Condyloma acuminatum is a sexually transmitted disease caused by human papillomavirus (HPV) infection with wart-like lesions. The disease is highly contagious, easily recurs, requires long and repeated treatment, and seriously affects the daily life of patients.
I. Diagnosis
(a) Diagnosis based on.
1, 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 the mother of a newborn child is HPV-infected.
2, clinical manifestations.
① incubation period: 3 weeks to 8 months, an average of 3 months.
The symptoms and signs: in men, the prepuce, glans, coronal sulcus, tether, penis, urethral opening, perineum and scrotum, in women, the labia majora and minora, urethral opening, vaginal opening, perineum, perineum, vaginal wall, cervix, etc. Passive anal intercourse can occur in the perineum, anal canal and rectum, oral intercourse 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 may range from pink to deep red (non-keratinized lesions), gray (severely keratinized lesions), or 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 means that the tissue or cells contain HPV but the appearance of the skin mucosa is normal, the lesion proliferation keratinization is not obvious, and the acetic acid white 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 the 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. It should be carried out in a laboratory accredited by the relevant institution.
(ii) Diagnostic criteria.
1, clinical diagnosis of cases: should be consistent with clinical manifestations, with or without epidemiological history.
2, confirmed cases: should meet both the requirements of clinical diagnosis of cases and laboratory tests in either.
II. Treatment
(A) general principles.
Remove warts as soon 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, out-of-hospital treatment: the recommended program for 0.5% tincture of haematoxylin (or 0.15% haematoxylin cream): topical application twice a day 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.
2, in-hospital treatment.
① recommended program: CO2 laser or high-frequency electric treatment, liquid nitrogen freezing, microwave, photodynamic therapy.
②Alternative solution: 30% to 50% trichloroacetic acid solution, single topical application. If necessary, repeat every 1 to 2 weeks for up to 6 times; or surgical excision; or intra-lesion injection of interferon.
Liquid nitrogen freezing with a freezing head is prohibited for the treatment of warts in the cavity to avoid vaginal-rectal fistula. 30% to 50% TCA solution 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. The adverse reactions are local irritation, redness, swelling, erosion, ulceration, etc.
(c) Treatment options.
In the past, some guidelines advocated the use of topical medications for the treatment of warts of less than moderate size (single warts < 0.5 cm in diameter, warts in clusters < 1 cm in diameter, and warts < 15 in number) in the external genital area of both sexes. 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 drug treatment 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 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. The actual low risk cervical warts can be treated with CO2 laser, microwave, or 30% to 50% trichloroacetic acid solution.
2, vaginal warts: liquid nitrogen cryotherapy (cold probe is not recommended, because there may be a risk of vaginal perforation and fistula formation), but also the choice of high-frequency electric knife, CO2 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 to 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. 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 dry when the surface is visible to form a layer of white cream, then use talc or sodium bicarbonate or liquid soap to neutralize the unreacted acid. If necessary, repeat 1 to 2 weeks later, up to 6 times. Surgical treatment: Some patients with perianal warts accompanied by rectal warts should undergo rectal examination and/or anoscopy. The treatment 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 anoscopy, high-resolution anoscope.
6, huge condyloma acuminata: more joint treatment program. Before treatment 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 over-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, 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
(i) Pregnancy.
Pregnancy is contraindicated with ghost toxin and imiquimod. Pregnant women with warts need to be informed that HPV 6 and 11 can cause inhalational 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, and that abortion increases the risk of pelvic inflammatory disease and HPV upstream infection. Pregnant women with acromegaly may be considered for cesarean section after the fetus and placenta are fully mature and before the amniotic membrane is broken. Postpartum newborns should avoid contact with HPV-infected individuals; joint consultation with obstetrics and gynecology and STD specialists is required if necessary. It can also be treated with topical trichloroacetic acid.
(ii) People with co-infection with HIV.
Patients whose immune function is suppressed due to HIV infection or other reasons, the efficacy of commonly used 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 based on acromegaly and therefore often require biopsy to confirm the diagnosis.
(iii) Cases of recurrence.
A few patients have multiple recurrences of condyloma acuminata 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.
IV. Follow-up
In the first 3 months after the treatment of warts, patients should be advised 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 receive timely and appropriate clinical management. 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 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 infections can occur in areas not covered or protected by condoms such as the scrotum, labia, or perianal area.