The management of difficult anogenital warts

Randomised controlled trial of 1% and 5% 5-fluorouracil creams compared with 90% trichloroacetic acid solution for anogenital wart treatment

To evaluate the efficacy and safety of 1% and 5% 5-fluorouracil (5-FU) creams compared with 90% trichloroacetic acid (TCA) for the treatment of anogenital warts. we conducted a randomised controlled study in 72 subjects allocated to three groups: 1% 5-FU, 90% TCA and 5% 5-FU; 90% TCA was administered once a week, whereas 5-FU cream was applied three times a week. Response to therapy and side-effects were evaluated weekly for seven weeks. Evaluation at week 7 demonstrated that there was no significant difference in the efficacy between 1% 5-FU cream and 90% TCA (p = 0.763) or between 5% 5-FU cream and 90% TCA (p = 0.274). Subjective side-effects with 1% 5-FU were significantly milder than 90% TCA; however, significantly milder objective side-effects were observed only at weeks 2, 6 and 7. The subjective side-effects with 5% 5-FU were also significantly milder than 90% TCA; however, significantly milder objective side-effects were observed only at week 2. 5-FU may become an alternative topical therapy as it offers the benefit of self-application; furthermore, a concentration of 1% 5-FU cream is recommended due to milder side-effects.

Anogenital warts treatment options: a practical approach

Anogenital warts (AGWs) are an important issue for public health centers dealing with Sexually Transmitted Infections. They are epidemiologically relevant, with significant morbidity and an established effective treatment is lacking. In this article, we examine the epidemiological, diagnostic, and therapeutic aspect of the problem in order to give an up to date picture of the situation and a practical clue for the management of AGWs.

Cost-effectiveness evaluation of a quadrivalent human papillomavirus vaccine in Belgium

BACKGROUND

The introduction of a quadrivalent human papillomavirus (HPV; types 6, 11, 16, 18) vaccine is expected to significantly reduce the burden of cervical cancer, cervical intraepithelial neoplasia (CIN), genital warts and other HPV-related diseases.

OBJECTIVE

To determine the cost effectiveness of providing a quadrivalent (6,11,16,18) HPV vaccine programme in adolescent females aged 12 years in addition to the existing cervical cancer screening programme in Belgium.

METHODS

A Markov state-transition model was developed for the Belgian context in order to evaluate the long-term impact of vaccinating a cohort of girls aged 12 years alongside the existing screening programme. Women were followed until the age of 85 years. A vaccine that would prevent 100% of diseases associated with HPV-6, -11, -16 and -18, with lifetime duration of efficacy, 80% coverage, in conjunction with current screening, was compared with screening alone. For this analysis, 35% of cases of CIN-1, 55% of CIN-2/3, 75% of cervical cancer and 90% of genital warts were considered to be attributable to HPV-6, -11, -16 or -18. The model estimated lifetime risks and total lifetime healthcare costs, survival and QALYs for cervical cancer, CIN and genital warts. Outcomes validation was applied. Model outcomes also included incremental costs per life-year gained and incremental costs per QALY gained. The analysis was conducted from the perspective of the Belgian healthcare payer, and costs were in year 2006 values.

RESULTS

The model estimated a reduction in the lifetime risk of cervical cancer from 0.94% to 0.34%, therefore preventing 362 cases of cervical cancer and 131 related deaths in a cohort of 60,000 girls aged 12 years in Belgium. The base-case scenario suggests quadrivalent HPV vaccination in addition to current cervical screening in Belgium to be cost effective at euro 10,546 per QALY. This is within the accepted range of cost-effective interventions in Europe. This cost effectiveness is maintained for different parameter assumptions in the sensitivity analysis, with the exception of very high discount rates for costs and medical benefits, but, even in the worst case, ratios were still less than euro 50,000 per QALY. Even when a separate scenario modelled the requirement for a booster vaccination to sustain a lifetime duration of protection, the results remained cost effective at eruo 17,388 per QALY.

CONCLUSIONS

Vaccination with a quadrivalent HPV vaccine appears to be a cost-effective public health intervention in conjunction with the existing screening programme in Belgium. The additional costs of introducing vaccination to the established screening programme would be offset by the potential savings from not having to treat the diseases caused by HPV-6, -11, -16 or -18.

[HPV vaccination is important for dermatologists]

The quadrivalent prophylactic HPV vaccination against HPV types 6, 11, 16 and 18 is not only highly effective in preventing HPV 16 and 18-associated cervical cancer, precancerous cervical lesions and high-grade precancerous vulvar and vaginal lesions but also against HPV 6 and 11-associated genital warts. Therefore, HPV-vaccination clearly belongs to the dermatologists' field of responsibility. A survey among 770 German dermatologists showed broad acceptance of the HPV vaccination; two-thirds of the persons asked would recommend the vaccination to their patients, regardless of reimbursement or STIKO recommendation, if they are convinced of the medical benefit. The survey also showed that HPV vaccination has not yet been fully established among dermatologists. Taking the high efficacy of the quadrivalent HPV vaccine into account, dermatologists should actively offer the HPV vaccination to their patients. The current AWMF-S3-guideline "Impfprävention HPV-assoziierter Neoplasien"can be used as a decision-making basis.

Intralesional immunotherapy with killed Mycobacterium w vaccine for the treatment of ano-genital warts: an open label pilot study

BACKGROUND

Intralesional immunotherapy with skin test antigens and vaccines has been found to be effective in the management of genital and extragenital warts.

OBJECTIVE

To evaluate the efficacy and safety of intralesional Mycobacterium w (Mw) vaccine monotherapy for the treatment of ano-genital warts.

PATIENTS AND METHODS

Ten patients clinically diagnosed to have external ano-genital warts, including three with giant ano-genital warts (Buschke Löwenstein tumour), were included in this open-label pilot study. Two patients were human immunodeficiency virus seropositive, and one was on iatrogenic immunosuppression for renal transplantation. Mw vaccine (0.1 mL) was initially injected intradermally in the deltoid region on both the sides, followed 2 weeks later by intradermal intralesional injection into the genital warts. Intralesional injections were repeated weekly until either complete clearance or a maximum of 10 injections was achieved.

RESULTS

One patient was lost to follow-up after the first intralesional injection. In 8 out of remaining 9 patients (88.9%), the genital warts cleared completely. In one patient with giant perianal wart, the lesion was reduced to less than 5% of its volume after 10 intralesional injections, which was later electrosurgically excised. The treatment was well tolerated by the majority of the patients. The adverse reactions were noted in four patients, which were reversible. No recurrence was seen after a mean follow-up of 5.1 months.

CONCLUSION

Intralesional immunotherapy of ano-genital warts with Mw vaccine seems to be a promising new approach, which needs to be evaluated in the randomized controlled trials.

Economic burden associated with the management of cervical cancer, cervical dysplasia and genital warts in Belgium

OBJECTIVE

Human papillomavirus (HPV) infections can lead to cervical intraepithelial neoplasia (CIN) lesions, cervical cancer (CC) and genital warts (GWs). This study intended to assess the annual cost of CC, CIN and GW management in Belgium.

METHOD

A retrospective study using a Belgian Hospital Disease Database (for yearly hospital cost of CC and GW patients) and a clinical expert survey were performed to assess the medical management of CC, CIN and GW patients. Belgian official sources were used to estimate the annual costs of management of CC, CIN and GW patients both from a healthcare payer perspectives (HCPP) and a societal perspective.

RESULTS

Based on the 667 patients diagnosed annually in Belgium with CC and an annual cost per patient of euro9,716, the total annual cost of CC is euro6.5 million (HCPP). The 10,495 estimated CIN 1, 2 and 3 patients led to an annual cost of euro1.97 million (HCPP). The 7,989 estimated annual number of diagnosed GW patients led to an estimated annual cost of euro2.53 million (HCPP).

CONCLUSION

HPV-related diseases represent an important burden on Belgian society, especially when considering that the estimates in this study are probably underestimations, as the management costs of other HPV-related diseases (vulvar, vaginal, penile, oropharyngeal (pre-) cancers, recurrent respiratory papillomatosis etc.) are not included in this analysis.