Enhances local immune response by stimulating production of interferon and other cytokines. Local inflammatory reactions are common and range from mild to moderate. Patient should be so advised. Expense and duration of treatment are drawbacks to use. Some experts have recommended use in the treatment of anal intraepithelial neoplasia in HIV positive men, but there have been no RCTs to test efficacy of such treatment.
Resin is an antimitotic agent. Must apply a VERY THIN layer. Over-application or failure to dry the area can lead to local irritation.
Caustic agents which destroy warts by chemical coagulation of proteins. These agents have low viscosity compared to water, therefore can spread rapidly if applied excessively. Hence, use sparingly and with care.
Nine-valent human papillomavirus vaccine (9vHPV)
Recommendations as above. Having genital warts is not a contraindication to vaccination as prevention of infection with the other types in the vaccine is still possible. Also, studies suggest that the titers against vaccine types are higher, and possibly more long-lived, than those following natural infection. The impact of the vaccine on the natural history of infection in patients with type-specific infection is not known.
No longer distributed in U.S. as of 2017.
No longer distributed in U.S. as of 2017.
Comment: This 2016 report provides further detail regarding the revised HPV vaccine recommendations, to include use only of the 9vHPV vaccine.
Comment: 9-valent vaccine as of 2017 only form available. See 2016 ACIP recommendations for 2 dose schedule for 9 - 14 yr olds.
Comment: This updated guide to the primary care of HIV-infected persons includes a summary of the limited data in support of screening HIV-infected persons with anal cytology to permit early detection of and precursors to anal cancer.
Comment: August 2014 HPV vaccine recommendations from ACIP and CDC. Includes review of efficacy, immunogenicity, and safety data from clinical trials of HPV4 vaccine.
Comment: Small study in children demonstrated that imiquimod 5% + salicylic acid 15% was superior to cryotherapy in eradicating plantar warts at three months. There were no differences in rates of eradication for common and plane warts between the two groups.
Comment: Placebo-controlled study of 31 adults with treatment-refractory facial flat warts showed a significant benefit of treatment with isotretinoin 30 mg/d for twelve weeks.
Comment: This randomized, international, double-blind study in 14,215 women showed the 9vHPV vaccine prevented cervical, vulvar, and vaginal disease and persistent infection associated with HPV-31, 33, 45, 52, and 58. Antibody responses to HPV-6, 11, 16, 18 were noninferior to those among participants who received the 4vHPV vaccine, and the incidence of disease related to HPV-6, 11, 16, and 18 was similar in the two vaccine groups.
Comment: Observational long-term follow-up data obtained from women who received bivalent HPV vaccination showed no risk of miscarriage for pregnancies conceived less than 90 days from vaccination. Among pregnancies conceived at any time from bivalent HPV vaccination, exposure was not associated with an increased risk of miscarriage overall or in subgroups, except for miscarriages at weeks 13-20 of gestation (relative risk 1.35), suggesting a need for further study.
Comment: Nice guideline document that lists the many therapeutics that have been utilized to manage cutaneous warts. Only salicylic acid gets an "A" recommendation, based in part upon studies referenced in the 2012 Cochrane review listed above.
Comment: ACOG guideline statement including recommendations for cervical cancer screening as well as the management of abnormal findings. In average risk women, beginning screening at age 21 is recommended. For women 30-65, screening with either (a) cytology every three years, or (b) cytology + HPV DNA testing every five years is recommended.
Comment: This lengthy review of topical therapies for cutaneous warts finds that only salicylic acid is found to be superior to placebo, despite the many remedies that have been pursued.
Comment: This revised document details the evidence in support of the cervical cancer screening guidelines summarized above.
Comment: This paper synthesizes and reviews head and neck cancer incidence and smoking prevalence over the past 70 years. Notably, squamous cell carcinoma of the head and neck (SCCHN) have declined in response to decreased smoking rates. However, certain HN cancers have not shown a similar decline, particularly among young adults <45 years of age. These include cancer of the tongue and pharynx (including tonsil with a 4% increase per year over the past 30 years). This trend is thought to reflect the increase in HPV 16/18 associated cancers with the likely exposures via oral sex. Current recommendations for immunizing only females with the current HPV vaccine are noted and note the need to study vaccine safety and efficacy in males.
Comment: Prevalence study report from the National Cancer Institute of NIH examining the prevalence of HPV among age-matched women enrolled in a large northwest U.S. HMO stratified by hysterectomy history (n=573 with hysterectomy [WH] and n=581 with no hysterectomy [WNH[). Routine pelvic examinations were conducted and ethanol-fixed Pap smears collected (cuff smears collected on WH) and a vaginal lavage using 10 mL of normal saline was conducted and the wash sample used for HPV testing. There was no significant difference in HPV infection status between the 2 groups [WH=86.2% HPV negative vs WNH=84.0%] nor a difference of HPV genotype distribution among the 2 groups [WH=1.4% with HPV-16 vs WNH=1.6% and WH=9.2% non-oncogenic types vs WNH=9.5%] Notably, however, in the absence of a cervix, WH women are at lower risk of cancer in the presence of HPV-16 than those women with a cervix in place (WNH)..
Comment: This Merck Research Laboratories funded study reports on data collected during its multicenter phase II/III RCTs (used to support their now licensed vaccine) examining the efficacy of prophylactic quadrivalent HPV 6/11/16/18 L1 VLP vaccine during up to 5 years of follow-up. 552 women (age 16-23 years) were enrolled in the trial from Brazil, Finland, Sweden, Norway, and USA; 276 entered the vaccination arm of the trial and 275 into the placebo arm. After vaccination on day 0, 2m, and 6 m, 256 women entered follow-up for months 7-36 and 260 similarly were followed in the placebo arm. After 3 years the non-USA participants were eligible for further follow-up that continued for 2 more yrs. At the 5-year point, the overall incidence of infection with vaccine-containing genotypes was reduced 96% in the vaccine vs the placebo group. There were no vaccine genotype related precancerous lesions or genital warts in the vaccinated group compared with 6 in the placebo arm (95% CI = 12-100%). The anti-HPV geometric mean titers in sera remained significantly higher among vaccinees than among women who became infected with one or more of the 4 vaccine genotypes during the follow-up period.
Comment: Report of a study to determine the usefulness and limitations of anal pap smears in screening for anal squamous intraepithelial lesions (ASIL) among 198 of 200 consecutively liquid media-based collected smears. The findings from these slides were correlated with surgical biopsies. Subsequently, the authors examined the findings at 6 months -- follow-up testing (smears and biopsies)-- among men (n = 71) who returned for evaluation by their usual providers. Liquid-based anal smears had a high sensitivity (98%) for detection of ASIL but a low specificity (50%) for predicting the severity of the abnormality in subsequent biopsy. Patients with cytologic diagnoses of atypical squamous cells of undetermined significance (ASC-US) and low grade SIL (LSIL) had a significant risk (46-56%) of HSIL at biopsy. These data suggest 1) liquid collection media is more sensitive than slide Pap smear results reported in the literature and 2) all patients with a diagnosis of ASC-US and above be recommended for biopsy.
Comment: A study of histological subtypes of penile condylomata, dysplasia, and carcinoma using PCR applied to formalin-fixed, paraffin-embedded tissue samples from US and Paraguay. HPV DNA in 42% of penile CA; 90% of dysplasia; 100% condyloma. Keratinizing SCC and verrucous CA were much less likely to be positive for HPV than basaloid and warty tumor subtypes of CA suggesting that there may be different pathogenetic mechanisms for penile cancer.
Comment: The Women's Interagency HIV study conducted in 5 US cities among HIV-infected women using q6mo Pap smear and cervicovaginal lavage for HPV DNA testing stratified by HAART exposure. Women w/ persistent HPV more likely to have lesions progress. CD4 cell count and Pap smear status adjusted data found women on HAART 40% more likely to have regression of lesions.
Comment: A very important contribution to our understanding of the natural hx of genital HPV in women. A 3-yr cohort study of 1075 15-19 y/o women who were cytologically WNL and HPV neg at start. Cumulative incidence of HPV infection over 3 years was 44% w/HPV type 16 the most common type. Among 246 w/ abnormal Pap, 28 progressed to high-grade. High viral load appeared to be associated with a higher cumulative risk of having an abnormal Pap smear.
Comment: This was an outstanding clinical study conducted by these Danish investigators to determine the role of sexual intercourse in HPV transmission, examine the determinants for seroconversion, and the correlation between HPV DNA, abnormal cervical cytology, and serological response to HPV 16. 100 virgins and 105 monogamous women were randomly selected from a population-based cohort in Denmark. Only virgins who initiated sexual activity became HPV DNA positive. The most important determinant for acquisition was the number of sexual partners between the 2 examinations conducted during 2-yr study.
Comment: A landmark cohort study examining the natural history of HPV in 1611 Brazilian women with no cytological lesions on enrollment and HPV test results from the 1st 2 study visits. Repeated measurements taken over a 24 month period. Incidence of SILs was 0.73/1000 women-months among those free of HPV at initial 2 visits; 8.68 among women w/ HPV type 16 or 18 persisting over both visits. RR of incident SIL was 10.19 for persistence with any oncogenic type; higher among those with HPV 16 and 18. Supports use of an algorithm that incorporates HPV testing if ASCUS identified.
Comment: Examination of a cohort of 1400 Brazilian women for an association between an index HPV infection and its effect on acquisition and persistence of other types. This question is important to vaccine development if only certain types of virus are being targeted. Persistence of HPV infection appeared to be independent of the presence of coinfection with multiple types, including type 16, the type that is associated with approx 50% of cervical cancers.
Comment: This is a report of a study to characterized anal HPV among MSM with (n=346) and without (n=262) HIV infection recruited from enrollees among 3 San Francisco cohorts groups. Polymerase chain reaction (PCR) detected HPV DNA in anal specimens collected using dacron swabs placed in transport media in 93% of HIV-positive (H-Pos) and 61% of HIV-negative (H-Neg) men. The detected HPV genotype spectrum was similar in both groups with HPV-16, an oncogenic genotype, the most common detected. Coinfection with multiple HPV types: H-Pos=73%, H-Neg=23%. A first-generation hybrid capture assay on unamplified collected material was used to examine oncogenic genotype (16/18/31/33/35/39/45/51/52/56/58) and non-oncogenic (6/11/42/43/44) spectra of infection among H-Pos men. Lower CD4 count was associated with higher levels of oncogenic types compared with non-oncogenic type Among HIV-positive men who were positive by hybrid capture for group B HPV type (p<0.005.
Comment: 608 women were followed at 6-mo intervals over 3 yrs. the cumulative 36 month incidence of HPV infection was 43% (C.I. 36-49%). Avg annual incidence was 14%. Median duration of new infections was 7 to 10 mo. Persistence of HPV for >6 mo related to older age, type of HPV associated w/cervical CA, and infection w/multiple types of HPV. Risk factors for infection: younger age, Hispanic ethnicity, black race, increase number of vaginal sex partners, high freq of vaginal sex, alcohol consumption, anal sex, partner with a high number of lifetime sex partners and who was not in school.
Comment: Genital HPV, determined by polymerase chain reaction (PCR) detection of HPV DNA (genotypes 6, 11, 16, 18, 31, 33, 35, 39, and 45) and prevalence of HPV-6 and -16 serum antibodies, was investigated in 149 women who were sexually active with women. HPV DNA was detected in 30% of subjects; of these, 20% had type 31/33/35/39, 18% had type 16, and 2% had type 6/11. 21 subjects reporting no prior sex with men; HPV DNA was detected in 19% and squamous intraepithelial lesions in 14%. Current smoking status correlated with detectable HPV DNA.
Comment: Old study that assessed the natural history of warts by following 1000 institutionalized children for two years. Source of the oft-repeated statement that two-thirds of warts spontaneously resolve in two years.
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