Warts and All

Dr Daniela Brawley ST4 Genitourinary medicine 23 rd November 2010

Cases of genital warts/year in UK

Human Papilloma Virus

 > 100 sub-types of HPV  HPV 6 and 11 cause 90% of genital warts  Most clear the infection in 9 months  HPV 16 and 18 risk for malignant change – Persistent infection with oncogenic sub-types increases risk of malignant change

Prevalence

 1% of population have visible warts  10% have active HPV infection  60% have cleared HPV – However can have long latent or lifelong phase  ? Missed opportunity with quadrivalent HPV vaccine (6/11/16/18)

Transmission

 Sexual in majority of cases – Female to male 71% at 3 months – Male to female 54% at 3 months  Condoms can reduce risk but don’t eliminate  Increased risk if immunocompromised and/or smoker

Diagnosis

 Diagnosis is by examination under good light  Consider referral/biopsy if atypical or unsure  STI screening  Partner notification not necessary

STI screening

 10-20% have co-existing STIs  Extensive warts – HIV indicator disease – BHIVA 2008 HIV testing guidelines  Chlamydia/ Gonorrhoea – Urine in males – Vulvovaginal/cervical swab in females  HIV/Syphilis

But first…

….what’s a normal lump?

Pearly penile papules

 Normal anatomy  No treatment  Common presentation in young men  Reassure strongly that are normal

Vulval papillomatosis

 Smooth and symmetrical  Easily confused with HPV  Don’t progress – review at 1 month  No treatment

Parafrenular glands

 Symmetrical, small and smooth surface  No treatment required

Fordyce spots or sebaceous follicles

 Glands in clusters  Prepuce, shaft of penis and vestibular area of vulva  More obvious when skin is stretched  Reassurance

Sebaceous cysts

 No treatment necessary unless become too large or get infected  Reassurance  In men scrotal sebaceous cysts may occur

Lymphocoele

 Hard swelling behind coronal surface  No treatment required  Usually resolves over time  Reassurance

And now…

other differentials

Molluscum contagiosum

 Pox virus  Skin to skin contact, most likely sexual  Cryotherapy  STI screening including HIV especially if extensive

Condyloma Lata of Secondary Syphilis

 Refer GUM  Syphilis PCR and serology  Dark ground microscopy  STI screening  Penicillin and GUM follow-up

Now for warts….

 Site, distribution and number  Morphology- keratinised or non keratinised  Patient features  Experience and equipment – Availability of cryotherapy

Treatments

 Podophyllotoxin (warticon)  Cryotherapy  Imiquimod (aldara)  Smoking cessation  Excision

Warticon

 Purified extract of podophyllin  Solution (0.5%) or cream (0.15%)  Non-keratinised warts, not perianal  3 days BD then 4 days rest for 4 weeks  Soreness and ulceration  NOT used in pregnancy

Cryotherapy

 Necrosis of dermal-epidermal junction  Keratinised warts and intrameatal warts  Weekly application with “Halo” and “Freeze and thaw” techniques  Safe in pregnancy

Aldara

 Immune response modulator  Non formulary and expensive (£50/month)  Used for resistant/extensive warts  3 times a week for maximum 16 weeks  NOT used in pregnancy

Source: Sandyford Protocols External Anogenital Warts.

Clearance rates TREATMENT

Cryotherapy Imiquimod (Aldara) Podophyllotoxin (Warticon)

END OF TREATMENT

63-88 (75) 50-62 (58) 42-88 (65) Surgical excision 89-93 (91)

>3 MONTHS

63-92 50-62 34-77 36

RECURRENCE RATES (%)

0-39 (20) 13-19 (16) 10-91 (50) 0-29 (15)

Source: United Kingdom National Guideline on the Management of Anogenital Warts, 2007. (BASHH)

Keratinised Warts

 Cryotherapy first line  Imiquimod if not improving  Warticon less likely to be effective but can try for 4 weeks

Non-keratinised warts

 Warticon  Cryotherapy or imiquimod if not improving

Perianal warts

 Cryotherapy first line  Imiquimod if not improving  Warticon can be used but not licensed  Proctoscopy not indicated unless immune suppressed, or symptoms in anal canal

Extensive Sub-preputial warts

 GUM referral  Imiquimod and cryotherapy  Surgical referral

20 week pregnant female

Warts in pregnancy

 Cryotherapy  Warticon and Imiquimod contraindicated  Improve/resolve 6-8 weeks after delivery  Not an indication for Caesarean Section  Small risk of transmission both genital and laryngeal papilloma – – 1 in 400 No reduction with c-section

Warts and Bowen’s Disease

 Referral for biopsy of suspicious areas  Cryotherapy/ electrocautery  Circumcision

Warts and VIN

 Referral for biopsy of suspicious areas  Localised surgical excision  Referral to Gynaecology

Features indicating biopsy

 Atypical  Pigmentation  Flat warts  Older age groups  Immunosuppression including HIV  Heavy smokers

Extensive warts

 Trial of imiquimod +/- cyrotherapy  Referral to Gynaecologist for surgical removal  STI screening

Single wart at fourchette

 Cryotherapy  Surgical excision

Extensive anal warts HIV positive gay man

 GUM referral  Syphilis PCR and serology  Cryotherapy and/or Imiquimod  Proctoscopy  Surgical referral – Risk of AIN

Meatal Warts

 Cryotherapy – If can see extent of warts  Concern about causing urethral stenosis  Warn about symptoms of urethral obstruction

Vaginal warts

 Usually resolve with treatment of external warts  Cryotherapy if not improving

Cervical warts

 Usually resolve with treatment of external warts  Ensure has had recent smear – No need for additional smears  If no external warts or no improvement with treatment of external warts refer to colposcopy

Summary points

 Treat the patient in front of you  Offer STI testing  Smoking cessation  Refer if unsure, not improving or suspicious features

Sandyford contacts

 www.sandyford.org

 0141 211 8130  [email protected]

Some final points…

Chlamydia/Gonorrhoea NAAT test

PREFERRED SAMPLE

VULVOVAGINAL SWAB

Tests for ulcers

 Syphilis  Herpes type 1 and 2  Combined PCR test  Confirm with syphilis serology

PRIMARY CARE VAGINAL DISCHARGE PROTOCOL History Low risk STI Typical BV or VVC history No symptoms of PID Examination and pH High risk STI Pregnant Requests testing Examination, pH and CT/GC NAAT CT/GC NAAT Recurrence Symptoms of PID Postpartum Gynaecological instrumentation Exam HVS CT/GC NAAT pH < 4.5

Treat for VVC pH > 4.5

Treat for BV pH < 4.5

Treat for VVC Await CT/GC NAAT pH > 4.5

Treat for BV Await CT/GC NAAT GUM referral if GC positive or unresolved BV- bacterial vaginosis VVC- vulvovaginal candida CT/GC NAAT- Chlamydia/Gonorrhoea molecular test GUM- genitourinary medicine clinic