Condylomata acuminata

Last Updated: 2021-10-15

Author(s): -

Genital warts, pointed condylomas, moist warts, anogenital warts.

Highly infectious sexually transmitted disease (STD).

Most frequently transmitted viral STD worldwide.

About 1% of the population (15-49 years of age) suffers from condylomata acuminata.

It is assumed that the probability of developing condylomata acuminata up to the age of 27 can be estimated at 4.7%.

HPV prevalence in women in the pre-vaccination era is estimated at 9-21%.

Due to HPV vaccines, the incidence of anogenital warts has already decreased in 15-19 year old women (data from Australia partly speak of a decrease of almost 90% in sick women!)

No gender difference. Highest prevalence in young adults up to 40 years of age.

Predisposing factors: Immunosuppression, nicotine abuse, promiscuity.

LR-HPVs, especially type 6 and 11, are considered to be the cause for more than 90% of all anogenital condylomata acuminata.

Incubation period from weeks to 6 months.

Spontaneous remission in up to 30%.

Condylomas can occur both genital and anal.

Painless, often confluent, skin-colored-livid, soft, partly exophytically growing papules, plaques and tumors.

Clinic

Biopsy, if necessary.

An acetic acid test for 5 minutes (5% external, 3% vaginal and intraanal) shows a white coloration. This traditional test is not always specific.

If necessary, proctoscopic examination (MSM).

If the urethra entrance is affected, no cystoscopy without prior remediation (contamination).

Determine hepatitis B, C, syphilis and HIV serology in each patient!

Discreet hyperkeratosis, focal parakeratosis, pronounced acanthosis, enlarged reteleists, coilocytes, no enlargement of the stratum granulosum (distinguishing feature from verruca vulgaris).

Frequent recurrences. Inform patients about this from the beginning!

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 been done, an individual decision must be made.

Follow-up checks to exclude a recurrence after approx. 6 months, earlier in case of recurrence if necessary.

Partner should be examined by a doctor in any case!

Inform patients about the ping-pong phenomenon, which stands for reinfection by the untreated partner. Therefore, both partners should be treated simultaneously.

 

Topical therapy (mostly off label use!)

Cryotherapy

Application: 2x to 15 seconds.

Note: effective, cheap, temporarily unpleasant for patients.

 

Immunomodulators

Imiquimod

Aldara® 3x a week for 12 weeks.

Off-label-use:

Application: 5x/ week over several weeks, maximum 16 weeks.

The wart surface must be removed beforehand.

Proof: redness, itching, burning, erosion of the skin. Inform Pat. about this before starting therapy!

 

Podophyllin/podophyllotoxin

Condyline® Lin: Apply 2x daily for 3 consecutive days. Repeat if necessary.

Off-label-use:

Application: Apply 2x daily for 3 consecutive days, protect surrounding skin. Repeat if necessary.

AI: < 12 years, open wounds, women of childbearing age, contraception recommended up to 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 swabs. Therapy belongs in the hands of a doctor. Also allowed during pregnancy, in case of overdose neutralization with sodium bicarbonates.

Removal with CO² laser/electrocution/curette/excision:

CAVE infectivity! Especially when laser cutting and electro chewing. Always wear a face mask or goggles and mouth guard! Smoke extraction is essential.

 

Other described therapies:

Interferon- β Gel application should be carried out for a maximum of 4 weeks.

In Switzerland only available from pharmacies abroad.

Germany: Fiblaferon® 0.1 million IU/g, 5x daily.

 

HPV vaccination

Bivalent vaccines against HPV 16 and 18 (Cervarix®) or quadrivalent vaccines against HPV 6, 11, 16 and 18 (Gardisil®) are currently available. Vaccines are approved for girls and boys aged 9 years and older. Vaccination of girls and boys is recommended before the first sexual intercourse. Data on the duration of the vaccination protection are not available.

Overall, the vaccinations are considered compatible and effective.

If at least one vaccination dose has been administered, an approx. 44% protection against CIN/VIN/VAIN can be expected. If a complete vaccination is carried out, there is almost 100% protection.

With regard to the data situation, no influence on 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, a cross-reaction to other HPV types, especially 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68, can be expected.

The efficiency of vaccines in immunosuppressed patients (HIV-infected, organ transplants) is difficult to assess with regard to the data situation.

The recommendations for vaccinations are partly different:

 

CH: Federal Office of Public Health (FOPH) and Confederate Commission for questions of vaccinations (EKIF):

11-14 years: 2 injections at 6-month intervals

Recommended for girls as basic vaccination, for boys as complementary vaccination

The vaccination is free for girls. For girls and women aged 15 to 26, coverage is planned at least until the end of 2017. There is still no information on the assumption of costs for boys.

 

D: Standing Vaccination Commission:

Vaccination against human papilloma viruses (types HPV 16, 18) is recommended for girls aged 9-14 years (however until the beginning of the 19 year of age) recommended.

 

Quadrivalent:

Gardisil® (HPV types 6, 11, 16, 18)

IM injection.

Also useful for boys.

Application:

Usual pattern: >9 years old: month 0/2/6.

Alternative scheme: >9 years: 3 doses within 12 months, but 2nd dose only after 1 month after the 1st dose and 3rd dose at the earliest 3 months after the 2nd dose. (See above recommendations!)

AI: fever. Pregnancy. Vaccination may take place during breastfeeding!

Proof: generally very well tolerated, very frequent: headache, erythema, pain and swelling at the injection site.

Cost absorption 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)

IM injection.

Application:

10-15 yrs: month 0/1/6 or month 0/ (5- ) 6(-7). (See above recommendations!)

15 yrs: month 0/1/6.

AI: Acute, severe feverish disease. Pregnancy (incl. 2 months before pregnancy). No data regarding use during lactation.

NW: generally very well tolerated, very frequent: headaches, myalgia, reactions at the injection site, pain, redness, swelling, fatigue.

Cost absorption by health insurance companies varies from region to region

Costs:

CH: 207, 15 CHF per vaccination

DE: 156, 38 €

AT: 146€

 

Booster shots: For vaccinations > 13 years or > 14 years or vaccination interval < 6 months a 3rd vaccination is recommended.

The STIKO (Standing Vaccination Commission) does not recommend the vaccination of boys. 
 

AT: Supreme Medical Council

Recommendation for all girls between 9-17, for boys the vaccination is considered "sensible".

In the case of the above vaccinations, however, it can be assumed that the vaccination interval 0, 6, 12 months will have the same desired effect.

 

HPV typing:

The detection of HPV proteins or HPV-specific antibodies is not considered sufficient for routine diagnostics. Detection by polymerase chain reaction (PCR) is recommended.

No routine HPV typing is recommended!

In the case of persistent HPV infections, the existence of individual infections can be assumed.

The probability of being infected with HPV 6, 11, 16 and 18 is probably 1:10000.

HPV typing reveals transient, clinically irrelevant infections without therapeutic consequences. However, increasing uncertainty among patients and doctors is to be expected here.

HPV testing with validated test in primary screening only recommended from the age of 30.

If an HR HPV test result exists before the first vaccination, it makes sense to perform HPV typing on HPV 16 and 18. Vaccination only makes sense if the result is negative.

If the test is positive (especially if HPV 16 is positive), the test should be repeated in 6-12 months.

If cytological changes are noticed after vaccination, HPV testing is recommended. In the majority of cases other than HPV 16 and 18 are detected.

According to the S3 guideline "Vaccination prevention of HPV-associated neoplasias", all girls and boys from the age of 9 should be vaccinated.

Although the benefit of the vaccination may be reduced, a benefit can still be expected if sexual intercourse has already taken place. Decisions must be made individually.

If CIN or cervical carcinoma already exists, treatment with an HPV vaccine is not recommended if no proof of effect is available.

The risk of relapse can be reduced by vaccination if HPV infection has already occurred. A prior HPV typing is not necessary even if HPV infection has already occurred before vaccination!

Since not all oncogenic HPV can be vaccinated, vaccinated women should continue to participate in cancer screening 

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