Condyloma acuminatum is a sexually transmitted disease caused by human papillomavirus (HPV) infection with wart-like lesions. The disease is highly contagious, easily recurs and requires long and repeated treatment, which seriously affects the daily life of patients.
I. Diagnosis
1, diagnosis based on
Epidemiology: multiple sexual partners, unsafe sex, or a history of sexual partner infection; or a history of close indirect contact with patients with condyloma acuminatum, or a newborn mother who is HPV infected.
Clinical manifestations: incubation period: 3 weeks to 8 months, average 3 months; signs and symptoms: prepuce, glans, coronal sulcus, tether, penis, urethra, perineum and scrotum in men; labia, urethra, vagina, perineum, perineum, vaginal wall, cervix in women; perineum, anal canal and rectum in passive anal sex; oral sex in the mouth.
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 appearance on the mucosal surface of the skin 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 with normal skin mucosal appearance, lesions that are not obviously hyperplastic and keratinized, and a negative acetic acid test.
Laboratory tests: The main tests 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 vasodilatation, 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. The test should be performed in a laboratory accredited by the relevant institution.
1.Diagnostic criteria
Clinical diagnosis: should be consistent with clinical manifestations, with or without epidemiological history.
Confirmed cases: should meet both the requirements of clinical diagnosis cases and any of the laboratory tests.
II. Treatment
1.General principles
Remove warts as soon as possible, eliminate subclinical infection and latent infection around warts as far as possible, and reduce recurrence.
2, treatment options
The recommended treatment plan for external genital warts is as follows.
Out-of-hospital treatment.
The recommended solution is 0.5% haematoxylin tincture (or 0.15% haematoxylin cream): topical application twice a day for 3 d, followed by 4 d of discontinuation, 7 d as a course of treatment. If necessary, treatment may 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, followed by soap and water after 10h, for up to 16 weeks.
In-hospital treatment.
Recommended regimens: CO2 laser or high-frequency electrical therapy, liquid nitrogen freezing, microwave, photodynamic therapy.
Alternative: 30%-50% trichloroacetic acid solution, single topical application. If necessary, repeat every 1-2 weeks up to 6 times; or surgical excision; or intra-lesion injection of interferon.
Liquid nitrogen freezing with a freezing head is contraindicated in the treatment of intracavitary warts to avoid vaginal-rectal fistulas, etc. 30%-50% TCA solution is suitable for small lesions or papular lesions and should not be used for hyperkeratotic or large warts, multiple warts, or large warts. Care should be taken to protect the surrounding normal skin and mucous membranes during treatment. The adverse reactions are local irritation, redness, swelling, erosion, ulceration, etc.
3, treatment method selection
In the past, some guidelines advocated the use of topical medication to treat warts of less than 12.5 px in diameter, warts of less than 25 px in diameter, and warts of less than 15 in number.
However, many domestic scholars disagree with this view. On the one hand, warts of 25px 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 to reduce the traumatic surface is a principle in the treatment of condyloma acuminata, and this is especially important to reduce recurrence. If the warts in the urethra and perineum in men, vestibule, urethral orifice, vaginal wall and cervical orifice in women, or if the size and number of warts in both sexes exceed the above criteria, physical treatment or combined with aminoglutamic acid photodynamic therapy is recommended.
Cervical warts.
For patients with ectocervical warts, HPV typing, CIN grade, exfoliative cytology and biopsy for cancerous lesions are required before starting treatment. A gynecologist should be consulted for ectopic cervical warts. Low-risk cervical warts that are diagnosed can be treated with CO2 laser, microwave, or 30%-50% trichloroacetic acid solution.
Vaginal warts.
Liquid nitrogen cryotherapy (cold probes are not recommended because of the risk of vaginal perforation and fistula formation), or high-frequency electric knife, C2 laser, or microwave treatment.
Urethral warts.
The first thing you need to do is to use liquid nitrogen cryotherapy or 10%-25% tincture of benzoin with ghost resin. The warts are coated and allowed to dry before contact with the normal mucosa. If necessary, repeat once a week. Although there is limited information on the evaluation of the application of onychomycin and imiquimod for the treatment of distal urethral warts, some experts advocate the use 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: apply only a small amount of the solution to the wart, and leave it to dry with a layer of white cream visible on the surface, then use or acid or acid in the liquid. If necessary, repeat 1-2 weeks later 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 done in consultation with an anorectal specialist.
Photodynamic therapy.
If the warts are less than 12.5 px in diameter, or less than 25 px in diameter, they can be treated directly with photodynamic therapy, but beyond that, it is recommended to use other physical therapy combined with photodynamic therapy.
Intra-anal warts.
Joint treatment by STD and anorectal specialists is required. The rectal mucosal warts are sometimes accompanied by rectal warts. Patients with anal warts should be routinely examined for rectal mucosa, using anal fingering, conventional anoscopy, and high-resolution anoscopy.
Giant condyloma acuminatum.
Mostly combined treatment protocols are used. Pathological biopsy is required before treatment to clarify whether the tissue is cancerous. The primary treatment is removal of the warts, either surgical or high-frequency electric knife removal of the warts, followed by photodynamic therapy or topical medication.
Subclinical infections.
There is no effective management 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 have potentially 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, a white acetate test can be performed first to try to clear the subclinical infection in order to reduce recurrence.
III. Treatment of special cases
Pregnancy.
The use of onychomycin and imiquimod is contraindicated during pregnancy. Pregnant women with warts should be informed that HPV6 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 recommend termination of pregnancy in pregnant women with warts if there is no other reason to do so.
Pregnant women with warts may be considered for cesarean section after the fetus and placenta are fully mature and before the amniotic membrane is broken. Topical trichloroacetic acid can also be used.
Co-infected HIV patients.
Patients with suppressed immune function due to HIV infection or other reasons are less effective with commonly used therapies than immunocompetent patients and are more likely to relapse after treatment. These patients are more likely to develop squamous carcinoma on top of the acromegaly, and therefore often require biopsy to confirm the diagnosis.
Cases 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 to treat beyond the lesions to a depth of 2 mm and to 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.
IV. Follow-up
For the first 3 months after treatment of warts, patients should be advised to follow up at least once every 2 weeks. Any special circumstances (e.g. new lesions or bleeding on the wound surface) should be seen at any time so that appropriate clinical management can be obtained in a timely manner. After 3 months, the follow-up interval can be extended to 6 months after treatment according to the patient’s specific condition.
V. Prevention
Condom use reduces the risk of HPV infection in the genital tract and the risk of HPV infection-related diseases (i.e., condyloma acuminata or cervical cancer). However, HPV infections can occur in areas that are not safely covered or protected such as the scrotum, labia, or perianal area.