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Thank you very much
I would like to thank professor Mr. Diakomanolis for inviting me to speak at this very succesful training course
The topics of my talk will be: Clinical presentation and diagnosis, as well as treatment protocols for genital warts.
Genital warts are a very common problem for the gynaecologist at everyday practice.
HPV infection is a common infection, sexually transmitted.
Genital warts appear in about 1% of general population
and as it seems, with the changes in the *** habbits which occur worldwide
the probability of developing genital warts during their lifetime of people who are teenagers nowadays,
Will be almost 10%
This is a study conducted using questionnaires to women in Nordic countries
in 2007
and many people were amazed by the results of the study.
because about 10% of women 18-45 years old, mentioned genital warts during their life.
and this was the average incidence of genital warts concerning these countries as you can see
10% incidence of genital warts
of course, at the second line you can see that the number of their *** partners
was quite high
Certainly, *** habbits today have been changed
and this is now considered (by young people) the usual average number of *** partners
the *** is the most common site of genital warts
and of course very often we find genital warts on the perineum
on the mucous membranes of the ***
and many times at the perianal area
about 10% of women with perianal condylomata have intra-*** involvement
It would be ideal to examine these women with a colposcope, if available
and we must know that we have metaplastic epithelium, like the previous speaker pointed out, in the *** canal, 3cm higher from the *** orifice
Genital warts do not appear so often, on the ***
As I told you before, it would be ideal for individuals appearing with external condylomata, to be examined by a colposcope.
Nonetheless, it is proven that only 2% of these women are found with HSIL lesions
Despite that a colposcopy is not recommended routinely, it would be appropriate to examine the whole lower genital tract and the perianal area of these women carefully.
Urethral warts are found in some cases and they may be difficult to treat.
Using laser is the best way to treat these warts.
More than 90% of genital warts are associated with HPV 6 or 11
about 5% are associated with HPV 16. This may explain its coexistence with HSIL
and other HPV types account for remainder
as you know, natural history is simple,
HPV enters through breaks in epithelium and settles into the basal layer
HPV sits latent for some time in the cells of the basal membrane,
and then if our immune system allows it, it begins replicating.
In the majority of cases, only subclinical lesions appear,
but if our immune system allows it, it may stimulate production of raised visible wart
which are results of a benign inflammation
it is important for us who must treat lesions
to remember the natural history of the disease
because there is the incubation period from 3 weeks up to 8 months
and then inflammation may occur, and therefore lesions
clinical and visible may appear,
There is a compensation by our immune system, as you can see in the diagram in the right
ie, from the first day of the infection until the appearance of the last wart
there is a timespan of a few months up to two or three years
therefore we must be patient about our course of treatement
because if we start to cauterize early lesions
and our immune system has not reached a good performance
we have a lot of recurrences.
Genital warts are highly infectious,
with a transmission rate ranging from 40% up to 80%
Transmissibility was proved by the “Korean war” study
Americans soldiers who returned from the war and had genital warts
passed them on to their wifes in a percentage of 66%.
Infectivity is highest in the cases of large visible lesions
this infection is treated by cell mediated immunity
As you know, immunity is lower in patients with immunosupression
Diabetic patients have some kind of immunosupression
most often problems apperar in women that use immunosuppresant drugs
like Ciclosporin Methotrexate Azathioprine for the treatment of rheumatic and other diseases.
and it seems that some kind of cell mediated immunosupression is caused by excessive smoking.
Genital warts usually cause no symptoms
they may cause irritation and soreness externally but usually they cause no symptoms
the symptom that is mostly irritating is the psycological distress
Genital warts cause psychological stress to women as well as to men.
Concerning clinical presentation of genital warts, they may be single or multiple,
they may be found in clusters or plaques
they may be flat, but the typical ones are the cauliflower-shaped
On the surface of the warts, we can see these papillaes and that is why they are called papillomas.
Non-keratinized warts on mucous membranes
like that on the left image
And keratinized wart on skin, as you can see on the right image.
this is important knowledge for the clinical doctor
becuse non keratinized warts respond therapeutically to chemicals locally applied
for treatement as we will discuss later.
Regarding diagnosis, diagnosis is clinical in the vast majority of cases
but when they present atypically,
or are resistant to treatments,
we must take biopsies
the woman of the right photo
had already had 3 cryotherapies in a hospital
and unfortunately these lesions were not warts, but it proved to be invasive cancer.
Deep biopsies are needed in such a case.
We check the whole lower genital tract
and as we already discussed the best way to do this is with the colposcope
we also check the perianal area
And the *** canal using proctoscopes,
you may use the plastic ones (dispersible).
We must always keep in mind
that if there are intra-*** lesions and we do not treat them
they may act as a reservoir of the virus.
Because HPV infection is sexually transmitted, if we suspect that the patient may have other STDs,
it is best to check for all STDs
Differential diagnosis is done in condylomata lata (syphilis)
they are not very often but it is good to keep an image of them in mind,
Differential diagnosis from molluscum contagiosum
from the benign fibroepithelial polyps which are also called acrochordones,
from seborrheic keratosis,
from nevis which are exophytical like the one you see,
and of course from the coexistence of warts with VIN
mainly in cases with grey lesions.
The verrucous carcinomas are rare. They are caused by HPV types 6 and 11.
Low form of malignancy, they rarely metastasize.
Verrucous carcinoma is usually a local disease
A rare variety of these carcinomas
In a woman 80 years old,
It is not typically exophytic tumor
You can see a micropapillary surface
As you know micropapillomatosis in the *** is considered normal finding in young women,
But it is not normal to have micropapillomatosis in a woman 70 or 80 years old.
like the patient seen in these photos
in women of these ages, the skin of the *** appears to be flat
if we have lesions with micropapillae, we have to be suspicious and to take biopsies
Micropapillomatosis in younger women is normal, and we do not treat it
because although sometimes it looks like warts,
Actually it is a normal finding.
How do we differentiate micropapillomatosis labialis from warty lesions?
Especially if you have large papillae, as you can see at the left and middle photo,
In MPL every papilla has its own base.
On the contrary, in the case of condyloma the papillae start from a common basis, which is elevated.
The colposcope, as we already discussed, is the ideal magnifying tool, in order to examine the lower genital tract and *** area
Colposcopy is not common practice
Especially by Dermatologists
Nonetheless, due to the bright light and the magnifications, provided by the colposcope,
we can distinguish micropapillomatosis and locate small condylomas.
The role of colposcopy though, is not to find subclinical HPV-infection
because we do not treat subclinical HPV infection.
There is no evidence that treatment of subcilinical HPV infection,
prevents transmission to a *** partner.
So, it is officially recommended, as you can see here on the slide,
We must not treat subclinical HPV infection,
because no therapy has been identified that can eradicate infection.
We check the whole lower genital track
ideally with a colposcope.
Are biopsies necessary?
Biopsies are taken when we have atypical appearance like the grey one, up on the left
Or if we have a papular lesion that is elevated
and looks keratinized.
When we have hyperkeratosis we are afraid that there is invasive cancer underneath
or when we have a hemorrhagic lesion with ulcers or erosions, as you can see below on the left
or in the case of the patient (down right) with recurrences after several therapeutic efforts (proved to be invasive cancer).
Therapy for condylomas is by no means straightforward due to the viral cause.
There are a large variety of therapies in use, which means that there is not a perfect one.
Recurrences are very common
if we see the therapeutic results of the several treatment methods that exist, in the middle column
we will notice that they all have their clearance percentages, ranging in different publications
There are no very good prospective studies, with large numbers of patients,
but it seems that these are the therapeutic results of the several methods
With a lot of recurrences.
Recurrences are not a problem only for the patient, but also for us
sometimes we find ourselves in a very difficult position, as health care providers,
because as you know, patients are in psychological distress.
In these cases we must explain to them the logic of the treatment
which is to reduce the viral load and restore normal function
as well as to relieve their symptoms, especially psychological.
Most patients consider these lesions as the stigma of an STD
and of course there is the fear of cancer, because they have heard that HPV are related to carcinogenesis.
Based on the natural history as we said before, we must not be in a hurry
the first step is the eradication of any associated infections in the lower genital track.
Often, we have fungal infections or anaerobic infections.
We have to treat any infection, even a non-specific vaginitis or a bacterial inflammation
or coexisting chlamydia. This policy will help us to be more efficient, treating the condylomata afterwards.
it will also help us because it will restore the health of mucous membranes and skin
and there will be a better healing process and probably less recurrences.
Now, which method is the best one?
It depends on the individual case.
It depends from the individual patient, the lesions that exist (number, topography, distribution)
and of course it depends from the experience of the health provider and the existed facilities.
Treatment methods can be categorized in Pharmaceuticals and surgical (excisional or destructive).
The most popular are the self applied agents,
Namely: Podophyllotoxin, Aldara, and Polyphenon-E (from green tea extract)
Trichloroacetic acid is a chemical method to destroy condylomata, but it is applied by the physician
It requires a lot of visits at the office
so one might say why not have cryotherapy or cauterization
usually requiring less visits.
than the treatment with trichloroacetic.
So we check the whole lower genital tract
and the perianal area. We have to treat every lesion
Otherwise we will have recurrences.
As I said before for vulvar condylomata, those on mucous membranes
are not keratinized,
and they respond better to podophyllotoxin and trichloroacetic acid.
Condylomata on the skin of the hairy areas, do not respond to these agents,
because the chemical cannot pass the keratine.
Imiquimod may be suitable for both types of condyloma.
This is an advantage of this method (treating with Aldara).
the same performance with imiquimod,
has the green tea extract
in the US it has been approved by the FDA.
This slides describes the treatment with podophyllotoxin
Available in solution and gel formulations.
Podophyllotoxin is not toxic but,
it is wise not to use more than 0.5ml of podophyllotoxin, daily.
As you know podophyllin is toxic, but not podophyllotoxin.
Nonetheless, we must not treat more than 10cm of condyloma daily (requiring amount of podophyllotoxin more than 0.5ml)
Imiquimod has certain advantages. It must be washed off the next morning,
while the green tea extract does not need to be washed off,
and it seems that it has similar treatment rates with imiquimod.
All of the described before treatments (Podophyllotoxin, Aldara, Veregen),
are very good as therapies of first line.
Before proceeding to excisional or destructive methods.
it is good to start with simple and cheap treatment modalities, applied by the patient.
But not all of these pharmaceutical agents are considered safe during pregnancy.
During pregnancy, condylomas might be a problem
because of the relative immunosupression.
I already told you, my opinion on trichloroacetic acid treatment,
You can use it if you like,
But don’t forget to cover the surrounding area with Vaseline,
because it is caustic for the surrounding tissues.
Cryotherapy is very popular by dermatologists.
We can use either liquid nitrogen spray or cryoprobe
which is adjusted to the size of the condyloma.
Basic rule is to freeze until a halo of a few millimeters in size appears around the lesion
Electrosurgery is a very good method for treating condylomata.
We can make a superficial loop, when treating cervical condylomata,
and feel that we need a biopsy.
Electrosurgery can be used either for vaginal,
or for vulvar
and perianal condylomata.
When is laser needed?
Laser is needed in special occasions
It is not used very often because it is expensive.
Sometimes it is used in patients with immunosupression, like the lady in the middle image,
Or if there are condylomata in the ***, the *** canal and the urethra.
New trends about the prevention and the treatment of warts are: vaccine,
green tea extracts.
Quadrivalent vaccine has been proved successful in the prevention of warts.
A new version of Aldara cream, is now used
(imiquimod 3.75% instead of 5%, now in use).
Therapeutic results with Aldara 3.75,
Are similar with those with Aldara 5%,
With less side effects (irritation of the skin).
Thank you very much for your attention!