Condylomata acuminata
Last Updated: 2023-07-07
Author(s): Anzengruber F., Navarini A.
ICD11: 1A95
Last Updated: 2023-07-07
Author(s): Anzengruber F., Navarini A.
ICD11: 1A95
Fig warts, pointed condylomas, wet nipples, anogenital warts.
Highly infectious STD (sexually transmitted disease).
World's most common transmitted viral STD.
Approximately 1% of the population (15-49 years of age) has condylomata acuminata.
It is assumed that the probability of contracting condylomata acuminata by the age of 27 can be put at 4, 7%.
HPV prevalence among women in the pre-vaccination era is estimated to be 9-21%.
Due to the HPV vaccines, a decrease in the incidence of anogenital warts has already been observed in 15-19 year old women (data from Australia speak in part of a decrease in the number of women with the disease by almost 90%!
No sex difference. Highest prevalence in young adults up to the age of 40.
Predisposition to warts
Predisposing factors: Immunosuppression, nicotine abuse, promiscuity.
LR-HPVs, especially types 6 and 11, are considered to be causative for more than 90% of all anogenital condylomata acuminata.
Incubation period of weeks to 6 months.
Spontaneous remission in up to 30%.
Condylomas can occur both genitally and anally.
>Painless, often confluent, skin-coloured-livid, soft, sometimes exophytic growing papules, plaques and tumours.
Clinic
If necessary, biopsy.
An acetic acid test for 5 minutes (5% external, 3% vaginal and intraanal) shows white staining. This traditional test is not always specific.
If necessary
If necessary, proctoscopic examination (MSM).
If the entrance to the urethra is affected, do not do a cystoscopy without prior sanitation (contamination).
Determine hepatitis B, C, syphilis and HIV serology in every patient!
Decent hyperkeratosis, focal parakeratosis, marked acanthosis, enlarged rete ridges, koilocytes, no enlargement of the stratum granulosum (distinguishing feature from verruca vulgaris).
Frequent recurrences. Inform patients about this right from the start!
>Both girls and boys should be vaccinated with a tetravalent vaccine (types 6, 11, 16, 18) from the age of 9, but before the first sexual intercourse. If this has already occurred, an individual decision must be made.
Follow-up checks to exclude recurrence after approx. 6 months, earlier if necessary in case of recurrence.
Partner should be examined by a doctor in any case!
Educate patients about ping-pong phenomenon, which stands for re-infection by the untreated partner. Therefore, both partners should be treated at the same time.
Topical therapy (mostly off label use!)
Cryotherapy
Application: 2x to 15 seconds.
Note: effective, cheap, briefly uncomfortable for patients.
Immune modulators
Imiquimod
Aldara® 3x weekly for 12 weeks.
off-label use:
Application: 5x/week for several weeks, maximum 16 weeks.
Necessary before ablation of the wart surface.
NW: Redness, itching, burning, erosion of the skin. Patients should be informed about this before starting the therapy!
Podophyllin/podophyllotoxin
Condyline® Lin: Apply 2x daily for 3 consecutive days. Repeat if necessary
off-label-use:
Apply 2x daily for 3 consecutive days, protecting surrounding skin. Repeat if necessary.
KI: < 12yrs, open wounds, women of childbearing age, contraception recommended until 30 days after therapy, pregnancy, lactation.
Sinecatechins (Veregen® - Ointment) Green tea extract
Application: 3x daily for up to 16 weeks
Trichloroacetic acid 85% (magistral formulation)
Application: 1x/week with cotton swab. Therapy belongs in the hands of a doctor. Also allowed during pregnancy, in case of overdose neutralisation with sodium bicarbonate solution
Removal with CO² laser/electrocautery/curette/excision:
CAVE infectivity! Especially with lasers and electrocautery. Always wear a face mask or goggles and a mouth guard! Fume extraction is essential
Other therapies described:
Interferon- β gel application should be carried out for a maximum of 4 weeks.
In Switzerland only available via foreign pharmacy.
Germany: Fiblaferon® 0, 1 million IU/g, 5x tgl.
HPV vaccination
Currently available are bivalent vaccines against HPV 16 and 18 (Cervarix®) or quadrivalent vaccines against HPV 6, 11, 16 and 18 (Gardisil®). The vaccines are licensed for girls and boys from the age of 9. Vaccination of girls and boys is recommended before the first sexual intercourse. Data on the duration of effect of the vaccine protection are not available.
In total, the vaccines are valid for girls and boys from 9 years of age
Overall, the vaccinations are considered to be tolerable and effective.
If at least one vaccine dose has been administered, protection against CIN/VIN/VAIN can be expected to be approx. 44%. If the vaccination has been fully administered, there is almost 100% protection.
In terms of data, no influence on already existing HPV infections is currently to be expected. However, there are case reports of remission of existing HPV infections, e.g. resistant warts, some of which were not covered by the vaccine
According to study results, cross-reactivity to other HPV types, especially 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68, can be expected.
Efficacy of the vaccine in immunocompromised patients (HIV-infected, organ transplant recipients) is difficult to assess in terms of data.
Vaccination recommendations are partly different:
CH: Federal Office of Public Health (FOPH) and Federal Commission on Immunisation (EKIF) recommend:
11-14 yrs: 2 injections with 6-month intervals
Recommended for girls as basic vaccination, for boys as supplementary vaccination
The vaccination is free of charge for girls. For 15- to 26-year-old girls and women, coverage is planned at least until the end of 2017. There is no information yet regarding the coverage of costs for boys.
D: Standing Commission on Vaccination:
Vaccination against human papillomaviruses (types HPV 16, 18) is recommended for girls aged 9-14 yrs. (but until the beginning of the 19th year of life) is recommended.
Quadrivalent:
Gardisil® (HPV types 6, 11, 16, 18)
I.m. Injection.
Also useful for boys.
Application:
Common regimen: >9 yrs: month 0/2/6.
Alternative regimen: >9 yrs: 3 doses within 12 months, but 2nd dose only after 1 mon after 1st dose and 3rd dose no earlier than 3 mon after 2nd dose. (cf. with above recommendations!)
KI: Fever. Pregnancy. Vaccination may take place during breastfeeding!
NW: in general
SIDE effects: generally very well tolerated, very common: headache, erythema, pain and swelling at injection site!
Cost coverage by health insurance companies varies from region to region.
Costs:
CH: 257, 50 CHF
D: 156, 38 € per vaccination
Ö: 208€
Bivalent:
Cervarix® (HPV types 16, 18)
I.m. Injection.
Application:
10–15 yrs: month 0/1/6 or month 0/(5–)6(–7). (cf. with above recommendations!)
<15 y.: month 0/1/6.
KI: Acute, severe febrile illness. Pregnancy (incl. 2 mon. before pregnancy). No data regarding use in lactation.
No data regarding use in lactation
NWs: generally very well tolerated, very common: headache, myalgia, injection site reactions, pain, redness, swelling, fatigue.
Cost coverage by health insurance companies varies regionally
Costs:
CH: 207, 15 CHF per vaccination
D: 156, 38 €
Ö: 146€
Post-vaccinations: At vaccinations > 13 yrs or > 14 yrs or vaccination interval < 6 months, a 3rd vaccination is recommended.
There is no recommendation by the STIKO (Standing Commission on Vaccination) to vaccinate boys.
Ö: Supreme Sanitary Council
Recommendation for all girls between 9-17. For boys, vaccination is considered „useful“.
However, for the above vaccinations, it can be assumed that the vaccination interval 0, 6, 12 months will bring the same desired effect.
HPV typing:
For routine diagnostics, the detection of HPV proteins or HPV-specific antibodies is not considered sufficient. Detection by polymerase chain reaction (PCR) is recommended:
It is not a routine diagnostic test
No routine HPV typing is recommended!
In case of persistent HPV infections, the existence of single infections should be assumed.
The probability of being infected with HPV 6, 11, 16 and 18 is probably 1:10000.
HPV typing reveals passive, clinically irrelevant infections without therapeutic consequences. However, increasing uncertainty among patients and physicians is to be expected here.
HPV testing with a validated test in primary screening is only recommended from the age of 30 onwards.
If there is an HR HPV test result before the first vaccination, it makes sense to perform HPV typing for HPV 16 and 18. Only if the result is negative, vaccination makes sense.
If the test is positive (especially if HPV 16 is positive), repeat the test again in 6-12 months.
If cytological changes are noticed after vaccination, HPV testing is useful. In the majority of cases, HPV other than HPV 16 and 18 are detected.
Lt
According to the S3 guideline Vaccination prevention of HPV-associated neoplasms, all girls and boys should be vaccinated from the age of 9.
Although there may be a reduction in the benefit of vaccination, a benefit can still be expected if sexual intercourse has already occurred. Decisions need to be made on an individual basis.
For pre-existing CIN or cervical carcinoma, treatment with an HPV vaccine is not advisable if there is no evidence of efficacy.
The risk of recurrence can be reduced by vaccination if the HPV infection has already occurred. Prior HPV typing is not necessary before vaccination, even if the HPV infection has already been contracted!
Since not all oncologic HPV infections are effective, vaccination is not recommended
Because not all oncogenic HPV can be vaccinated, vaccinated women should continue to attend cancer screening examinations.
