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, which 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 newborns whose mothers are HPV-infected.
The incubation period: 3 weeks to 8 months, an average of 3 months; signs and symptoms: in men, the prepuce, glans, coronal sulcus, ties, penis, urethra, perineum and scrotum; in women, the labia, urethra, vagina, 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 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 few patients have large warts due to immune deficiency or pregnancy, which can involve the entire vulva, perineum, and buttocks, 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 and breakage, maceration, erosion, bleeding or secondary infection. 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 white acetate 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. In the superficial layer of the epidermis (granular layer and the upper part of the spiny layer), focal, lamellar and scattered vacuolated cells can be seen; sometimes dense stained granular material of varying sizes, i.e. viral inclusion bodies, can be seen in the keratinocytes;
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. They should be performed in laboratories accredited by relevant institutions.
1.2 Diagnostic criteria
Clinical diagnosis 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 of the laboratory tests.
2.Treatment
2.1 General principles
Remove warts as early as possible, eliminate subclinical infection and latent infection around the warts as far as possible, and reduce recurrence.
2.2 Treatment options
The recommended treatment plan for external genital warts is as follows.
The recommended regimen is 0.5% tincture of haematoxylin (or 0.15% haematoxylin cream): apply topically twice a day for 3 days, then stop for 4 d. 7 d is 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 overnight, 3 times a week, followed by soap and water for 10h, for up to 16 weeks.
In-hospital treatment.
Recommended options: 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 warts in the cavity to avoid vaginal-rectal fistulas, etc. 30%-50% TCA is suitable for the treatment of small lesions or papular lesions, but not 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. 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.
The first thing is that the wart is already very large at 1cm, and there are many warts within 15, so 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 warts, and this is especially important to reduce recurrence.
Cervical warts: Before starting treatment for ectocervical warts, it is necessary to determine the HPV type, the grade of CIN, and to perform an exfoliative cytology and biopsy for the presence of cancerous lesions. 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.
The Urethral warts: liquid nitrogen cryotherapy or 10%-25% tincture of benzoin of 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 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.
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 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 infected areas 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 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.
In pregnant women with warts, a cesarean section may be considered after the fetus and placenta have fully matured and before the amniotic membrane has broken. Topical trichloroacetic acid can also be used.
Patients with co-infection with HIV: Patients with suppressed immune function due to HIV infection or other reasons are less effective than those with normal immune status 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 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.
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 management. At the same time, the patient should be advised to pay attention to the site of the lesions and to observe carefully for recurrence, which mostly occurs in the first 3 months. 3 months later, the follow-up interval can be extended to 6 months after treatment according to the patient’s specific condition.
5. 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 infection can occur in areas that are not safely covered or protected such as the scrotum, labia, or perianal area.
This guideline was developed under the leadership of the Dermatology and Venereology Branch of the Chinese Medical Association and the Dermatology Branch of the Chinese Medical Association, and was discussed collectively by all members of the STD Group, the STD Subspecialty Committee, and relevant experts from the STD Control Center of the Chinese Center for Disease Control and Prevention.