Condylomata acuminata in children--detection of HPV 6/11 and 2. Local therapy with interferon-beta hydrogel]

Four cases of genital warts in children (girls) are reported. HPV 6/11-DNA was identified in two cases, and HPV 2-DNA in one. In one case no virus identification was possible. The clinical features of the HPV 2-induced genital warts showed the typical morphology of condylomata acuminata. The mode of transmission of the virus, in absence of sexual contact, could not be explained. The HPV 2-associated genital warts might have been transmitted by autoinoculation from warts on the hands. Topical treatment with IFN-beta-hydrogel was applied over 8 weeks, either as single-agent therapy (1 case) or as adjuvant therapy after removal of the condylomata (3 cases). No remission was seen with the single-agent therapy. In one case the genital warts reappeared after adjuvant therapy, but in the other two cases no recurrence was seen.     

A prospective,open, comparative study of 5% potassium hydroxide solution versus cryotherapy in the treatment of genital warts in men

BACKGROUND

Genital warts are caused by human papillomavirus infection and represent one of the most common sexually transmitted diseases. Many infections are transient but the virus may recur, persist, or become latent. To date, there is no effective antiviral treatment to eliminate HPV infection and most therapies are aimed at the destruction of visible lesions. Potassium hydroxide is a strong alkali that has been shown to be safe and effective for the treatment of genital warts and molluscum contagiosum. Cryotherapy is considered one of the most established treatments for genital warts. No comparative trials have been reported to date on the use of potassium hydroxide for genital warts.

OBJECTIVE

A prospective, open-label, randomized clinical trial was conducted to compare topical potassium hydroxide versus cryotherapy in the treatment of genital warts affecting immunocompetent, sexually active men.

METHODS

Over a period of 10 months, 48 patients were enrolled. They were randomly divided into two groups and selected on an alternative basis for either potassium hydroxide therapy or cryotherapy. While response to therapy did not differ substantially between both treatment modalities, side effects such as local pain and post-treatment hypopigmentation were considerably more prevalent in the groups treated using cryotherapy.

RESULT

In our study, potassium hydroxide therapy proved to be at least as effective as cryotherapy and offered the benefit of a better safety profile.

CONCLUSION

Topical 5% potassium hydroxide presents an effective, safe, and low-cost treatment modality for genital warts in men and should be included in the spectrum of therapies for genital warts.     

Plantar warts treated with an immune response modifier: a report of two cases

Summary Viral warts are the most common disease of the skin and are caused by human papillomavirus (HPV). Plantar warts, a manifestation of infection by HPV-1, -2 and -4, tend to be smoother and flatter than common warts and can also be painful when pressure is applied. A variety of local treatments, including topical salicyclic acid, cryotherapy, topical 5-fluorouracil, intralesional interferons and photodynamic therapy, are available to treat plantar warts. Here we report two cases of plantar warts, which had been previously treated without success. Total clearance of the warts was observed in both cases after treatment with imiquimod 5% cream over a period of 12 weeks. No evidence of local skin reactions was observed in either case during the treatment period. Recurrent lesions were not evident in the follow-up period for each patient.     

CO2 laser treatment for plantar warts in children: A case series

Several types of human papillomaviruses induce warts. Warts are one of the most common infections in childhood with a reported prevalence of up to 20%. Warts are divided clinically into genital and nongenital forms. Plantar warts are common nongenital warts. In this series, five pediatric cases treated with CO₂ laser for their plantar warts are presented. One patient was a known case of Hodgkin's lymphoma. Three of our patients had history of unsuccessful treatments with other modalities, while the other had received no previous treatment. CO₂ laser with continuous mode (focused and defocused) was used. In our cases, only one session was enough for clearance of the warts. All the patients were visited 1 week and 3 months after treatment to assess the efficacy and any possible recurrences. Follow‐up showed that all the patients remained in remission up to 3 months posttreatment with no adverse events.     

Condylomata acuminata in women: the effect of concomitant genital infection on response to treatment

316 women with genital warts were studied to relate treatment response to concomitant genital infection at presentation. There was a highly significant difference between the response patterns of those patients who presented with warts alone, and those presenting with other infections (most commonly candidiasis and non-specific vaginitis). The diagnosis and treatment of associated infections hastens the response of warts to cytotoxic therapy, but there appears to be a subgroup amongst women presenting with warts alone, who require a considerably longer course of treatment. The relevance of these findings to the pathogenesis and management of genital warts is discussed.     

Meta-analysis of 5% imiquimod and 0.5% podophyllotoxin in the treatment of condylomata acuminata

BACKGROUND: Genital warts are a common sexually transmitted disease caused by human papillomaviruses. Podophyllotoxin 0.5%, approved for patient self-administration, has been used most extensively in the treatment of genital warts. Imiquimod, a novel immune response modifier capable of inducing interferon-alpha and a variety of cytokines, has been examined as a potential treatment for genital warts. But 0.5% podophyllotoxin and 5% imiquimod have not been compared in any extensive and formal studies, although they are the common topical agents for genital warts. OBJECTIVE: To evaluate the efficacy and safety of topical 5% imiquimod and 0.5% podophyllotoxin in the treatment of genital warts. METHODS: We searched Medline (1966 to June 2005), Embase (1974 to June 2005) and the Cochrane Controlled Trials Register (issue 3, 2005). Randomized controlled trials of 5% imiquimod or 0.5% podophyllotoxin in the treatment of genital warts were collected. Two reviewers extracted the data and independently assessed the quality of the included medical literature. Then, meta-analysis was conducted. RESULTS: Twelve studies including 3 placebo-controlled trials of imiquimod and 9 placebo-controlled trials of podophyllotoxin were included. The clinical cure rates of imiquimod and podophyllotoxin were 50.34 and 56.41%, respectively, without statistically significant differences between the two (p > 0.05). A combined analysis of the 3 studies on imiquimod showed a statistically significant difference to the placebo group [pooled odds ratio (OR) 11.65, 95% confidence interval (CI) 6.05-22.44], as did a combined analysis of the 9 studies on podophyllotoxin (pooled OR 16.70, 95% CI 7.06-39.48). The most common adverse events of imiquimod were erythema, erosion, excoriation, itching and burning; those of podophyllotoxin were burning, pain, erosion, itching and inflammation. CONCLUSION: Imiquimod and podophyllotoxin possess similar curative effects on condylomata acuminata but podophyllotoxin has more serious adverse effects.     

Increased incidence of cervical cytological abnormalities in women with genital warts or contact with genital warts: a need for increased vigilance?

OBJECTIVE--To determine whether women who have a history of genital warts or whose sexual partners have such a history were more likely to have borderline or dyskaryotic cervical smears than other women. DESIGN--Prospective study conducted over a five month period. SETTING--A genitourinary medicine clinic in Cambridge, UK. PATIENTS--One hundred and eighty five women who attended the clinic during the study period, on whom cervical cytology was performed. Ninety-seven had a history of genital warts and twenty had partners with genital warts. METHODS--Cervical cytology taken by standard methods. Demographic data and sexual history obtained by questionnaire. Colposcopy was performed on patients with a history of warts or wart contact. OUTCOME MEASURED--Relative incidence of cytological abnormalities in the various groups of patients. RESULTS--"Borderline" nuclear change was the most frequent abnormality reported in the wart contact group (six cases) whereas mild dyskaryosis was the most frequent abnormal finding in those women with a history of warts (21 cases). CONCLUSIONS--Women with warts or contact with genital warts were more likely to have borderline or dyskaryotic cervical smears than women without such a history. Recommendations for follow-up of these patients are made.     

Holmium laser treatment of genital warts: an observational study of 1500 cases

The treatment and relapse rate of genital warts are significant problems. The aim of this observational study was to assess the efficacy of holmium laser treatment of genital warts. A total of 1500 outpatients with genital human papillomavirus-induced lesions presenting from August 2002 to June 2005 were treated with holmium laser. The effects and side-effects of treatment were observed and analysed. Of this large cohort, lesions were excised at the first visit in 1488 cases. Twelve cases were treated a second or third time in the event that the lesions were too large to be removed at the first visit. The incidence of side-effects and complications after treatment with holmium laser was found to be low. Almost all warts can be excised at first treatment by holmium laser therapy with little bleeding during the treatment.     

Therapy for genital warts.

This article presents the spectrum of genital wart infection, including possible subclinical infection and reinfection from partners. Present therapy is effective in warts of recent onset but usually requires multiple treatments and is painful, and warts are frequently recurrent. Trials of combination therapy appear to have greater efficacy than does single-agent treatment. Problems for the future include the best management of warts in the sexually abused child, the immunocompromised host, and the pregnant patient. Genital warts are increasingly linked with the potential development of carcinoma, mandating more effective treatment regimens in the future.     

Topical imiquimod for recalcitrant facial flat warts

Imiquimod is a unique topical therapeutic agent useful in the treatment of external genital and perianal warts (condyloma acuminata) in adults. The authors report a case of a 21-year-old woman who experienced complete clearance of recalcitrant facial flat warts after 3 weeks of therapy with topical imiquimod 5% cream.     

Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation.

Four hundred and fifty patients were enrolled into a randomised clinical trial in a public sexually transmitted diseases clinic to evaluate the efficacy of podophyllin, cryotherapy, and electrodesiccation for treatment of external genital warts. Complete clearance of warts was observed in 41%, 79%, and 94% of patients who received up to six weekly treatments of podophyllin, cryotherapy, and electrodesiccation, respectively. Relapses occurred in 25% of all patients, yielding 3 month clearance rates of 17%, 55%, and 71% for podophyllin, cryotherapy, and electrodesiccation, respectively. Wart volume and duration did not influence treatment outcome. Response to therapy was greater in women than in men, and did not differ by treatment modality. Electrodesiccation and cryotherapy were more effective than podophyllin for the treatment of external genital warts, but none of these three treatments were highly successful.     

Cryotherapy for anogenital warts: factors affecting therapeutic response

Human papilloma virus genital infection remains a treatment dilemma; there is still no gold standard therapy, treatment options are limited, expensive and often ineffective, and recurrence rates are relatively high. The primary objective of this study is to establish the efficacy, safety, and tolerability of cryotherapy in the treatment of these lesions. From 1999 to 2003, 100 consecutive patients with at least ten genital warts were treated with liquid nitrogen cryotherapy using a cotton-tipped applicator and two freeze-thaw cycles at the outpatient dermatology clinic of Hazrat-e Rasool University Hospital. Treatment was repeated every 3 weeks until the disappearance of all visible lesions was achieved. Patients were followed up every 4 months for 18 months. Complete clinical cure (CCC) was defined as complete clearance of all lesions and no evidence of disease for a minimum of 18 months. The CCC and relapse rate were evaluated based on different demographic and clinical characteristics. Overall, 86 percent of the patients achieved CCC after an average of 3.31 treatment sessions. All of the failed cases were attributed to recurrence of warts in new sites. The cure rate increased in parallel with increasing treatment sessions until the 6th session, after which it remained constant. The cure rate was lower and the number of treatment sessions higher in older patients. The age of the patient and number of treatment sessions affect the cure rate. The recurrence rate was significantly higher for the married or multi-partner group than for unmarried patients. We concluded that cryotherapy is an effective method for treatment of anogenital warts. The age of the patient and size of the lesions affect the cure rate. However, the most important factor in relapse of the lesions is unprotected sexual contact during and after treatment.     

Colposcopic evaluation of men with genital warts

Colposcopy, which is the examination of the female genital tract that generally is performed after the application of acetic acid, has been an effective tool in the diagnosis of genital warts (condyloma acuminatum) in women for years. With the help of colposcopy, both microscopic and flat warts that cannot be visualized with traditional, noncolposcopic methods can be seen and, hence, treated. Recently, studies reported in the gynecologic and urologic literature have evaluated the usefulness of colposcopy in male patients. We present a patient whose genital warts were recalcitrant to treatment. When examined with colposcopy he was noted to have multiple additional areas of involvement. In view of the neoplastic potential of the human papillomavirus, the ease with which it is transmitted sexually, and the difficulty in discerning certain kinds of warts without colposcopy, we believe colposcopic examination should be routine in all men with genital warts and in those whose sexual partners have tested positive for human papillomavirus.     

Low risk of contamination with human papilloma virus during treatment of condylomata acuminata with multilayer argon plasma coagulation and CO<Subscript>2</Subscript> laser ablation

Multilayer argon plasma coagulation (APC) is a new effective method for the treatment of genital warts. We assessed the generation of aerosols containing human papilloma virus (HPV) DNA during treatment of genital warts with multilayer APC and with CO₂ laser ablation. Surveillance petri dishes, swabs from the glasses and nasolabial folds of the operating physician, and swabs taken from the suction units used during CO₂ laser ablation were tested by HPV PCR. HPV DNA corresponding to patient derived HPV types of genital warts was not found in any of the petri dishes and swabs obtained during APC treatment. HPV DNA was detected in none of the petri dishes obtained during CO₂ laser treatment, but in suction filters. In conclusion, both CO₂ laser ablation with plume suction and APC treatment seem to have a low risk of HPV contamination of the operation room.     

Investigation of patients with genital warts presenting to dermatological and to genito-urinary departments

Although many patients with genital warts attend a genito-urinary clinic, a number are referred by their general practitioners directly to a dermatologist. Studies from genito-urinary clinics have suggested that a high proportion of patients have other genital infections. A recent study has suggested that patients with genital warts referred to dermatologists are similar (Fairris, Statham & Waugh, 1984).
Fifty male patients with anogenital warts referred to the Skin Hospital were studied. Details of sexual history, contact with anogenital or other viral warts, and history of previous or concomitant sexually transmitted disease were obtained. Patients were examined for urethral discharge, and for proctitis in the case of perianal warts. Urethral swabs for Gram stain, gonococcal culture and Chlamydia culture were taken from all patients, with rectal swabs for gonococcal culture from patients with perianal warts. Serological tests for syphilis were performed.
Clinical evidence of genital infections other than warts was found in only one patient with a urethral discharge, who was found to have gonococcal urethritis. Genital infections were detected in three patients. Urethral swabs from two grew Gonococcus , and from one grew Chlamydia.
Of 50 male patients presenting with anogenital warts to the genito-urinary department of the Manchester Royal Infirmary, eight had other genital infections. These included one with gonococcal urethritis, five with non-specific urethritis and two Chlamydia infections.
A similar study of female patients is being undertaken and preliminary results suggest a higher rate of genital infections than in men.     

Topical imiquimod 5% cream as an effective treatment for external genital and perianal warts in different patient populations

BACKGROUND: Genital infection with human papillomavirus, the cause of genital warts, is one of the most common sexually transmitted diseases. GOAL: The aim of this analysis was to determine whether patients' demographic variables affect the efficacy of imiquimod 5% cream versus vehicle cream for the treatment of external genital and perianal warts. STUDY DESIGN: Male and female immunocompetent patients applied imiquimod 5% cream topically to external genital warts 3 times a week until wart clearance or for up to 16 weeks. RESULTS: As previously published, the intent-to-treat (ITT) clearance rate was 50% (54/109) in the imiquimod-treated group and 11% (11/100) in the vehicle-treated group ( P< 0.0001). The ITT clearance rate in the imiquimod-treated group was higher in females (72%) than in males (33%). We have examined the clearance rates for subgroups based on variables of gender, baseline wart area, duration of current outbreak of warts, previous wart treatment, and tobacco use. For each of these subgroups, imiquimod was statistically more effective than vehicle in eradicating external genital and perianal warts. CONCLUSION: Imiquimod 5% cream is an effective treatment for external genital and perianal warts and provides a significant benefit in comparison with vehicle cream, independent of gender, initial wart size, duration of current outbreak of warts, previous wart treatment, or tobacco use.     

Diagnostic Pearls of Vulvar Epidermolytic Acanthoma: Case Report

Epidermolytic acanthomas (EA) are uncommon benign tumors clinically presenting as single to multiple papules. Histologically, EA display hyperkeratosis, hypergranulosis, acanthosis, and epidermal degeneration—also known as epidermolytic hyperkeratosis (EH). EA may be misdiagnosed as condyloma both clinically and histopathologically when located on the genitalia. Thus, this diagnosis carries a significant psychological burden and must remain in the differential when initially considering genital warts. We utilize the case of a 62-year old female referred to dermatology for a 5-year history of multiple pruritic and hypopigmented vulvar papules—misdiagnosed as genital warts—to highlight the impact of differentiating EA from genital warts. This patient was initially misdiagnosed with common genital warts at her gynecologist’s office and treated unsuccessfully for years. A shave biopsy was performed and histology revealed EH, consistent with EA.     

Intralesional immunotherapy with killed Mycobacterium w vaccine for the treatment of ano-genital warts: an open label pilot study

Background  Intralesional immunotherapy with skin test antigens and vaccines has been found to be effective in the management of genital and extragenital warts.
Objective  To evaluate the efficacy and safety of intralesional Mycobacterium w (M w ) vaccine monotherapy for the treatment of ano-genital warts.
Patients and methods  Ten patients clinically diagnosed to have external ano-genital warts, including three with giant ano-genital warts (Buschke Löwenstein tumour), were included in this open-label pilot study. Two patients were human immunodeficiency virus seropositive, and one was on iatrogenic immunosuppression for renal transplantation. M w vaccine (0.1 mL) was initially injected intradermally in the deltoid region on both the sides, followed 2 weeks later by intradermal intralesional injection into the genital warts. Intralesional injections were repeated weekly until either complete clearance or a maximum of 10 injections was achieved.
Results  One patient was lost to follow-up after the first intralesional injection. In 8 out of remaining 9 patients (88.9%), the genital warts cleared completely. In one patient with giant perianal wart, the lesion was reduced to less than 5% of its volume after 10 intralesional injections, which was later electrosurgically excised. The treatment was well tolerated by the majority of the patients. The adverse reactions were noted in four patients, which were reversible. No recurrence was seen after a mean follow-up of 5.1 months.
Conclusion  Intralesional immunotherapy of ano-genital warts with M w vaccine seems to be a promising new approach, which needs to be evaluated in the randomized controlled trials.     

Treatment of external genital warts in men using 5% imiquimod cream applied three times a week, once daily, twice daily, or three times a day

BACKGROUND: Medical therapy for genital warts remains suboptimal. The topical interferon and cytokine inducer, imiquimod, has been proved effective for the treatment of external genital and perianal warts, but there is a substantial difference in the response rates between men and women. When 5% imiquimod cream is applied three times a week up to 16 weeks, approximately two thirds of women treated with imiquimod achieve complete clearance of genital warts, whereas only about one third of men clear completely. GOAL: This study was undertaken to determine whether more frequent application of topical imiquimod cream would improve the rate of genital wart clearance in men. STUDY DESIGN: A randomized treatment trial involving adult men with biopsy-proven genital warts was conducted at nine centers in the United States and Canada using four different application frequencies. RESULTS: Complete clearance rates during the 16-week treatment period were as follows for the different imiquimod treatment frequencies: three times a week (35 %), once daily (28 %), twice daily (24%), and three times a day (27%)(P = 0.88). The four treatment groups all showed comparable reductions in the total lesion area, with a median of more than a 90% reduction in the lesion area by the end of treatment. There was a significant increase in the incidence and severity of local skin reactions including erythema, vesicle formation, ulceration, and excoriation as the dosing frequency increased from three times a week to three times a day. CONCLUSIONS: In this study, the optimal dosage regimen was the approved three times a week regimen. More frequent application (up to three times a day) did not improve clearance and was associated with an increase in local adverse events.     

Treatment of Human Papilloma Virus in a 6-Month-Old Infant with Imiquimod 5% Cream

A healthy female infant was diagnosed with genital warts at six months of age. She was the product of an uncomplicated vaginal delivery to a mother who was diagnosed with genital warts during the pregnancy, but did not undergo any treatment. The infant's warts were clinically resolved following a three week course of 5% imiquimod cream, an immunomodulating agent that has been demonstrated to be a potent inducer of several cytokines promoting an antiviral cell-mediated immune response.