Condyloma acuminatum is a sexually transmitted disease caused by human papillomavirus (HPV) infection with wart-like lesions. The disease is highly contagious, easily recurring and requires long and repeated treatment, seriously affecting the patient’s daily life.
I. Diagnosis
(A) Diagnosis based on.
1, epidemiology: there are 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 newborn mothers for HPV infection.
2, clinical performance: ① incubation period: 3 weeks to 8 months, an average of 3 months; ② symptoms and signs: men are prevalent in the foreskin, glans, coronal groove, ties, penis, urethral opening, perineum and scrotum, women are the labia, urethral opening, vaginal opening, perineum, perineum, vaginal wall, cervix, etc. Passive anal sex can occur in the perineum, anal canal and rectum, oral sex can appear 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 to the surrounding area and developing into papillae, corns, cauliflower-shaped or masses. The lesions may be solitary or multiple.
The color can range from pink to deep red (non-keratinized lesions), gray (severely keratinized lesions) and even brownish black (hyperpigmented lesions). A few patients develop large warts due to immunocompromise or pregnancy, which can involve the entire vulva, perineum, and buttock groove, called giant condyloma acuminata.
The patient usually has no conscious symptoms, but a few patients may feel itchy, foreign body, pressure or burning pain, which can be caused by increased brittleness of the lesions, friction, ulceration, erosion, bleeding or secondary infection. Female patients may have increased vaginal discharge.
Subclinical and latent infections: Subclinical infections have a normal appearance on the surface of the skin and mucous membranes, and may appear as well-defined whitish areas if a 5% acetic acid solution (white acetate test) is applied. Latent infection is the tissue or cells containing HPV but the skin mucosa appearance is normal, the lesion proliferation keratinization is not obvious, the white acetate test is negative.
3, laboratory tests: the main histopathological examination and nucleic acid testing. ①Pathological examination:papilloma or warty hyperplasia, hyperkeratosis, lamellar hyperkeratosis, epidermal spine layer hypertrophy, basal cell hyperplasia, superficial dermal vascular dilatation, and lymphocyte-based inflammatory cell infiltration.
In the superficial layer of the epidermis (granular layer and the upper part of the spiny layer), focal, lamellar and scattered vacuolated cells were seen; sometimes densely stained granular material of varying sizes, i.e. viral inclusion bodies, could be seen in keratin-forming cells.
②Nucleic 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. They should be carried out in laboratories accredited by the relevant institutions.
(II) Diagnostic criteria.
1, clinical diagnostic cases:should be consistent with clinical manifestations, with or without epidemiological history.
2, confirmed cases: should meet both the requirements of the clinical diagnosis of the case and laboratory tests in either one.
II. Treatment
(A) general principles: remove warts as early as possible, eliminate subclinical infection and latent infection around warts as far as possible, reduce recurrence.
(B) Treatment options:The recommended treatment options for external genital warts are as follows.
1, outside the hospital treatment: the recommended program for 0, 5% of the tincture of haematoxylin (or 0, 15% haematoxylin cream): 2 times daily topical, for 3 d, then, stop 4 d, 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, overnight once, 3 times a week, 10h after the drug, soap and water to wash the site with the drug, the longest available up to 16 weeks.
2, in-hospital treatment: ① recommended program: C02 laser or high-frequency electric treatment, liquid nitrogen freezing, microwave, photodynamic therapy; ② alternative program: 30% to 50% trichloroacetic acid solution, a single topical application. If necessary, repeat once every 1-2 weeks up to 6 times; or surgical excision; or intra-dermal injection of interferon.
Liquid nitrogen freezing with a freezing head is contraindicated for the treatment of warts in the cavity to avoid vaginal-rectal fistulas, etc.
The 30% to 50% TCA solution is suitable for treating 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.
(C) Treatment options.
The external genital area of both sexes can be seen as below moderate warts (single warts <0, 5cm in diameter, warts masses <1cm in diameter, number of warts <15): some previous guidelines advocate topical drug treatment.
However, many domestic scholars disagree with this view. On the one hand, warts of 1cm 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 traumatic surfaces is a principle in the treatment of condyloma acuminata, and this is especially important to reduce recurrence.
The actual fact is that you can find a lot of people who are not able to get a good deal on a lot of things. A gynecologist should be consulted for ectocervix warts. If the cervical warts are diagnosed to be of low risk, CO2 excitation or microwave treatment can be used.
The actual fact is that you can find a lot of people who are not able to get a good deal on this.
2, vaginal warts: liquid nitrogen cryotherapy (not recommended to use cold probe, because there may be a risk of vaginal perforation and fistula formation), can also choose high-frequency electric knife, C02 laser, microwave and other treatment methods.
3, urethral warts: liquid nitrogen cryotherapy or 10% to 25% ghost resin benzoin tincture. Warts coated with drugs, to dry, and then only with normal mucous membrane contact. If necessary, repeat once in 1 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. Photodynamic therapy in the treatment of urethral warts has a unique effect has been confirmed by a number of domestic experiments.
4, perianal warts: liquid nitrogen cryotherapy, or 30% to 50% trichloroacetic acid: only a small amount of liquid on the warts, to be dry when the surface is visible to form a layer of white cream, and then use talc or sodium bicarbonate or liquid soap to neutralize the unreacted acid. If necessary, repeat 1 time after 1 to 2 weeks, 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 a specialist in anorectal medicine.
5, anal warts: the need for sexually transmitted diseases and anorectal specialist doctors together. The anal warts are sometimes accompanied by rectal mucosal warts, patients with anal warts should routinely check the rectal mucosa, can be used anal diagnosis, conventional anoscope, high-resolution anoscope.
6, huge condyloma acuminata: the use of joint treatment program. In the treatment before the need to do pathological biopsy to clarify whether the tissue is cancerous. The first treatment is to remove the warts, you can choose surgery or high-frequency electric knife to remove the warts, and then with photodynamic therapy or topical drug treatment.
7, subclinical infection: for asymptomatic subclinical infection there is no effective way to deal with it, and generally do not recommend treatment, because there is no effective way to remove HPV from the infected cells, and excessive treatment but cause 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 in order to reduce recurrence.
III. Treatment of special cases
(a) Pregnancy:
Pregnancy is contraindicated by the use of ghost toxin and imiquimod.
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 newborns should avoid contact with HPV-infected individuals; if necessary, joint obstetrics and gynecology and venereal disease specialists should be consulted for treatment. It can also be treated with topical trichloroacetic acid.
(II) People with co-infection of HIV
Patients whose immune function is suppressed due to HIV infection or other reasons, the efficacy of common therapies is not as good as those with normal immunity, and they 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.
(C) recurring cases
A few patients will have multiple recurrences of condyloma acuminata lesions, for these patients, there is no clear and effective treatment. When using laser treatment, attention should be paid to early detection of subclinical infection, 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.
IV. Follow-up
The first 3 months after the treatment of warts, patients should be asked to follow up at least once every 2 weeks, if 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, the patient should be informed to pay attention to the good site of skin lesions and carefully observe whether there is any 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 until 6 months after the last treatment.
V. Prevention
Condom use can reduce the risk of HPV infection in the genital tract and the risk of HPV infection-related diseases (i.e., condyloma acuminatum or cervical cancer). However, HPV infection can occur in areas not covered or protected by condoms such as the scrotum, labia, or perianal area.