Condyloma acuminatum is a sexually transmitted disease caused by human papillomavirus (HPV) infection with wart-like lesions. The disease is highly contagious, easy to recur, requires long time repeated treatment, and seriously affects the daily life of patients.
1, diagnosis
1.1 Diagnosis basis
Epidemiology: multiple sexual partners, unsafe sex, or a history of sexual partner infection; or a history of close indirect contact with patients with condyloma acuminata, or a newborn mother with HPV infection. Zhihong Feng, Department of Dermatology, Workshop
Clinical manifestations: incubation period: 3 weeks to 8 months, average 3 months; signs and symptoms: prevalent in the foreskin, glans, coronal sulcus, ties, penis, urethral opening, perineum and scrotum in men, and in the labia majora and minora, urethral opening, vaginal opening, perineum, perineum, vaginal wall and cervix in women, and in the perineum, anal canal and rectum in those with passive anal intercourse, and in the oral cavity in those with oral intercourse.
The lesions initially appear as small localized papules, the size of a pinhead to a green bean, gradually increasing in size or number, spreading and spreading to the surrounding area, gradually developing into papillae, coronary, cauliflower, or shaped growths. The damage can be solitary or multiple. The color can range from pink to deep red (non-keratotic lesions), gray (severe keratotic lesions) and even brownish black (hyperpigmented lesions). A small number of patients develop large warts due to immunocompromise or pregnancy, which can involve the entire vulva, perineum, and gluteal sulcus, called giant warts.
Patients usually have no conscious symptoms, but a few patients may feel itching, foreign body sensation, pressure or burning pain, and may experience rupture, maceration, erosion, bleeding or secondary infection due to increased brittleness of the lesions and friction. Female patients may have increased vaginal discharge.
Subclinical and latent infections: subclinical infections have a normal surface appearance of the skin mucosa and may appear as well-defined whitish areas if a 5% acetic acid solution (white acetate test) is applied. Latent infection is defined as the presence of HPV in tissues or cells while the skin mucosa has a normal appearance, the lesion is not obviously hyperplastic and keratinized, and the acetic acid white test is negative.
Laboratory tests: the main ones are histopathological examination and nucleic acid testing.
Pathological examination: papilloma or verrucous hyperplasia, hyperkeratosis, lamellar hyperkeratosis, epidermal spine layer hypertrophy, basal cell hyperplasia, superficial dermal vascular dilatation, and lymphocyte-dominated inflammatory cell infiltration. Focal, lamellar and scattered vacuolated cells were seen in the superficial epidermis (granular layer and upper spiny layer); sometimes densely stained granular material of varying sizes, i.e. viral inclusion bodies, could be seen in keratin-forming cells.
Nucleic acid amplification test: amplification of HPV-specific genes (L1, E6, E7 region genes). A variety of nucleic acid detection methods are available, including fluorescent real-time PCR and nucleic acid probe hybridization tests. It should be carried out in laboratories accredited by relevant institutions.
1.2 Diagnostic criteria
Clinical diagnostic cases: should be consistent with clinical manifestations with or without epidemiological history.
Confirmed cases: should meet both the requirements of clinical diagnostic cases and any one of the laboratory tests.
2.Treatment
2.1 General principles
Remove warts as early as possible, eliminate subclinical infection and latent infection around warts as far as possible, and reduce recurrence.
2.2 Treatment options
The recommended treatment plan for external genital warts is as follows.
Outside the hospital treatment: the recommended program is 0.5% tincture of onychotoxin (or 0.15% onychotoxin cream): topical application twice a day for 3 d, followed by 4 d of discontinuation, 7 d for a course of treatment. If necessary, the treatment can be repeated for no more than 3 courses of treatment. Or 5% Imiquimod cream, applied to the wart, once every other night, 3 times a week, after 10h of application, wash the area with soap and water, up to 16 weeks.
In-hospital treatment.
Recommended regimens: CO2 laser or high-frequency electrical treatment, liquid nitrogen freezing, microwave, photodynamic therapy.
Alternative regimen: 30%-50% trichloroacetic acid solution, single topical application. If necessary, repeat every 1-2 weeks for up to 6 times; or surgical excision; or intra-dermal injection of interferon.
Liquid nitrogen freezing with a freezing head is contraindicated in the treatment of warts in the cavity to avoid vaginal-rectal fistulas, etc. 30%-50% TCA solution is suitable for the treatment of small lesions or papular lesions and should not be used for hyperkeratotic or large warts, multiple warts, or warts of large size. Care should be taken to protect the surrounding normal skin and mucous membranes during treatment. Adverse reactions are local irritation, redness, swelling, erosion, ulceration, etc.
2.3 Treatment options
In the past, some guidelines advocated the use of topical medication for the treatment of warts with a diameter of <0.5 cm, a diameter of <1 cm and a number of <15 warts.
However, many domestic scholars disagree with this view. On the one hand, warts of 1 cm are already large and warts of 15 or less are already numerous, and topical medication is not as timely as physical therapy; on the other hand, early removal of warts and reduction of the traumatic surface is a principle in the treatment of condyloma acuminata, and this is especially important to reduce recurrence. The most important thing is that the warts in the urethra and perineum in men, the vestibule, urethral opening, vaginal wall and cervical opening in women, or the size and number of warts in both sexes exceed the above criteria, are recommended to be treated with physical methods or combined with amino ketovaleric acid photodynamic therapy.
Cervical warts: For patients with cervical warts, HPV type, CIN grade, exfoliative cytology and biopsy for cancerous lesions should be determined before starting treatment. A gynecologist should be consulted for ectocervix warts. If you are diagnosed with low-risk cervical warts, you can use CO2 laser, microwave, or 30%-50% trichloroacetic acid solution for treatment.
Vaginal warts: liquid nitrogen cryotherapy (cold probe is not recommended because of the risk of vaginal perforation and fistula formation), or high-frequency electric knife, C2 laser, microwave and other treatment options.
Urethral warts: liquid nitrogen cryotherapy or 10%-25% tincture of benzoin of ghost resin. The warts are coated and allowed to dry before they can come into contact with the normal mucosa. If necessary, repeat once a week. Despite the limited information on the evaluation of the application of onychomycin and imiquimod for the treatment of distal urethral warts, some experts advocate the application of this treatment in some patients. The unique effectiveness of photodynamic therapy in the treatment of urethral warts has been confirmed by several national trials.
Perianal warts: liquid nitrogen cryotherapy, or 30%-50% trichloroacetic acid: only a small amount of the solution is applied to the wart, and when it dries a layer of white cream is visible on the surface, followed by or acid or acid in liquid. Have to, 1-2 weeks later repeat 1 time, up to 6 times. Surgical treatment: Some patients with perianal warts accompanied by rectal warts should undergo rectal finger examination and/or anoscopy. The management of rectal warts should be consulted by an anorectal specialist.
The most important thing is that you can use photodynamic therapy to treat the warts, but it is recommended to use other physical therapies combined with photodynamic therapy to treat the warts.
The anal warts: need to be treated jointly by STD and anal specialist. The anus warts are sometimes accompanied by rectal mucosal warts. Patients with anus warts should be routinely examined for rectal mucosa, using anal finger diagnosis, conventional anoscopy, and high-resolution anoscopy.
Pathological biopsy is required before treatment to clarify whether the tissue is cancerous. The primary treatment is to remove the warts, either surgically or with high-frequency electrosurgery, followed by photodynamic therapy or topical medication.
Subclinical infections: There is no effective treatment for asymptomatic subclinical infections, and treatment is generally not recommended because there is no effective way to remove HPV from infected cells, and overtreatment can lead to potential adverse consequences. Treatment is based on close follow-up and prevention of transmission to others. Treatment (e.g., laser, cryotherapy) may be given on a case-by-case basis to suspected sites of infection with a positive white acetate test. Some studies suggest that photodynamic therapy may be effective for subclinical infections.
Whether it is drug therapy or physical therapy, the white acetate test can be done first to try to clear the subclinical infection to reduce recurrence.
3.Treatment of special cases
Pregnancy: pregnancy is contraindicated with ghost toxin and imiquimod. As a result of the rapid growth of warts during pregnancy, pregnant women’s warts should be treated with physical methods such as liquid nitrogen freezing or surgery as early as possible in the early stages of pregnancy. Pregnant women with warts should be informed that HPV 6 and 11 can cause respiratory papillomatosis in infants and children, that newborns born to women with warts are at risk of developing the disease, and that there is no good reason to advise pregnant women with warts to terminate their pregnancy if there is no other reason to do so, and that abortion increases the risk of pelvic inflammatory disease and HPV upstream infection.
In pregnant women with acromegaly, a cesarean section may be considered after the fetus and placenta are fully mature and before the amniotic membranes are broken. Postpartum neonates should avoid contact with HPV-infected individuals; if necessary, joint obstetrics and gynecology and venereal disease specialists should be consulted for treatment. Topical trichloroacetic acid can also be used for treatment.
Patients with co-infection with HIV: Patients whose immune function is suppressed due to HIV infection or other reasons are less effective than those with normal immunity and are more likely to relapse after treatment. These patients are more likely to develop squamous carcinoma on top of acromegaly and therefore often require biopsy to confirm the diagnosis.
In the case of recurrence, a small number of patients have multiple recurrences of condyloma acuminatum lesions, for which there is no clear and effective therapy. When using laser treatment, care should be taken to detect subclinical infections early, and treatment should extend beyond the lesions by 2 mm to a depth of the superficial dermis. Removal of possible etiologies, such as other coexisting infections. After extensive and complete removal of warts, topical treatment with photodynamic therapy or imiquimod may reduce the recurrence rate.
4.Follow up
The first 3 months after the treatment of warts, patients should be asked to follow up at least once every 2 weeks, there are special circumstances (such as the discovery of new lesions or trauma bleeding, etc.) should be consulted at any time, in order to get the appropriate clinical treatment in a timely manner. At the same time, patients should be informed to pay attention to the good site of skin lesions and carefully observe whether there is recurrence, which mostly occurs in the first 3 months. after 3 months, the follow-up interval can be appropriately extended according to the patient’s specific situation, 6 months after treatment.
5.Prevention
Condom use can reduce the risk of HPV infection in the genital tract, as well as the risk of HPV infection-related diseases (i.e., condyloma acuminatum or cervical cancer). However, HPV infection can occur in areas that are not safely covered or protected such as the scrotum, labia, or perianal area.