6 and 11 are examples of low risk genotypes, and both are associated with 90% of GWs. Data on HPV genotypes causing genital warts in the population under study are scarce.What do the results of this study add? A high prevalence (98%) of HPV DNA in genital warts, confirms that the biopsied lesions were HPV related. Over and above the high prevalence of low risk HPV 11 (47%) and HPV 6 (42%), the women had 14% prevalence of HPV 16, an oncogenic genotype, in genital warts. Seventy-eight percent of the participants were HIV infected. The HIV infected women had a 33.3% prevalence of HR-HPV as compared to the 15.8% prevalence in the HIV uninfected women.What are the implications of these findings for clinical practice and/or further research? The population under study will benefit more if an HPV vaccine that includes anti-HPV 6 and 11 is used. The high prevalence of the HR-HPV in apparently benign lesions shows that warts should have histological analysis to exclude vulvar cancer and vulvar intraepithelial neoplasia. All women presenting with genital warts should be offered an HIV test.

Viral metagenomics updated the prevalence of human papillomavirus types in anogenital warts

To investigate the composition of human papillomavirus (HPV) types in anogenital warts (AGWs), viral nucleic acid in 110 AGWs, pooled into 11 specimen pools, were subjected to viral metagenomic analysis. After finding HPV7 in AGWs, conventional PCR screening was performed for HPV7 in other 190 individual AGW specimens. Viral metagenomic results indicated that 29 different types of HPV were recovered, with HPV11 and HPV6 showing the highest proportion of sequence reads. HPV7 was detected in 7 of 11 pools, 5 of which contained abundant HPV7 sequence reads. 24 complete genomes of HPV were acquired in viral metagenomic analysis, including 5 HPV7 genomes, based on which phylogenetic analysis and pairwise sequence comparison were conducted. PCR screening for HPV7 in other 190 individual AGW specimens revealed 25 positive cases (13.16%), of which the amplified fragments were sequenced and confirmed to be HPV7 sequences. Although HPV7 was generally found in hand warts and recently also in warts in toe webs, our data suggested that the role of HPV7 in AGW should be considered in the future clinical test and vaccine development for AGWs.