Condyloma and Anal Dysplasia

Anal intraepithelial neoplasia (AIN) are precancerous lesions and are sequela of human papilloma virus (HPV) infection. AIN is classified as low-grade squamous intraepithelial lesion or high-grade squamous intraepithelial lesion. Screening with anal cytology and anoscopy should be considered for high-risk populations. Diagnosis is made through high resolution anaoscopy and biopsy. Options for treatment include ablation and several topical therapies; however, recurrence rates are high for all treatment options, and an ongoing surveillance is necessary to prevent progression to anal squamous cell carcinoma. HPV vaccination is recommended to prevent disease.

Intralesional bivalent and quadrivalent human papillomavirus vaccines didn't significantly enhance the response of multiple anogenital warts when co-administered with intralesional Candida antigen immunotherapy. A randomized controlled trial

Treatment of anogenital warts (AGWs) is challenging. Candida antigen immunotherapy has been proven to be a safe and relatively effective therapeutic modality; nevertheless, some patients may experience a partial or no response. Combining Candida antigen with other immunotherapies has been proposed to improve the cure rate. Immunotherapy with human papillomavirus (HPV) vaccines has been tried with conflicting outcomes. This study aimed to  assess the efficacy and safety of intralesional Candida antigen, either alone or in combination with intralesional bivalent or quadrivalent HPV vaccines, for treating multiple AGWs. Eighty patients with multiple AGWs were included and randomly assigned to four equal groups: group A treated with intralesional Candida antigen only; group B treated with intralesional bivalent HPV vaccine (Cervarix) and Candida; group C treated with intralesional quadrivalent HPV vaccine (Gardasil) and Candida; and group D (control) treated with intralesional saline. Complete clearance of lesions was detected in 40%, 20%, and 60% of patients in Candida monotherapy, Cervarix/Candida, and Gardasil/Candida groups, respectively, whereas 40%, 60%, and 20% of patients in the three groups, respectively, showed partial response. Only 10% of the control group had a partial response. Therapeutic outcomes were significantly better in the three treatment groups compared to the control group, with no statistically significant difference between the Candida monotherapy group and the combination groups, but the response was significantly better in the Gardasil/Candida group than in the Cervarix/Candida group. No statistically significant difference was found between the studied groups regarding the development of side effects. Moreover, no recurrence was detected in any of the groups throughout the 3-month follow-up period.  Based on our results, combining intralesional HPV vaccines with Candida antigen immunotherapy may have no significant benefit for treating multiple AGWs. Candida antigen may be recommended as a relatively effective and inexpensive therapeutic modality. The combination of Gardasil and Candida was also effective but very expensive. The results of the Cervarix/Candida combination were unsatisfactory.  This clinical trial was registered and approved prospectively by the ethical review board at Faculty of Medicine, Zagazig University.

Updated estimate of the annual direct medical cost of screening and treatment for human papillomavirus associated disease in the United States

The annual direct medical cost attributable to human papillomavirus (HPV) in the United States over the period 2004-2007 was estimated at $9.36 billion in 2012 (updated to 2020 dollars). The purpose of this report was to update that estimate to account for the impact of HPV vaccination on HPV-attributable disease, reductions in the frequency of cervical cancer screening, and new data on the cost per case of treating HPV-attributable cancers. Based primarily on data from the literature, we estimated the annual direct medical cost burden as the sum of the costs of cervical cancer screening and follow-up and the cost of treating HPV-attributable cancers, anogenital warts, and recurrent respiratory papillomatosis (RRP). We estimated the total direct medical cost of HPV to be $9.01 billion annually over the period 2014-2018 (2020 U.S. dollars). Of this total cost, 55.0% was for routine cervical cancer screening and follow-up, 43.8% was for treatment of HPV-attributable cancer, and less than 2% was for treating anogenital warts and RRP. Although our updated estimate of the direct medical cost of HPV is slightly lower than the previous estimate, it would have been substantially lower had we not incorporated more recent, higher cancer treatment costs.

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.

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).

Unrecognized Bowen's disease in previously treated condylomata acuminata: indication of a common etiology?

Bowen's disease (BD) is an intraepidermal squamous cell carcinoma (SCC) with the capacity to become invasive SCC giving rise to distant metastasis. In rare cases it can be associated with human papillomavirus (HPV) infection, specifically with HPV types 16, 18, 31, 32, and 34. Here we report a case of an immunocompetent white male, age 37, with an erythematous, irregularly-shaped patch in his suprapubic region, appearing 1 year after treatment for condylomata acuminata with cryotherapy and podophyllin in the same area. At the time of clinically active disease, a urethral smear was positive for high-risk HPV types. The lesion was considered a scar by several physicians because it emerged in an area of previous postinflammatory hyperpigmentation. The aim of this report is to raise awareness of the emerging causative association between anogenital HPV infection and the development of BD, which was the possible etiological agent in the case of the patient presented here. Hereby we also advocate primary preventive measures in terms of safe sexual habits and HPV vaccination.

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.

Cronkhite-Canada syndrome associated with perianal condyloma acuminatum with malignant transformation: A case report

RATIONALE

Cronkhite-Canada syndrome (CCS) is a rare non-familial polyposis syndrome characterized by multiple gastrointestinal polyps with the ectodermal triad. To date, many complications of CCS have been reported in the literature, but perianal condyloma acuminatum with malignant transformation has not been included.

PATIENT CONCERNS

This report presents the case of a 52-year-old Chinese man who presented with diarrhea, loss of appetite, and weight loss. He developed skin pigmentation and atrophy of the fingernails and toenails. Upper gastrointestinal endoscopy, colonoscopy, capsule endoscopy, and enteroscopy revealed diffuse polyps along the entire digestive tract. Histopathological examination revealed polyps of different pathological types dominated by hamartoma. Physical examination revealed a crissum cauliflower-like neoplasm (2.5 × 2.0 cm). After perianal tumor resection, pathology suggested that this was a perianal condylomatous lesion with malignant transformation, as well as well-differentiated squamous cell carcinoma.

DIAGNOSES

These clinical features and endoscopic findings were consistent with CCS which associated with perianal condyloma acuminatum with malignant transformation.

INTERVENTION

Clinical remission was achieved with glucocorticoid, azathioprine, and nutritional support.

OUTCOME

At the 4-year follow-up, the patient had no diarrhea or loss of appetite, had gained 13 kg in weight, and the perianal tumor had not recurred.

LESSONS

No previous report has described CCS in a patient with perianal condyloma acuminatum with malignant transformation. As both conditions are related to immune disorders, their occurrence may be correlated.

Effectiveness of a combination therapy of traditional Chinese medicine and CO2 laser treatment for condyloma acuminatum

BACKGROUND

Condyloma acuminatum (CA) is both highly infectious and frequently recurring and requires long-term, repeated treatments, which seriously affect the physical and psychological health of patients. The purpose of the present study was to investigate the effectiveness of a combination therapy of traditional Chinese medicine and CO2 laser on CA and the relationship between CA relapse and cellular immunity.

METHODS

The study cohort consisted of 160 CA patients who underwent ambulatory treatment between January 2017 and January 2019 in the Department of Dermatology and Venerology of our hospital. The 160 patients were randomly divided into two groups: a combination therapy group (80 cases), who underwent CO2 -laser treatment followed by three courses of oral traditional Chinese medicine and a control group (80 cases), who were only treated with the CO2 laser to remove warts. The efficacy of the CO2 -laser treatment was evaluated on the first month after treatment and relapse was evaluated at monthly follow-ups for 6 months. Additionally, 20 normal volunteers were also recruited. Three months before and after treatment, the cellular immunity factors of peripheral blood T lymphocyte subsets, including CD4+, CD8+, CD4+/CD8+, and interleukin-2 (IL-2), were detected and compared between CA patients and normal volunteers, the combination therapy and control groups, and the relapse and cure groups to determine whether there were statistical differences.

RESULTS

Compared with normal volunteers, CA patients exhibited lower CD4+, CD4+/CD8+, and IL-2 levels and higher CD8+ levels (P < .05). In addition, the rates of relapse for the combination therapy and control groups were 25.7% and 40.8%, respectively. However, the comprehensive immunity factors showed no statistical difference (P > .05) before treatment. Three months after treatment, factors including CD4+ and CD4+/CD8+ were higher in the combination therapy group than in the control group (P < .05), and CD8+ and IL-2 showed no statistical difference (P > .05); factors including CD4+, CD4+/CD8+, and IL-2 were higher and CD8+ was lower in the cure group than in the relapse group (P < .05).

CONCLUSION

The therapy combination of traditional Chinese medicine and CO2 -laser treatment can reduce the relapse rate of CA. It might be that traditional Chinese medicine combined with CO2-laser treatment regulate liver meridian, Qi and blood, and restore the balance between various subgroups.

[5-aminolevulinic acid photodynamic therapy for condyloma acuminata with high-risk HPV infection and local cellular immunoactivity of the patient]

OBJECTIVE

To observe the clinical effects of the 5-aminolevulinic acid photodynamic therapy (ALA-PDT) on condyloma acuminata with high-risk human papillomavirus (HPV) infection and cellular immunoactivity in the local tissue of the patient.

METHODS

From January 2015 to January 2017, we treated 47 cases of condyloma acuminata with high-risk HPV infection in our hospital by simple excision of the wart (the control group, n = 21) or 1－5 times of ALA-PDT plus wart excision (the observation group, n = 26) and observed the changes in the number of warts and recurrence at 6 months after surgery. We excised all the warts in the control group and those >5 mm before ALA-PDT and >2 mm at 48 hours after 1－5 times of ALA-PDT in the observation group, followed by examination of the counts of CD4+ and CD8+ T cells, CD4+ / CD8+ ratio, and number of CD68+ macrophages in the local tissue by immunohistochemistry.

RESULTS

In the control group, the warts were completely removed in all the 21 cases but recurred in 9 (42.9%) at 6 months after surgery. In the observation group, 5 times of ALA-PDT achieved complete removal of the warts in 16 (61.5%) of the 26 patients, partial removal in 7 (26.9%), and inefficient removal in 3 (11.5%), with a total effective removal rate of 88.5% (23/26), a significantly lower 6-month recurrence rate (11.5% ［3/26］) than in the control (P < 0.05), but no such severe complications as festering, scarring and pigmentation. Compared with the control group and the baseline, the observation group showed remarkable increases after 1, 3 and 5 times of ALA-PDT in the counts of CD4+ T lymphocytes (31.21 ± 6.23 and 30.27 ± 5.63 vs 56.88 ± 4.72, 54.67 ± 2.84 and 42.62 ± 2.31, P < 0.05) and CD8+ T cells (25.31 ± 3.51 and 27.35 ± 3.78 vs 48.87 ± 2.47, 45.41 ± 3.17 and 37.58 ± 3.32, P < 0.01) and the CD4+ / CD8+ ratio (1.21 ± 0.52 and 1.09 ± 0.37 vs 1.68 ± 0.52, 1.63 ± 0.45 and 1.42 ± 0.13, P < 0.05 or P < 0.01), but exhibited no significant change in the count of CD68+ macrophages in the local tissue (23.31 ± 1.54 and 20.25 ± 1.28 vs 22.31 ± 2.73, 23.17 ± 2.41 and 21.35 ± 3.72, P > 0.05).

CONCLUSIONS

ALA-PDT, with its advantages of high efficiency, little invasion and high safety, is effective for the treatment of condyloma acuminata with high-risk HPV infection and it can also improve cellular immunoactivity in the local tissue and reduce recurrence.

Clinical Efficacy of Combination Therapy with Podophyllotoxin and Liquid Nitrogen Cryotherapy in the Treatment of Genital Warts in Men

High prevalence, peculiar etiopathogenesis, and ineffective therapies have contributed to the fact that genital warts are one of the most challenging issues in modern medicine. This prospective study was aimed at determining the clinical efficacy of combination therapy with 0.5% podophyllotoxin solution and liquid nitrogen cryotherapy in the local treatment of genital warts in men. One hundred and ten consecutive male patients with genital warts were randomly assigned to two groups. The control group consisted of two subgroups: 30 patients treated with podophyllotoxin and 30 patients treated with cryotherapy. The experimental group included 50 patients treated with combination therapy. The therapy continued until complete regression, but not longer than six weeks. Analysis of the average increase in the number of cleared warts compared to week zero found a significant clinical improvement in the group treated with a combination therapy in relation to the group treated with podophyllotoxin at the end of each of the six weeks and in comparison with the group treated with cryotherapy at the end of each of the first three weeks. After discontinuation of therapy, a significantly lower recurrence rate and appearance of new condylomas was observed at the end of the third month in the group treated with a combination therapy compared with each group treated with monotherapy, and at the end of the sixth month compared with patients treated with cryotherapy. The combination of podophyllotoxin and cryotherapy showed a significantly higher efficacy in the treatment of genital warts in comparison with monotherapy with podophyllotoxin after 6 weeks of treatment (P<0.001), with considerably lower recurrence and appearance of new warts compared with cryotherapy during the 6 months after therapy (P<0.005).

Coexistence of Anogenital Psoriasis and Genital Warts - Is There an Optimal Treatment?

The prevalence of psoriasis is 2% of the world's population (1). Inverse psoriasis is characterized by the development of erythematous shiny plaques at intertriginous areas of the body. The prevalence of only anogenital involvement appears to be low, but involvement of the anogenital area together with other areas is found in up to 45% of patients with psoriasis (2). A 21-year-old female student with a 3-month history of mild psoriasis (erythematosquamous plaque on the elbows and nail pitting on the nails of the hand) was referred to our Department. One month earlier, suddenly appearance of erythematous, smooth, clearly demarcated plaques was observed on the labia majora, the mons pubis, the perineal and perianal region together with a brownish hyperkeratotic papule on the pubic region (Figure 1, a-b). The patient underwent excisional biopsy at the Department of Surgery, and the pathohistological finding was unavailable to us. The elbows were treated with corticosteroid-keratolytic preparation, whereas the anogenital lesions were treated with moderately potent topical corticosteroids. In addition to anogenital erythema, on clinical examination we noticed an erythematosquamous plaque on the site of excision with a hyperkeratotic verrucous papule on the edge of the lesion (the Koebner phenomenon on the site of skin injury). In the pubic region, we noticed two hyperkeratotic papules and a few verrucous papules on labia majora. Localized dermatophyte or candida infection were excluded with a KOH test and scrapings culture. Serology for syphilis, HIV, and hepatitis were negative. Cervical Pap smear was normal. Biopsy of erythematosus lesion from the mons pubis was conclusive for psoriasis, and of the keratotic papule with the genital wart with positive HPV 6 and 11. The patient's older sister had chronic plaque psoriasis. We employed physically ablative methods like liquid nitrogen cryosurgery, electrocauterization, and curettage, applied topical agents like 0.5% podophyllotoxin solution, 20% podophyllin, and 80% trichloroacetic acid, and treated the psoriatic lesions with a short course of moderate-potency corticosteroids and tacrolimus ointment. All therapeutic attempts were ineffective for curing both diseases. Our patient either had psoriasis with sparse genital warts or exacerbation of multiple anogenital warts (Figure 2, a-b). Anogenital psoriasis is a skin disease that causes great discomfort. The disease-related quality of life is significantly reduced, especially regarding sexual behavior. Therapy for either anogenital psoriasis or genital warts is not entirely satisfactory. Many topical agents suitable for use on the psoriatic lesions on the body, such as coal tar, anthralin, vitamin D derivatives or retinoids, may be too irritating in the anogenital region. The most useful therapy for treatment of anogenital psoriasis are moderately potent topical corticosteroids and topical tacrolimus or pimecrolimus (1). However, corticosteroid-induced atrophy is possible in intertriginous sites. The Koebner phenomenon isomorphic response is the appearance of new skin lesions on areas of cutaneous injury in otherwise healthy skin (3). About 25% of patients with psoriasis have elicitation of psoriatic lesions by injury to the skin (4). Other than in patients with psoriasis, the Koebner phenomenon can be found in other skin diseases like vitiligo, lichen planus, lichen nitidus, pityriasis rubra pilaris, flat warts, and keratosis follicularis (Darier disease) (5). According to Eyre at al., about 67% patients with psoriasis (4) present with clearing of psoriatic lesions following skin injury (positive "reverse" Koebner reaction) (4). There is no single treatment for genital warts that is 100% effective, and different types of treatment are very often combined. Accepted methods of treatment involve chemical and physical destruction or removal (6). Since psoriasis koebnerizes, any destructive technique may exacerbate the psoriasis. Coexistence of anogenital psoriasis and HPV presents a huge therapeutic problem because a therapy for psoriasis such as corticosteroids can provoke appearance and/or reappearance of HPV infection, while some therapies for anogenital warts, like cryotherapy, curettage, laser ablation, electrosurgery, or surgery can provoke the appearance and/or reappearance of psoriatic infection due to the Koebner phenomenon.

Effectiveness of topical and ablative therapies in treatment of anogenital warts: a systematic review and network meta-analysis

OBJECTIVE

To generate estimates of comparative clinical effectiveness for interventions used in the treatment of anogenital warts (AGWs) through the systematic review, appraisal and synthesis of data from randomised controlled trials (RCTs).

DESIGN

Systematic review and network meta-analysis of RCTs. Search strategies were developed for MEDLINE, Embase, the Cochrane Library and the Web of Science. For electronic databases, searches were run from inception to March 2018. The systematic review was carried out following the general principles recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

PARTICIPANTS

People aged ≥16 years with clinically diagnosed AGWs (irrespective of biopsy confirmation).

INTERVENTIONS

Topical and ablative treatments recommended by the British Association for Sexual Health and HIV for the treatment of AGWs, either as monotherapy or in combination versus each other.

OUTCOME MEASURES

Complete clearance of AGWs at the end of treatment and at other scheduled visits, and rate of recurrence.

RESULTS

Thirty-seven RCTs met inclusion criteria. Twenty studies were assessed as being at unclear risk of bias, with the remaining studies categorised as high risk of bias. Network meta-analysis indicates that, of the treatment options compared, carbon dioxide laser therapy is the most effective treatment for achieving complete clearance of AGWs at the end of treatment. Of patient-applied topical treatments, podophyllotoxin 0.5% solution was found to be the most effective at achieving complete clearance, and was associated with a statistically significant difference compared with imiquimod 5% cream and polyphenon E 10% ointment (p<0.05). Few data were available on recurrence of AGWs after complete clearance. Of the interventions evaluated, surgical excision was the most effective at minimising risk of recurrence.

CONCLUSION

Of the studies assessed, as a collective, the quality of the evidence is low. Few studies are available that evaluate treatment options versus each other.

TRIAL REGISTRATION NUMBER

CRD42013005457.

Position statement for the diagnosis and management of anogenital warts

BACKGROUND

Anogenital warts (AGW) can cause economic burden on healthcare systems and are associated with emotional, psychological and physical issues.

OBJECTIVE

To provide guidance to physicians on the diagnosis and management of AGW.

METHODS

Fourteen global experts on AGW developed guidance on the diagnosis and management of AGW in an effort to unify international recommendations. Guidance was developed based on published international and national AGW guidelines and an evaluation of relevant literature published up to August 2016. Authors provided expert opinion based on their clinical experiences.

RESULTS

A checklist for a patient's initial consultation is provided to help physicians when diagnosing AGW to get the relevant information from the patient in order to manage and treat the AGW effectively. A number of frequently asked questions are also provided to aid physicians when communicating with patients about AGW. Treatment of AGW should be individualized and selected based on the number, size, morphology, location, and keratinization of warts, and whether they are new or recurrent. Different techniques can be used to treat AGW including ablation, immunotherapy and other topical therapies. Combinations of these techniques are thought to be more effective at reducing AGW recurrence than monotherapy. A simplified algorithm was created suggesting patients with 1-5 warts should be treated with ablation followed by immunotherapy. Patients with >5 warts should use immunotherapy for 2 months followed by ablation and a second 2-month course of immunotherapy. Guidance for daily practice situations and the subsequent action that can be taken, as well as an algorithm for treatment of large warts, were also created.

CONCLUSION

The guidance provided will help physicians with the diagnosis and management of AGW in order to improve the health and quality of life of patients with AGW.

HIGHER LESION NUMBERS RESULT IN HIGHER RECURRENCE RATES: A RETROSPECTIVE COHORT STUDY IN CONDYLOMATA ACUMINATA TREATED WITH ELECTROCAUTERIZATION

Condylomata acuminata (anogenital warts/CA) is the most frequent sexually transmitted disease with high recurrence rates in young adults resulting in considerable morbidity. An analysis performed on the five-year retrospective data of the CA patients who have visited our dermatology clinic, was aimed at the success rate of treatment with electrocauterization and recurrence dynamics, as well at determining the demographic structure of the patients. 237 patients with CA, who were treated at our hospital's dermatology clinic with electrocauterization under local anesthesia, during 2012-2017 were followed up retrospectively. The lesion number of each patient was recorded at the first visit. All the visible lesions were removed and cleared in all patients in all sessions. After the treatment, each patient was followed up every three months for one year. The data on demographic features, disease duration, lesion counts, treatment efficacy, and recurrence rates were statistically analyzed. Males were older in age and had higher number of recurrences after treatment compared to females (36.7 vs. 30.8; p=0.0015), but there was no statistically significant difference in disease durations prior to the first visit. Total recurrence ratios and the relevant patient numbers were 26.4% (n=53) and 22.2% (n=8) for male and female patients respectively (p=0.0001). For both male and female patients, the lesion numbers recorded at the first visit were found significantly higher in the patients with recurrence, compared to the patients without recurrence (p=0.0027 and p=0.0006, respectively). Electrocauterization is an effective modality in treatment of CA and the recurrence rate is relatively low in comparison to the published data on recurrence with other ablative therapy methods. The significantly higher recurrence in males may be the result of more risky (frivolous) sexual behavior adopted by them. Due to the higher probability of recurrence, the patients with multiple lesions should be followed closely after the treatment.

Pulsed-dye laser versus intralesional Candida albicans antigen injection in treatment of genital warts

INTRODUCTION

Genital warts are a troublesome therapeutic issue. Pulsed-dye laser (PDL) is a non-ablative therapeutic tool for viral warts. Intralesional Candida albicans (C. albicans) immunotherapy has yielded promising results in treatment of various types of warts. We aimed to evaluate the effectiveness of PDL versus C. albicans immunotherapy for treatment of genital warts.

METHODS

Forty adult patients with genital warts were divided into two equal groups; the first was treated using PDL and the second using intralesional C. albicans antigen injection. Treatments were performed at 3-week intervals until complete lesion resolution or for a maximum of three sessions.

RESULTS

PDL yielded higher complete clearance rates (95%) than C. albicans antigen (50%; p = 0.001), which in turn had the advantage of treating distant and internal genital warts. Apart from pain during the session in PDL, both modalities were well tolerated with no recurrence in cured patients during the 16-week follow-up period.

CONCLUSIONS

PDL and C. albicans antigen injection are safe and effective treatment alternatives for genital warts. PDL yielded better frequencies of clearance, but C. albicans antigen has additional advantages, including a single injection site and treating distant and internal mucosal uninjected warts, which are usually difficult to treat.

[Proctology for internists]

In proctology patients can often be helped with very little effort. With knowledge of the most common disease symptoms the treating physician can in many cases correctly recognize the cause of the complaints and initiate the appropriate therapy or arrange referral to a proctological institution. This article aims to briefly and succinctly present the most common diseases in proctology (e.g. mariscae, hemorrhoids, anal fissures, perianal venous thrombosis, abscesses and fistulas, condyloma acuminatum and anal carcinoma) and to provide the treating internist, even outside of gastroenterology, assistance with the management of proctological symptoms.

Coexistence of genital lichen sclerosus and genital warts

Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of the genital and extragenital skin. Anogenital warts are benign proliferative lesions caused by human papillomavirus (HPV), which is found in > 95% of lesions. We present two cases of the coexistence of LS and genital warts: one patient with and one without a previous history of genital warts. According to our knowledge and a literature search, only a few cases of the coexistence of LS and genital warts have been reported.

Medical Care Costs Associated with Genital Warts for Commercially Insured US Patients

INTRODUCTION

Genital warts are caused by infection with human papillomavirus (HPV) and are associated with significant morbidity. Primary prevention of genital warts is possible through HPV vaccination, but vaccination rates remain low in the USA. When deciding to implement HPV vaccination programs, public health officials and policy makers rely on cost-effectiveness studies that accurately reflect costs associated with morbidity and mortality. However, previous information on the cost of treating genital warts was outdated.

OBJECTIVES

We estimated the mean direct medical care costs associated with genital warts in the USA.

METHODS

This was a retrospective case-control study of patients diagnosed with genital warts and matched controls. We used commercial healthcare claims data from 2011 through 2014 to estimate total 1- and 2-year costs from date of diagnosis. We used a generalized linear model to identify factors associated with monthly costs.

RESULTS

We identified 34,686 eligible cases of genital warts during the period 2011-2014. The first 2-year mean direct medical cost differences between cases and controls were US$6737 for the USA. Costs were significantly higher in the first 3 months following diagnosis and were higher among older individuals, women, those with co-morbidities or psychiatric illnesses, and those located in the south and southwest USA.

CONCLUSIONS

The mean direct cost of treating genital warts is approximately US$6700 in the first 2 years after diagnosis in the USA. These data can assist policy makers in decisions with respect to allocation of resources to implement HPV vaccine programs.

Effectiveness of physically ablative and pharmacological treatments for anal condyloma in HIV-infected men

BACKGROUND

There is limited information on the effectiveness of available treatments for anal condyloma acuminata in HIV-1-infected men.

AIM

To provide data on the effectiveness of electrosurgical excision, infrared coagulation and pharmacological (imiquimod) treatments for anal condyloma acuminata (peri-anal and/or intra-anal) in HIV-1-infected men based on authors' practice.

METHODS

Single-center, retrospective descriptive analysis of HIV-1-infected men, 18 years or older treated for anal condyloma acuminata. Standard treatments were offered: electrosurgery excision, infrared coagulation and topical imiquimod. Effectiveness was evaluated by the recurrence rate at 1 year after treatment. Recurrence was defined as any anal condyloma acuminata diagnosed after 3 months of condyloma-free survival post-treatment. Anal cytology and human-papillomavirus-infection (HPV) was assessed.

RESULTS

Between January 2005 and May 2009, 101 men were treated for anal condyloma acuminata: 65 (64%) with electrosurgery, 27 (27%) with infrared coagulation and 9 (9%) with imiquimod. At 1 year after treatment, the cumulative recurrence rate was 8% (4/65, 95%CI: 2-15%) with electrosurgery excision, 11% (3/27, 95%CI: 4-28%) with infrared coagulation and 11% (1/9, 95%CI: 2-44%) with imiquimod treatment. No predictive factors were associated with recurrence. Anal HPV-6 or HPV-11 was detectable in 98 (97%) patients and all had high-risk HPV genotypes, and 89 (88%) patients had abnormal anal canal cytology. Limitations: this was a retrospective descriptive analysis; limited to a single center; it cannot know if the recurrence is related to new infection.

CONCLUSION

Recurrence of anal condyloma after any treatment was common. Abnormal anal cytology and high-risk HPV-infection were highly prevalent in this population, therefore at high-risk of anal cancer, and warrants careful follow-up.

[Ano-genital warts are more than benign lesions]

Ano-genital warts are in general considered as benign lesions, as they are mostly caused by the non-oncogenic HPV types 6 and 11. In this review, there is a focus on the problematic issues, that these lesions and their treatments can cause. Both topical and ablative treatments are associated with side effects, and the varying effect of the treatments combined with an uncertain timeline to clearance are known to cause psychological distress. Vaccination against HPV-6 and -11 has been shown to reduce the incidence of this troublesome infection substantially in both women and men in countries with high vaccine coverage.

The Direct Medical Costs of Diseases Associated with Human Papillomavirus Infection in Manitoba, Canada

BACKGROUND

The total direct cost of screening and treating all human papillomavirus-related diseases (HPV-RD) has not been measured in a single study. Accurate cost estimates are needed to inform decisions on intervention priorities and evaluate the cost-effectiveness of existing programs. We used province-wide clinical, administrative, and accounting databases to measure direct medical costs of HPV infection in Manitoba (Canada).

METHODS

All persons 9 years or older with health insurance coverage in Manitoba between April 2000 and March 2015 were eligible. We identified all persons with an incident HPV-RD and aggregated all medical costs (in 2014 Canadian dollars) related to that condition, including prescription drugs, diagnostic procedures, in-hospital and outpatient treatment, and physician visits.

RESULTS

We found that the median cost of treating a case of anogenital warts was $130. An episode of cervical dysplasia had a median cost of $220, compared to $1300 for an episode of cervical carcinoma in situ. The cost of treating HPV-related invasive cancer varied from $15,000 for cervical cancer to $33,000 for oral cavity cancer. Overall, 80% ($145 million) of the total cost was attributable to HPV infection. Cervical screening and follow-up accounted for $96 million (66%) of all costs and this cost component has declined following the introduction of new screening guidelines.

CONCLUSIONS

Overall, the average direct medical cost of HPV infection was $720 per newborn. The economic burden of HPV remains significant, although changes in cervical screening guidelines, prompted by the introduction of a public HPV vaccine program, appear to have promoted a promising trend towards lower costs.

Clearance of human papillomavirus related anal condylomas after oral and endorectal multistrain probiotic supplementation in an HIV positive male: A case report

INTRODUCTION

Here we present the case of a 56-year-old human immunodeficiency virus (HIV)-infected man with multiple anal condylomas and positivity for human papilloma virus (HPV) 18 on anal brushing. Biopsies of the anal mucosa led to the diagnosis of Bowen's disease and a subsequent pelvic magnetic resonance imaging (MRI) scan evidenced multiple reactive lymphoadenopathies and large intra-anal condylomas. The patient was treated with a complete excision of Bowen's lesion and with a 4 months course of supplementation with a high concentration multistrain probiotic formulation administered orally and by rectal instillation with the purpose to reduce local inflammation and to enhance local mucosal immunity.

CONCLUSION

An MRI performed at the end of the supplementation period evidenced the clearance of the anal condylomas previously described and no evidence of residual lymphadenopathies. Trials are therefore required to confirm this therapeutic possibility and for a better understanding of the mechanisms by which this specific probiotic formulation interacts with local epithelium when administered by the anal route.

Invasive penile squamous cell carcinoma

Invasive penile squamous cell carcinoma (PSCC) is a rare malignancy with considerable morbidity and mortality. Because a delayed or incorrect diagnosis can have a devastating outcome, physicians should maintain a high index of clinical suspicion for PSCC in patients presenting with penile lesions, particularly in young or middle-aged patients in whom presentation of PSCC is uncommon. We report the case of a 27-year-old circumcised man who presented with invasive PSCC following a diagnosis of condyloma 8 years prior. The patient underwent robotic laparoscopic bilateral pelvis and inguinal lymph node dissection and re-excision of the primary PSCC, with one of 15 superficial right inguinal lymph nodes testing positive for squamous cell carcinoma. Given the patient's single-node positivity as well as the risks associated with chemotherapy with respect to his concurrent medical conditions, close follow-up with repeat imaging was planned following surgery. This case highlights the importance of biopsy in any lesion recalcitrant to conventional treatment modalities regardless of age. Early detection and treatment of PSCC can prevent organ dysfunction, loss of organ, or even death.

A cross-sectional study estimating the burden of illness related to genital warts in South Korea

OBJECTIVES

Estimate the prevalence of genital warts (GW) and GW-related healthcare resource use and costs among male and female patients seeking treatment in South Korea.

DESIGN

To estimate GW prevalence, physicians in five major South Korean regions recorded daily logs of patients (n=71 655) seeking care between July 26 and September 27, 2011. Overall prevalence estimates (and 95% CIs) were weighted by the estimated number of physicians in each specialty and the estimated proportion of total patients visiting each specialist type. Healthcare resource use was compared among different specialties. Corresponding p values were calculated using Mann-Whitney U tests.

SETTING

The database covers 5098 clinics and hospitals for five major regions in South Korea: Seoul, Busan, Daegu, Gwangju and Daejeon.

PARTICIPANTS

Primary care physicians (general practice/family medicine), obstetricians/gynaecologists, urologists and dermatologists with 2-30 years' experience.

RESULTS

The estimated overall GW prevalence was 0.7% (95% CI 0.7% to 0.8%). Among women, GW prevalence was 0.6% (95% CI 0.6% to 0.7%); among men prevalence was 1.0% (95% CI 0.9% to 1.0%), peaking among patients aged 18-24 years. Median costs for GW diagnosis and treatment for male patients were US$58.2 (South Korean Won (KRW) ₩66 857) and US$66.3 (KRW₩76 113) for female patients.

CONCLUSIONS

The estimated overall GW prevalence in South Korea was 0.7% and was higher for male patients. The overall median costs associated with a GW episode were higher for female patients than for male patients.

Controlling Human Papilloma Virus: A Public Health Perspective of Treatment of Anogenital Warts

The success of human papilloma virus (HPV) screening is attributable to clear‐cut guidelines on the detection and management of premalignant HPV lesions. A similar approach is necessary for both low‐risk and high‐risk lesions, including anogenital warts.

[Anogenital warts: a new way of solving the common problem of urology (results of long-term follow-up)]

AIM

To evaluate the effectiveness of combined use of the imiquimod 5% cream and vaccination against human papillomavirus (HPV) using a quadrivalent recombinant vaccine to achieve long-term clinical remission of chronic HPV infection manifested by anogenital warts.

MATERIAL AND METHODS

The study comprised 36 patients, including 22 men, aged 26.4+/-4.1 years, who had from 1 to 5 anogenital warts. Participants of the study were vaccinated by quadrivalent recombinant vaccine under a 3-dose scheme 0-2-6 months co-administered with imiquimod 5% cream three times per week up to 16 weeks. The follow-up period was 2 years.

RESULTS

Complete disappearance of genital warts within 1 year from baseline was observed in 34 (94.4%) patients. Two patients with anogenital warts after 1 year were treated for 1 year 3 months and 1 year and 4 months with Solcoderm which lead to the complete disappearance of genital warts. There were no recurrences of genital warts during the 2 years of follow-up.

CONCLUSION

Vaccination with a recombinant quadrivalent vaccine concurrently with using imiquimod 5% cream results in prolonged clinical remission of chronic HPV infection manifested by anogenital warts in at least 94.4% of the cases (2 year follow-up).

[CONDYDAV: A multicentre observational study of patients presenting external genital warts in France]

BACKGROUND

Since 2007 in France, human papilloma virus (HPV) vaccination has been licensed for use as a vaccine against HPV 6, 11, 16 and 18. The impact on the epidemiology of external genital warts (EGWs) in a large population remains unclear.

OBJECTIVES

To determine epidemiologic and clinical features of patients presenting EGWs in France in the era of HPV vaccination.

PATIENTS AND METHODS

In this prospective, observational study, we analyzed clinical features and treatments between January 1st, 2012 and March 31, 2012 for patients consulting for EGWs at 15 STI clinics throughout France.

RESULTS

A total of 372 men and 111 women were included; mean age 31.2 years. The women were younger than the men (31.7 and 28.9 years respectively P<0.05). Among the patients, 416 (85.7%) were heterosexual, 13 bisexual and 54 (11.2%) homosexual, including one female. Males reported more sexual partners in the last 12 months (more than 3 partners in 32.6% versus 11.9%, P<0.01). Among the men, 230 had involvement of the penis alone and 46 had involvement of the anus alone. Seventy-six patients had EGWs of the anus, and of these 26 were MSM. In females, 76 had an infection of the vulva alone and 22 co-infection of the vulva and anus. MSM and females were at higher risk than heterosexual males for anal involvement (P<0.0001 and P=0.004, respectively). Three women had been vaccinated: two with Gardasil^® and one with Cervarix^®. Cryotherapy was the preferred treatment.

CONCLUSION

With the advent of HPV vaccination, a global strategy for the prevention and treatment of EGW should be implemented.

Genital warts in a transsexual

Genital warts are the commonest sexually transmitted viral infection seen in genitourinary medicine clinics. As common as warts are, with extensive previous studies, literature searches on genital warts in transsexuals were unfruitful. Due to the nature and rarity of such a case, it was felt that it would be interesting to detail its management.

The role of illness perceptions: psychological distress and treatment-seeking delay in patients with genital warts

This study examined the relationships between illness perceptions, psychological distress and treatment-seeking delay in genital warts patients. Sixty-six genital warts patients were approached while attending a sexual health clinic. They completed a questionnaire assessing their illness perceptions, psychological distress and treatment-seeking delay. Negative perceptions of illness consequences and control and a perceived cyclical timeline were associated with increased psychological distress. Perceived illness consequences maintained significance in a multiple regression equation, which accounted for 25% variance in distress. Depression was associated with treatment-seeking delay ( r = 0.28, P = 0.03). In conclusion, illness perceptions may play an important role in the experience of psychological distress in genital warts patients. The implications of these findings for the design of health-care interventions are discussed.

Effectiveness of an educational leaflet on the prevention of external genital warts recurrences

The study aims to assess the effectiveness of an educational leaflet in the prevention of external genital warts recurrences after achieving clearance with topical immune response modifiers treatment. A six-month follow-up, prospective, open, multi-centre randomized by centres study was conducted, which included a total of 216 patients. A total of 103 (47.7%) patients were given an educational leaflet. In all, 201 subjects (93.1%) came to the second follow-up visit, of which 62.7% achieved condyloma acuminatum (CA) clearance. During follow-up, 15% (confidence intervals [CI] 95%, 7.1–26.6%) of the patients who were given the educational leaflet, and 33.3% (CI 95%, 20.4–48.4%) of those who were not given the educational leaflet showed CA recurrences; the global rate of CA recurrence at the end of the six-month follow-up was 23.1% (CI 95%, 15.6–32.2%). The educational leaflet has therefore proved to be effective at reducing the recurrence rate after successful treatment with immune response modifiers.

Use of complementary therapies in a sexual health clinic setting

This prospective cohort study examined the health-seeking behaviour of patients diagnosed with genital warts and vulvodynia who presented to Manly Sexual Health Service from March to June 2000. A self-administered questionnaire was used to assess patients' perceptions of their condition and their use of complementary therapies. Thirty-seven patients with genital warts and 26 patients with vulvodynia participated in the study. The use of at least one complementary health product or method was reported by 59% of patients with genital warts and 96% of vulvodynia patients ( P < 0.001). Having received conflicting information and being worried about the condition was significantly associated with visits to complementary health providers. Acknowledgement of this search for complementary therapies and open discussion can help patients make informed decisions and to avoid drug interactions, and should ultimately lead to better patient care.

Sexually Transmitted Infections

Sexually transmitted infections (STIs) remain a significant burden on public health in the United States. Primary prevention counseling with early diagnosis and treatment remain the best methods to decrease the incidence of STIs. Through significant public heath interventions, the incidence of gonorrhea, Chlamydia, and trichomoniasis is decreasing; however, the incidence of primary and secondary syphilis is increasing. Human papilloma virus remains the most common STI, but new vaccinations have the possibility of having a significant impact on this virus's disease potential. This review discusses the most common STIs in the United States, focusing on clinical presentation, diagnosis, and treatment.

[Combined treatment of genital human papillomavirus infection in men]

This study aimed to assess the efficacy of treatment of genital human papillomavirus infection in 107 men. Patients in group 1 (n=51) underwent laser ablation of genital warts, patients in group 2 (n=56) were treated with laser ablation in conjunction with the administration of an immune system medication izoprinozin. During the first 9 months post-treatment, human papillomavirus infection relapse rate in group 1 was 23,5% and in group 2 - 5,4%. It was likewise observed that the combined treatment of genital warts resulted in reduced incidence of infective complications and the time of wound epithelialization after laser papilloma ablation.

Cost of Preventing, Managing, and Treating Human Papillomavirus (HPV)-Related Diseases in Sweden before the Introduction of Quadrivalent HPV Vaccination

Objective

Costs associated with HPV-related diseases such as cervical dysplasia, cervical cancer, and genital warts have not been evaluated in Sweden. These costs must be estimated in order to determine the potential savings if these diseases were eradicated and to assess the combined cost-effectiveness of HPV vaccination and cervical cancer screening. The present study aimed to estimate prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts from a societal perspective in Sweden in 2009, 1 year before the quadrivalent HPV vaccination program was implemented.

Methods and Materials

Data from the Swedish cervical cancer screening program was used to calculate the costs associated with prevention (cytological cervical cancer screening), management (colposcopy and biopsy following inadequate/abnormal cytological results), and treatment of CIN. Swedish official statistics were used to estimate treatment costs associated with cervical cancer. Published epidemiological data were used to estimate the number of incident, recurrent, and persistent cases of genital warts; a clinical expert panel assessed management and treatment procedures. Estimated visits, procedures, and use of medications were used to calculate the annual cost associated with genital warts.

Results

From a societal perspective, total estimated costs associated with cervical cancer and genital warts in 2009 were €106.6 million, of which €81.4 million (76%) were direct medical costs. Costs associated with prevention, management, and treatment of CIN were €74 million; screening and management costs for women with normal and inadequate cytology alone accounted for 76% of this sum. The treatment costs associated with incident and prevalent cervical cancer and palliative care were €23 million. Estimated costs for incident, recurrent and persistent cases of genital warts were €9.8 million.

Conclusion

Prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts are substantial. Defining these costs is important for future cost-effectiveness analyses of the quadrivalent HPV vaccination program in Sweden.

[OPTIMAL APPROACH TO COMBINED TREATMENT OF PATIENTS WITH UROGENITAL PAPILLOMATOSIS]

The review analyzed 59 sources of domestic and foreign literature on the use of immunomodulator izoprinozin in treating patients infected with human papilloma virus, and the results of their own experience. The high prevalence of HPV and its role in the development of cervical cancer are shown, the mechanisms of HPV development and the host protection from this infection are described. The authors present approaches to the treatment of HPV-infected patients with particular attention to izoprinozin. Isoprinosine belongs to immunomodulators with antiviral activity. It inhibits the replication of viral DNA and RNA by binding to cell ribosomes and changing their stereochemical structure. HPV infection, especially in the early stages, may be successfully cured till the complete elimination of the virus. Inosine Pranobex (izoprinozin) having dual action and the most abundant evidence base, may be recognized as the optimal treatment option.

Sexually transmitted diseases treatment guidelines, 2015

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Recurrent vulvar Buschke-Löwenstein's tumor-like condylomata acuminata and Hodgkin's disease effectively treated with recombinant interferon-alpha 2c gel as adjuvant to electrosurgery

The local application of recombinant interferon-alpha 2c hydrogel (1 x 10(6) IU IFN-alpha 2c per g) given as an adjuvant after electrosurgery led to a complete cure of previously recalcitrant untreatable giant Buschke-Löwenstein's tumor-like condylomata acuminata of a 19-year-old patient suffering from Hodgkin's disease (stage II/II). Interferon-alpha 2c hydrogel given as adjuvant with surgery may have more direct antiproliferative and antiviral activities than immunomodulating defects. This combined topical application is an effective and safe treatment which is recommended especially in immunocompromised individuals suffering from genital HPV disease nonresponsive against systemic interferon and conventional therapy modalities.

A single-blinded randomized controlled study to assess the efficacy of twice daily application of sinecatechins 15% ointment when used sequentially with cryotherapy in the treatment of external genital warts

OBJECTIVE

To evaluate the efficacy of sequential therapy of cryotherapy and sinecatechins 15% ointment BID versus cryotherapy alone in treatment of external genital warts (EGW).

METHODS

Forty-two subjects with at least two EGW lesions underwent cryotherapy to all lesions. One week following cryotherapy, subjects were randomized 1:1 to receive either no additional treatment or treatment with sinecatechins 15% ointment BID up to 16 weeks or until complete clearance. The total number of visible baseline and new EGW were recorded at each visit. Subjects were followed for a total of 65 weeks post-treatment.

RESULTS

There was a significant reduction in mean number of lesions from baseline after 16 weeks of treatment in the cryotherapy-sinecatechins ointment group compared to cryotherapy alone (-5.0 lesions vs -2.1 lesions respectively, P=0.07).

CONCLUSION

Cryotherapy plus sinecatechins 15% ointment BID resulted in a significant improvement in the reduction of EGW compared to cryotherapy alone. Clinicaltrials.gov registration identifier: NCT02147353.

[Proven and new methods in the treatment of genital warts]

Anogenital warts are the most common clinical manifestation of human papillomavirus (HPV) infections. Although easy to recognize, asymptomatic anogenital warts (condylomata acuminata) may be overlooked, leading to unaware transmission to the sexual partner. On the other hand awareness of this sexually transmitted disease (STD) is largely associated with a great psychological and social burden, in men as well as women. Spontaneous regression of genital warts has been observed mostly within 2-5 years; however, persisting condylomata may prove refractory to all current treatment options. Because removal of the warts does not totally eliminate the underlying viral infection, treatment of genital warts can often be of long duration, of varying effectiveness and with high recurrence rates. Without a doubt only the patient's own immune system is capable of clearing HPV infections. Therefore, the solution to one of mankind's oldest health problems will depend on the future acceptability of HPV vaccines.

Management of external genital warts

Genital warts affect 1% of the sexually active U.S. population and are commonly seen in primary care. Human papillomavirus types 6 and 11 are responsible for most genital warts. Warts vary from small, flat-topped papules to large, cauliflower-like lesions on the anogenital mucosa and surrounding skin. Diagnosis is clinical, but atypical lesions should be confirmed by histology. Treatments may be applied by patients, or by a clinician in the office. Patient-applied treatments include topical imiquimod, podofilox, and sinecatechins, whereas clinician-applied treatments include podophyllin, bichloroacetic acid, and trichloroacetic acid. Surgical treatments include excision, cryotherapy, and electrosurgery. The quadrivalent human papillomavirus vaccine is active against virus subtypes that cause genital warts in men and women. Additionally, male circumcision may be effective in decreasing the transmission of human immunodeficiency virus, human papillomavirus, and herpes simplex virus.

Anal warts (condylomata acuminata) - current issues and treatment modalities

HPV infections are currently the most frequent cause of genital infections in the USA. Risk factors are early onset of sexual activity, multiple sexual partners, a history STDs, an early age of first pregnancy and tobacco use. In the past, HPV viruses were thought to be STDs, but it is now known that penetration is not necessary. Skin-to-skin or mucosa-to-mucosa contact is enough to transmit the virus, which presents high tropism for those tissues. The Papillomaviridae family includes over 120 viruses, some of which have high malignant transformation rates. The most common malignancy connected to HPV is uterine cervix cancer and anal canal cancer. The range of morphology of perianal lesions means that a thorough clinical examination is required, including an anoscopy. Therapeutic modalities often seek to eliminate macroscopic changes rather than focus on the cause of the infection, which leads to a high recurrence rate. Externally located changes can be eliminated with patient-applied treatments. Those located in the anal canal and distal end of the rectal ampulla require treatment by a qualified medical provider. Due to the high recurrence rate after standard treatment, special attention has been given to vaccinations. The polyvalent vaccine includes HPV viruses with both low and high malignant transformation risk. This has led to a decrease in the rate of malignancies.