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Warts and All

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

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Warts and All

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  1. Warts and All Dr Daniela Brawley ST4 Genitourinary medicine 23rd November 2010

  2. Cases of genital warts/year in UK

  3. 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

  4. 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)

  5. 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

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

  7. 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

  8. But first… ….what’s a normal lump?

  9. Pearly penile papules • Normal anatomy • No treatment • Common presentation in young men • Reassure strongly that are normal

  10. Vulval papillomatosis • Smooth and symmetrical • Easily confused with HPV • Don’t progress • review at 1 month • No treatment

  11. Parafrenular glands • Symmetrical, small and smooth surface • No treatment required

  12. Fordyce spots or sebaceous follicles • Glands in clusters • Prepuce, shaft of penis and vestibular area of vulva • More obvious when skin is stretched • Reassurance

  13. Sebaceous cysts • No treatment necessary unless become too large or get infected • Reassurance • In men scrotal sebaceous cysts may occur

  14. Lymphocoele • Hard swelling behind coronal surface • No treatment required • Usually resolves over time • Reassurance

  15. And now… other differentials

  16. Molluscum contagiosum • Pox virus • Skin to skin contact, most likely sexual • Cryotherapy • STI screening including HIV especially if extensive

  17. Condyloma Lata of Secondary Syphilis • Refer GUM • Syphilis PCR and serology • Dark ground microscopy • STI screening • Penicillin and GUM follow-up

  18. Now for warts…. • Site, distribution and number • Morphology- keratinised or non keratinised • Patient features • Experience and equipment • Availability of cryotherapy

  19. Treatments • Podophyllotoxin (warticon) • Cryotherapy • Imiquimod (aldara) • Smoking cessation • Excision

  20. 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

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

  22. 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

  23. Source: Sandyford Protocols- External Anogenital Warts.

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

  25. Keratinised Warts • Cryotherapy first line • Imiquimod if not improving • Warticon less likely to be effective but can try for 4 weeks

  26. Non-keratinised warts • Warticon • Cryotherapy or imiquimod if not improving

  27. 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

  28. Extensive Sub-preputial warts • GUM referral • Imiquimod and cryotherapy • Surgical referral

  29. 20 week pregnant female

  30. 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

  31. Warts and Bowen’s Disease • Referral for biopsy of suspicious areas • Cryotherapy/ electrocautery • Circumcision

  32. Warts and VIN • Referral for biopsy of suspicious areas • Localised surgical excision • Referral to Gynaecology

  33. Features indicating biopsy • Atypical • Pigmentation • Flat warts • Older age groups • Immunosuppression including HIV • Heavy smokers

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