Systematic review of the incidence and prevalence of genital warts

Efficacy of sinecatechins 10% as proactive sequential therapy of external genital warts after laser CO2 ablative therapy: The PACT study (post-ablation immunomodulator treatment of condylomata with sinecatechins): a randomized, masked outcome assessment, multicenter trial

External genital warts (EGW) are the most common viral sexually transmitted infection. Ablative treatments like cryotherapy, curettage, and CO₂ laser therapies offer rapid onset of effect, fast clearance, and reduction of virus load. However, these procedures are associated with high recurrence rates (RRs) ranging from 20% to 77% in the short and medium terms and do not provide sustained clearance. After laser therapy removal of EGW, an RR up to 77% has been reported. Topical sinecatechins (TS) 10% is a patient-applied regimen for the treatment of EGW with a low RR (<6.5%) at three months after completion of the therapy in the pivotal trials conducted so far. Sinecatechins can be considered a suitable proactive sequential therapy (PST) after ablative strategies to obtain a low RR. So far, no prospective data are available regarding the efficacy of sinecatechins 10% as PST. We evaluated the efficacy and tolerability of TS 10% ointment applied twice daily in subjects with "difficult to treat" EGW after CO₂ laser ablative treatment in a prospective controlled trial. A total of 87 subjects (76 men and 11 women; mean age 42 years) were enrolled in this three-month masked outcome assessment parallel group trial with imbalanced randomization allocation (2:1). One week after a successful CO₂ laser treatment, 60 subjects were randomized to TS 10% treatment and 27 subjects to no treatment (control group: ConTRol (CTR); no sequential therapy). All patients had a history of an average of 4.5 previous ablative treatments in the last 12 months due to recurrent EGW. Mean (standard deviation) baseline number of treated lesions was 6.5 (2.7). One subject in the TS arm dropped out due to burning sensation after the application of the product. Therefore, 86 subjects completed the study. After three months, in the TS group, three subjects presented new EGW lesions (RR: 5%) on treated sites. In the CTR group, eight subjects presented new EGW lesions (RR: 29%) on treated sites (p = 0.0024; odds ratio: 0.16; 95% confidence interval: 0.04-0.68). In the TS group, 34 subjects (56%) reported mild to moderate erythema or burning sensation at the application site. In this prospective multicenter trial, the use of TS 10% as PST after ablative treatment with CO₂ laser was associated with a lower recurrence rate of new EGW lesions in the short term in comparison with the control group. Comparative larger trials are warranted to evaluate the role of this approach as PST (Trial Registration Number: ISRCTN44037479).

Verruciform and Condyloma-like Squamous Proliferations in the Anogenital Region

CONTEXT.—

Histologic distinction between condyloma acuminatum and various benign and malignant condyloma-like lesions in the anogenital area poses a common diagnostic challenge to pathologists across subspecialties.

OBJECTIVE.—

To review the overlapping and distinguishing features of condyloma acuminatum and its mimics, and to clarify confusing terminology and diagnostic criteria for problematic entities.

DATA SOURCES.—

A review of the literature on condyloma acuminatum (ordinary and giant types), verrucous carcinoma, warty/warty-basaloid high-grade squamous intraepithelial lesion and squamous cell carcinoma, papillary squamous cell carcinoma, bowenoid papulosis, verruca vulgaris, epidermolytic acanthoma, and verruciform xanthoma was performed.

CONCLUSIONS.—

Correct diagnosis of condyloma acuminatum and condyloma-like lesions has important clinical implication and entails familiarization with their clinical presentations and histopathologic features. Contrary to historical belief, giant condyloma acuminatum and verrucous carcinoma should be considered distinct entities based on different pathogenetic pathways. Ancillary tools available for identifying and genotyping human papillomavirus can aid in diagnosis when histopathologic findings are inconclusive. Recognition of relatively rare entities such as bowenoid papulosis, epidermolytic acanthoma, and verruciform xanthoma would avoid overdiagnosis and unnecessary, overaggressive treatment.

Prevalence and treatment of sexually transmitted infections in men followed by urologists in Germany - a cross sectional study with 347,090 men

Aim: The goal of this retrospective analysis was to study the prevalence and treatment of the most common sexually transmitted infections (STI) in men followed by urologists in Germany. Methods: This study included a total of 347,090 men followed in 71 urology practices in Germany between 2013 and 2015. The first outcome was the prevalence of individuals diagnosed with STI between 2013 and 2015. The following eight types of STI infections were included in the analysis: chlamydial infection, gonococcal infection, anogenital warts, anogenital herpes infection, trichomoniasis, ulcus molle, phthiriasis, and syphilis. The second outcome was the prevalence of individuals with STI who received an appropriate therapy within 90 days of their initial STI diagnosis. Results: The most frequent STI was anogenital warts (0.64%), whereas the least frequent STI was syphilis (0.03%). The median age at diagnosis ranged from 30.3 years for chlamydia infection to 47.5 years for trichomoniasis. The proportion of individuals receiving treatment was the highest for trichomoniasis (90.6%) and the lowest for anogenital warts (49.9%). Conclusions: Overall, approximately 1.25% of men followed in urology practices in Germany between 2013 and 2015 were diagnosed with at least one STI. Further research is needed to gain a better understanding of the factors potentially associated with the risk of being diagnosed with STI in this setting in Germany. Moreover, there is a need for enabling higher rates of diagnosis and thus treatment of infected persons.

Effectiveness of physically ablative and pharmacological treatments for anal condyloma in HIV-infected men

BACKGROUND

There is limited information on the effectiveness of available treatments for anal condyloma acuminata in HIV-1-infected men.

AIM

To provide data on the effectiveness of electrosurgical excision, infrared coagulation and pharmacological (imiquimod) treatments for anal condyloma acuminata (peri-anal and/or intra-anal) in HIV-1-infected men based on authors' practice.

METHODS

Single-center, retrospective descriptive analysis of HIV-1-infected men, 18 years or older treated for anal condyloma acuminata. Standard treatments were offered: electrosurgery excision, infrared coagulation and topical imiquimod. Effectiveness was evaluated by the recurrence rate at 1 year after treatment. Recurrence was defined as any anal condyloma acuminata diagnosed after 3 months of condyloma-free survival post-treatment. Anal cytology and human-papillomavirus-infection (HPV) was assessed.

RESULTS

Between January 2005 and May 2009, 101 men were treated for anal condyloma acuminata: 65 (64%) with electrosurgery, 27 (27%) with infrared coagulation and 9 (9%) with imiquimod. At 1 year after treatment, the cumulative recurrence rate was 8% (4/65, 95%CI: 2-15%) with electrosurgery excision, 11% (3/27, 95%CI: 4-28%) with infrared coagulation and 11% (1/9, 95%CI: 2-44%) with imiquimod treatment. No predictive factors were associated with recurrence. Anal HPV-6 or HPV-11 was detectable in 98 (97%) patients and all had high-risk HPV genotypes, and 89 (88%) patients had abnormal anal canal cytology. Limitations: this was a retrospective descriptive analysis; limited to a single center; it cannot know if the recurrence is related to new infection.

CONCLUSION

Recurrence of anal condyloma after any treatment was common. Abnormal anal cytology and high-risk HPV-infection were highly prevalent in this population, therefore at high-risk of anal cancer, and warrants careful follow-up.

Development of a human papillomavirus type 6/11 vaccine candidate for the prevention of condyloma acuminatum

Condyloma acuminatum (CA) represents a significant human papillomavirus (HPV) disease burden worldwide, resulting in substantial healthcare costs and loss of life quality in both genders. To address this problem, we tried to develop a bivalent HPV6/11 virus-like particle (VLP) vaccine targeting CA. HPV6/11 VLPs were generated in Hansenula polymorpha, and a disassembly and reassembly (D/R) treatment was further conducted to improve the stability and monodispersity of the VLPs. The HPV6/11 VLPs were identified by transmission electron microscopy (TEM), high performance liquid chromatography (HPLC), mass spectrum (MS) and dynamic light scattering (DLS), and were evaluated for their immunogenicity in both mice and cynomolgus monkeys. The results showed that the HPV6/11 L1 proteins were correctly expressed and assembled into HPV6/11 VLPs, and the HPV6/11 VLPs formulated with aluminum phosphate induced vigorous production of specific neutralizing antibodies against HPV6/11 VLPs in mice and cynomolgus monkeys. These data indicated that the Hansenula polymorpha-derived HPV6/11 VLPs could be formulated into a bivalent vaccine used in prevention of CA.

The efficacy and safety of other cryotherapy compounds for the treatment of genital warts: a randomized controlled trial

BACKGROUND

Cryotherapy using Wartner compound that contains a mixture of dimethyl ether (75%) and propane (25%) has been recently reported as an effective treatment for warts. The present study aimed to evaluate the safety and efficacy of Wartner in male patients with genital warts.

METHODS

A Phase II parallel-randomized clinical trial was performed on 16 Iranian men affected by genital warts who were referred to a dermatology clinic at Tehran University of Medical Sciences. Two genital warts of each patient were selected and randomly assigned to receive either Wartner (intervention) or liquid nitrogen (control).

RESULTS

Two weeks after the treatment, the sizes of the lesions in control and intervention groups decreased by 17.87 ± 2.14 mm² and 15.81 ± 1.80 mm², respectively (p = .299). Fourteen days after a single session of treatment, 81% of lesions in the control group and 50% in the Wartner group were completely eradicated, however, the difference was not statistically significant (p = .063).

CONCLUSIONS

The Wartner compound is as effective as the conventional cryotherapy method for treating genital warts. It is particularly valuable when there are contraindications or no access to common treatment options.

Acceptability of HPV vaccines and associations with perceptions related to HPV and HPV vaccines among male baccalaureate students in Hong Kong

Objectives

The highly infectious human papillomavirus (HPV) causes both genital warts and cervical cancer in women. In 2009, the prevalence of genital warts in Hong Kong was 203.7 per 100,000 person-years. Cervical cancer, more seriously, was the eight most common cancer among women and girls in Hong Kong, accounting for 2.3% of all new cancer cases in females in 2014. Cervical cancer is a significant global public health problem and HPV is a major risk factor leading to the development of cervical cancer. HPV is also the most common sexually transmitted disease among university students. This is the first study to examine the acceptability of HPV vaccines and associations with perceptions related to HPV and HPV vaccines among the male baccalaureate student population locally.

Methods

A self-administrative cross-sectional survey was used to assess whether male baccalaureate students from eight local Hong Kong universities intended to be immunized for HPV. The study also asked questions concerning how its subjects perceived HPV and HPV vaccines using the Health Belief Model. Data collection spanned from June to September 2015. A multiple stepwise regression model was used to examine associations between cognitive factors and subjects’ intention to take up the HPV vaccine.

Results

A total of 1,004 (83.7%) students aged 18 and 26 participated in this study. 23.3% found vaccinating for HPV acceptable, a level correlating with a number of indicators. Subjects were more likely to find vaccinating acceptable if 1) they knew something about HPV vaccines; 2) they understood that men were susceptible to infection by HPV; 3) they realised they could benefit by HPV vaccination, and 4) they were aware of the arguments for and against HPV vaccination, as disseminated by either the media or peers.

Conclusions

HPV remains a significant public health concern in Hong Kong and China more broadly. This study’s findings show a disconnect between the perceived and actual risk of being infected with the HPV vaccine among male baccalaureate students. This disconnect may be bridged by informing young men of the benefits of their being vaccinated against HPV, by removing the psychological and financial barriers that prevent them from taking up the vaccine and by improving how primary healthcare providers motivate them to get immunized.

Prevalence and Burden Related to Genital Warts in India

The prevalence of genital warts (GW) and self-reported human papillomavirus (HPV) as well as disease-related psychosocial impact among male and female patients aged 18-60 years in India were assessed. GW prevalence was estimated using a 2-week daily log of patients examined from June 7-September 22, 2011 by 200 participating physicians in 6 regions of India. Psychosocial impact was estimated using one-time, self-administered surveys, including HPV Impact Profile (HIP), Cuestionario Específico para Condiloma Acuminado ([Spanish] CECA; "Specific questionnaire for Condylomata Acuminata") and EuroQol-5 Dimension survey. T-tests or Mann-Whitney U-tests were used for continuous comparisons and Chi-square or Fisher exact tests were applied for categorical comparisons. Overall GW prevalence in India was estimated at 1.07% (95% confidence interval = 0.97-1.17) and was higher among men than women. Regional prevalence ranged from high in Delhi (2.17%) to low in Bangalore (0.40%). Patients aged 25-29 years had the highest GW prevalence (1.42%). GW patients were most often newly diagnosed (74.07%). Among those with existing GW, 56.24% were recurrent, and 43.76% were resistant. According to total HIP scores, 55.4% of male GW patients and 20.0% of those without GW reported moderate psychological impact (p < 0.0001). HIP scores among women revealed that patients with abnormal Papanicolaou (Pap) test results (34.3%), precancerous lesions (46.2%), external GW (48.0%), and those without HPV-related disease (18.5%) reported moderate psychological impact (p = 0.0089) (Psychosocial impact results are reported in the Supplementary Data ). Estimated national GW prevalence, diagnosis, and treatment costs in India were higher for men than for women. GW in men and HPV infection in women had a negative psychosocial impact on well-being and health-related quality of life (HRQoL) scores, especially among women diagnosed with GW and precancerous lesions compared to those with other selected HPV-related diseases. Despite its limitations, this study provides an estimation of GW data in India not previously available.

Human papillomavirus vaccine efficacy in the prevention of anogenital warts: systematic review and meta-analysis

Objective:

To review evidence on the efficacy of HPV vaccines in the prevention of non-cancer lesions (anogenital warts [AGW], recurrent laryngeal papillomatosis and oral papillomatosis).

Materials and methods:

We conducted a systematic review of randomized trials. We performed random effect models and effects were reported as relative risks (RR) and their confidence intervals (95%CI) following both intention to treat (ITT) and per protocol (PP) analyses.

Results:

We included six studies (n=27 078). One study was rated as high risk of bias. One study could not be included in the meta-analysis because it provided combined results. We found that quadrivalent vaccine reduced the risk of AGW by 62% (RR: 0.38, 95%CI:0.32-0.45, I2:0%) in the ITT analysis and by 95% (RR: 0.05, 95%CI:0.01-0.25, I2:66%) in the PP analysis. Subgroup analyses of studies in women or with low-risk of bias provided similar results.

Conclusion:

HPV quadrivalent vaccine is efficacious in preventing AGW in men and women.

Photodynamic therapy with topical photosensitizers in mucosal and semimucosal areas: Review from a dermatologic perspective

Photodynamic Therapy is a procedure based on the interaction between a Photosensitizer, a light source with a specific wavelength and oxygen. The aim of this review is to provide a brief and updated analysis of scientific reports on the use of PDT with topical PS in the management of oncological, infectious, and inflammatory disorders involving mucosal and semimucosal areas, with a specific focus on diseases of dermatologic interest.

Genital warts treatment: Beyond imiquimod

Genital warts are one of the most common sexually transmitted diseases worldwide. The disease is a result of infection with low-risk types of human papillomaviruses, mostly type 6 and 11. Current therapies for genital warts are mainly ablative, or alternatively topical application of imiquimod cream and sinecatechin (polyphenon E) ointment to the warts. However, low patient compliance and high recurrence rate are significant problems for the treatment of genital warts by imiquimod and ablative therapies. We summarise recent literature in this area and propose combining imiquimod with other therapies to increase the efficacy of imiquimod.

Reliability and validity of the Chinese CECA10 questionnaire for Chinese patients with condyloma acuminata

Condyloma acuminata (CA) is a sexually transmitted disease that affects quality of life (QOL). CECA10 is an English-language questionnaire for assessing QOL in patients with CA, but there is no equivalent in China. This study aimed to develop a validated and reliable Chinese version of CECA10.The Chinese CECA10 was developed from the English version by forward translation, back translation, comparison with the original, cultural adjustments, and a pre-test (5 patients). The Chinese CECA10 and EuroQol Five Dimensions Three Level Questionnaire (EQ-5D-3L) was administered to patients with CA. Content validity (item/scale content validity indexes, I-CVI/S-CVI), test-retest reliability (intraclass coefficient, ICC), internal consistency (Cronbach α), criterion validity (comparison with the Dermatology Life Quality Index, DLQL, using Spearman correlation analysis), construct validity (exploratory factor analysis), and discriminant validity (between subgroups based on number of warts, number of recurrences, or number of sites involved) were assessed.The Chinese CECA10 had good test-retest reliability (ICC = 0.98, P < .001), internal consistency (Cronbach α values of 0.88, 0.84, and 0.83 for the total questionnaire, psychological dimension, and sexual dimension, respectively), content validity (I-CVI = 1 for all items), and criterion validity (r = -0.50, P < .001). Exploratory factor analysis extracted 2 factors with a cumulative contribution of 61.75%; the factor loading with each item was >0.4. Discriminant validity was not high. The mean CECA10 and EQ-VAS scores of 211 patients with CA (28.19 ± 7.16 years; 139 males) were 34.56 ± 19.01 and 64.64 ± 19.28, respectively.The Chinese CECA10 has good reliability and validity for evaluating the QOL of Chinese patients with CA.

Anogenital warts in pediatric population

The approach to children with anogenital warts in the context of sexual abuse is a challenge in clinical practice. This study aims to review the current knowledge of anogenital warts in children, the forms of transmission, and the association with sexual abuse and to propose a cross-sectional approach involving all medical specialties. A systematic review of the literature was conducted in Portuguese and English from January 2000 to June 2016 using the ISI Web of Knowledge and PubMed databases. Children aged 12 years or younger were included. The ethical and legal aspects were consulted in the Declaration and Convention on the Rights of Children and in the World Health Organization. Non-sexual and sexual transmission events of human papillomavirus in children have been well documented. The possibility of sexual transmission appears to be greater in children older than 4 years. In the case of anogenital warts in children younger than 4 years of age, the possibility of non-sexual transmission should be strongly considered in the absence of another sexually transmitted infection, clinical indicators, or history of sexual abuse. The importance of human papillomavirus genotyping in the evaluation of sexual abuse is controversial. A detailed medical history and physical examination of both the child and caregivers are critical during the course of the investigation. The likelihood of an association between human papillomavirus infection and sexual abuse increases directly with age. A multidisciplinary clinical approach improves the ability to identify sexual abuse in children with anogenital warts.

An exploratory, prospective, open-label trial of ingenol mebutate gel 0.05% for the treatment of external anogenital warts

BACKGROUND

Anogenital warts (AGW) can cause physical discomfort and decreased quality of life. Recent case reports suggest that ingenol mebutate gel might be an effective treatment of AGW.

OBJECTIVE

To explore primarily the safety, and secondarily the efficacy of ingenol mebutate gel 0.05% in patients with AGW.

METHODS

This was an exploratory, open-label, 1-arm trial of ingenol mebutate gel 0.05% administered up to three times to patients with AGW. Safety was assessed by occurrence and severity of local skin reactions (LSRs) and treatment-related adverse events (AEs). Efficacy was assessed by complete clearance and reduction in AGW count 14 days after last treatment, and recurrence 12 weeks after clearance.

RESULTS

Of 41 patients enrolled, 40 received treatment and 26 completed the trial. Patients had a median AGW count of 11.0 and AGW duration of 3.0 years at baseline. All patients experienced transient LSRs following treatment with a maximum composite LSR score of 7.5 (on a scale from 0 to 18). A total of 93% of patients reported treatment-related AEs, most frequently pain (85%) and procedural complications (35%) due to smearing of the gel. 78% of patients took mild analgesics for the pain, typically for 1-2 days following treatment. The majority of AEs were of moderate-to-severe intensity. Seventeen of 39 patients (43.6%) had complete clearance 14 days after last treatment, and AGW count was reduced by 90.9%. There was a tendency towards lower clearance rate in patients with longer duration of AGW. Eight of 14 patients (57.1%) had AGW recurrence 12 weeks after clearance.

CONCLUSION

Ingenol mebutate gel was associated with a high number of AEs and withdrawals due to painful local and adjacent skin reactions. Furthermore, it showed promising efficacy in reducing AGW despite a difficult-to-treat population. Optimization of the formulation is warranted to improve the safety profile of the treatment.

Self-reported genital warts among sexually-active university students: a cross-sectional study

BACKGROUND

Genital warts are one of the most common forms of sexually-transmitted disease, but their epidemiology has yet to be thoroughly elucidated. The present study was designed to shed light on the prevalence of clinically-confirmed, self-reported genital warts (GWs) in a representative sample of the university population.

METHODS

In 2015, a cross-sectional survey was conducted on 11,096 individuals approached at the Students Information Bureau where they came to enroll for a university degree course. Participants completed an anonymous, self-administered questionnaire providing information on their sociodemographic characteristics, sexual behavior, and any history of clinically-diagnosed genital warts. Multivariate logistic regression was then used to identify any factors associated with the disease.

RESULTS

Our analysis was conducted on 9259 questionnaires (83.4%). Participants were a mean 21.8 ± 4.8 years of age, and 59.6% were female. Overall, 124 individuals (1.3%, 95%CI: 1.0-1.6) reported having been diagnosed with genital warts: 48 men (1.3%, 95%CI: 0.9-1.6), and 76 women (1.4% 95%CI: 1.1-1.7). Overall, 22.5% of the sample were vaccinated (1.3% of the males and 36.8% of the females). The group of respondents aged 30 years or more had the highest incidence of genital warts (males: 5.6%, 95%CI: 2.5-8.6; females: 6.9%, 95%CI: 3.4-10.4). The independent risk factors associated with a history of disease were (for both genders) a history of other sexually-transmitted diseases, and ≥2 sex partners in the previous 24 months. A protective role emerged for routine condom use. Additional risk factors associated with genital warts in males concerned men who have sex with men, bisexuality vis-à-vis heterosexuality, and smoking.

CONCLUSIONS

The findings emerging from our study help to further clarify the epidemiology of genital warts in young people, and may be useful to public health decision-makers. This study showed that genital warts occur in men as well as women, and suggests that both genders should be monitored for this disease to ascertain the effects of the free HPV vaccination offered to all girls in the Veneto in their 12th year of life since 2008, and to all boys of the same age since 2015.

Incidence of anogenital warts in Liuzhou, south China: a comparison of data from a prospective study and from the national surveillance system

To determine the incidence of anogenital warts (AGWs) in the Chinese general population, we compared the data from a prospective study and from the National Notifiable Disease Report System (NNDRS). A cohort study including 2378 women and 2309 men aged 18-55 years old enrolled from Liuzhou, China, was conducted with three scheduled visits at 6-month intervals from May 2014 to March 2016. And, a questionnaire survey was performed to collect the diagnosis history of AGWs at the enrollment visit. The data on reported AGW cases of Liuzhou in the NNDRS from 2006 to 2015 were also analyzed. Overall, the incidence rates of AGWs in the prospective study, in the self-reported diagnosis during past 12 months and in the NNDRS were 1.26 per 1000 person-years (95% confidence interval (CI): 0.16-2.37), 2.35 (95% CI: 1.17-4.20) and 0.183 (95% CI: 0.178-0.187), respectively. Human papillomavirus 6 or 11 were found in all the AGW biopsy samples (10/10). The onset time of AGWs in women was earlier, and the cumulative risk increased more quickly at a young age along with each subsequent younger birth cohort (P<0.0001), whereas slight differences were observed in the different male birth cohorts (P=0.0785). The sexual behavior of individuals and their sexual partners had a strong relationship with self-reported AGWs. Our study indicates that the incidence of AGWs in China is as high as that in developed countries, and the data based on the national surveillance system seriously underestimate the real disease burden of AGWs.

Annual prevalence and economic burden of genital warts in Korea: Health Insurance Review and Assessment (HIRA) service data from 2007 to 2015

This study evaluated the annual prevalence of anogenital warts (AGW) caused by human papillomavirus (HPV) and analysed the trend in annual per cent changes (APC) by using national claims data from the Health Insurance Review and Assessment of Korea, 2007-2015. We also estimated the socio-economic burden and co-morbidities of AGW. All analyses were performed based on data for primary A63.0, the specific diagnosis code for AGW. The socio-economic cost of AGW was calculated based on the direct medical cost, direct non-medical cost and indirect cost. The overall AGW prevalence and socio-economic burden has increased during the last 9 years. However, the prevalence of AGW differed significantly by sex. The female prevalence increased until 2012, and decreased thereafter (APC + 3·6%). It would fall after the introduction of routine HPV vaccination, principally for females, in Korea. The male prevalence increased continuously over time (APC + 11·6%), especially in those aged 20-49 years. Referring to the increasing AGW prevalence and its disease burden, active HPV infection control surveillance and prevention in males are worth consideration.

A Pilot Study of the Prevalence of Anal Human Papillomavirus and Dysplasia in a Cohort of Patients With IBD

BACKGROUND

Defective cell-mediated immunity increases the risk of human papillomavirus-associated anal dysplasia and cancer. There is limited information on anal canal disease in patients with IBD.

OBJECTIVE

The purpose of this study was to assess anal/vaginal human papillomavirus and anal dysplasia prevalence in patients with IBD.

DESIGN

Patients had an anal examination before routine colonoscopy.

SETTINGS

The study was conducted at a tertiary IBD referral center.

PATIENTS

We studied a convenience sample of sexually active male and female patients with IBD who were not on biological therapy.

INTERVENTION

Anal examination, anal and vaginal human papillomavirus testing, anal cytology, and high-resolution anoscopy/biopsy were carried out.

MAIN OUTCOME MEASURES

Anal and vaginal human papillomavirus types, anal cytology, and biopsy grade were measured.

RESULTS

Twenty-five male and 21 female evaluable participants, 31 with Crohn's disease, 14 with ulcerative colitis, and 1 with indeterminate colitis, were predominantly white (91.3%), treatment experienced (76.1%), an average age of 38.1 years (range, 22.0-66.0 y), and had an average length of IBD diagnosis of 9.3 years (range, 1.0-33.0 y). Eighteen (39.1%) had an abnormal perianal examination and 3 (6.5%) had an abnormal digital examination. Forty-one (89.1%) had anal human papillomavirus, 16 with a single type and 25 with multiple types (range, 2-5 types). Human papillomavirus type 16 was most common (65.2%), followed by human papillomavirus types 11 and 45 (37.0% each). Nineteen of 21 (90.5%) women had vaginal human papillomavirus. Overall, 21 (45.7%) had abnormal anal cytology. Thirty three (71.7%) had ≥1 anal biopsy (9 had multiple), with dysplasia diagnosed in 28 (60.9%) and high-grade and low-grade squamous intraepithelial lesions diagnosed in 4 (8.7%) and 24 (43.5%).

LIMITATIONS

No control group was included, and no detailed sexual history was taken.

CONCLUSIONS

A high prevalence of anal and vaginal human papillomavirus and anal dysplasia was demonstrated in the study population outcomes. See Video Abstract at http://links.lww.com/DCR/A379.

The prevalence and concordance of human papillomavirus infection in different anogenital sites among men and women in Liuzhou, China: A population-based study

Human papillomavirus (HPV) infection is the pathogenesis of anogenital cancers and genital warts in both men and women, whereas there is a scarcity of large studies focused on HPV prevalence in different anogenital sites of both sexes in the same population. From May to July 2014, 2,309 men and 2,378 women aged 18-55 were enrolled from communities in Liuzhou, China. Penis/glans penis/coronary sulcus (PGC) and perianal/anal canal (PA) specimens of men, and vaginal (VA), vulvar (VU) and PA specimens of women, were collected and genotyped for HPV. The prevalence of any HPV tested in PGC and PA samples from men and VA, VU and PA samples from women was 10.8%, 3.8%, 14.2%, 13.3% and 8.4%, respectively. The concordance of VA and VU was highest (kappa = 0.74), followed by VU and PA (0.44), VA and PA (0.38) and PGC and PA (0.14). Besides sex behavior, ever having used a towel supplied by a hotel was a risk factor for both external genital and PA HPV infection. Our data indicated that women were more of a major reservoir for oncogenic HPV infection of both genital sites and PA sites than was men. In both sexes, the genital sites were more likely than PA sites to harbor HPV infection. The concordance rates of HPV infection between genital sites and PA infection were poor.

[Genital warts in HIV-infected individuals]

Anogenital warts (condylomata acuminata) are much more frequent in human immunodeficiency (HIV)-positive patients compared to HIV-negative individuals. Anogenital warts of HIV-infected patients differ from those of HIV-negative individuals with respect to their spread, occurrence on more unusual anatomical sites, human papillomavirus (HPV)-type spectrum, tendency to recur, and risk of malignant transformation. Between 18 and 56% of anogenital warts of HIV-positive patients harbor high-grade dysplasia. Therefore, anogenital warts of HIV-infected patients should be preferentially treated with ablative methods and should be evaluated histopathologically. Gender-neutral prophylactic HPV vaccination of HPV-naive boys and girls could also lead to a significant reduction of anogenital warts in this patient group in the future.

HPV11 E6 mutation by overexpression of APOBEC3A and effects of interferon-ω on APOBEC3s and HPV11 E6 expression in HPV11.HaCaT cells

BACKGROUND

Condyloma acuminatum, infected by low-risk human papillomaviruses (e.g., HPV6 and HPV11), is one of the most widespread sexually transmitted diseases. Apolipoprotein B mRNA-editing enzyme catalytic polypeptide-like 3 proteins (APOBEC3s, A3s) are cellular cytidine deaminases acting as antiviral factors through hypermutation of viral genome. However, it remains unknown whether A3s results in HPV11 gene mutations and interferon-ω (IFN-ω) exhibits antiviral activities through the A3s system. Here we investigated whether enhanced APOBEC3A (A3A) resulted in the E6 gene mutations and explore the effects of recombinant human interferon-ω (rhIFN-ω) on A3s/E6 expression in HaCaT keratinocytes containing the genome of HPV 11 (HPV11.HaCaT cells).

METHODS

A3A-overexpressed HPV11.HaCaT (A3A-HPV11.HaCaT) cells were established by lentiviral infection and verified by immunofluorescence and western-blotting. Cell cycle, E6 gene mutations, APOBEC3s/E6 gene expression and subcellular localization were detected by FACS, 3D-PCR and sequencing, qRT-PCR and immunofluorescence respectively.

RESULTS

The results suggested that A3A-HPV11.HaCaT cells were successfully established. Enhanced A3A induced S-phase arrest, G > A/C > T mutations and obvious reduction of E6 mRNA expression. A3A/A3B mRNA expression was up-regulated at 6 h and 12 h and obvious A3A staining existed throughout HPV11.HaCaT cells after rhIFN-ω treatment. RhIFN-ω could also inhibit mRNA expression of HPV11 E6 significantly.

CONCLUSIONS

Enhanced A3A repressed HPV11 E6 expression through gene hypermutation, and rhIFN-ω might be an effective agent against HPV11 infection by up-regulation of A3A.

Epidemiology and burden of HPV-related disease

Human papillomavirus (HPV) infection is recognized as one of the major causes of infection-related cancer in both men and women. High-risk HPV types are not only responsible for virtually all cervical cancer cases but also for a fraction of cancers of the vulva, vagina, penis, anus, and head and neck cancers. Furthermore, HPV is also the cause of anogenital warts and recurrent respiratory papillomatosis. Despite the availability of multiple preventative strategies, HPV-related cancer remains a leading cause of morbi-mortality in many parts of the world, particularly in less developed countries. Thus, in this review, we summarize the latest estimates of the global burden of HPV-related diseases, trends, the attributable fraction by HPV types, and the potential preventative fraction.

Resource Use and Cost of Treating Human Papillomavirus-Related Lesions in Japanese Women

BACKGROUND

Human papillomavirus (HPV) infection is established as a necessary causal factor in several pathologies including cervical cancer (CC), which recorded over 11,000 new cases in 2011 in Japan. Nevertheless, cost burden data of human papillomavirus-related diseases in Japan are lacking.

OBJECTIVES

To evaluate resource use and costs in women with HPV-related lesions.

METHODS

A retrospective study using insurance claims databases was performed to assess the annual medical cost for suspected cervical intra-epithelial neoplasia (CIN)/CC, genital warts (GWs), CIN (all grades), and CC. Information on the treatment of GWs was obtained from the Claims Database developed by Japan Medical Data Center Co., Ltd. Information on CIN and CC was obtained from the Evidence-Based Medicine provider database developed by Medical Data Vision Co., Ltd. Databases cover about 1% of the Japanese population. Total annual cost in Japanese yen (¥) per patient in 2011 was calculated on the basis of resource used and unit costs from Japan medical insurance tariffs.

RESULTS

Average annual costs were as follows: GWs, ¥34,424; suspected CIN/CC, ¥6,240; CIN 1, ¥17,484; CIN 2, ¥46,583; CIN 3, ¥166,227; and CC, ¥474,756.

CONCLUSIONS

To our knowledge, this is the first observational study to estimate the annual medical costs of HPV-related diseases in Japan using real-world data collected in routine clinical practice. It could provide help in estimating the economic burden of HPV-related lesions in Japanese women.

Role of Human Papillomavirus in Vulvar Cancer

Human papillomavirus (HPV) is involved in one of the at least 2 pathways leading to vulvar squamous cell carcinoma (VSCC). Inactivation of p53 and retinoblastoma by the viral products E6 and E7 is involved in malignant transformation. The percentage of HPV-positive VSCCs ranges from 18% to 75%, depending on the geographical area. HPV-associated tumors affect relatively young women and arise from high-grade intraepithelial lesions, identical to other HPV-associated premalignant lesions of the anogenital tract. HPV-independent tumors tend to affect older women and usually arise in a background of inflammatory skin disorders and a subtle variant of in situ lesion called differentiated vulvar intraepithelial neoplasia. HPV-positive tumors tend to be of basaloid or warty types, whereas HPV-independent tumors tend to be of keratinizing type, but there is frequent overlap between histologic types. There is no conclusive evidence yet on the best strategy in terms of determining HPV attribution. HPV DNA detection is generally considered the gold standard although there is some concern about misclassification when using this technique alone. p16 immunostaining has shown to be an excellent surrogate marker of HPV infection. Positive results for both techniques are considered the best evidence for HPV-association. The prognostic role of HPV in VSCC is still contradictory, but increasing evidence suggests that HPV-associated tumors are less aggressive. Currently, there are no differences in treatment between HPV-associated and HPV-independent VSCC, but novel immunological strategies based on anti-HPV antigens are being evaluated in clinical trials.

Cryotherapy to treat anogenital warts in nonimmunocompromised adults: Systematic review and meta-analysis

BACKGROUND

Cryotherapy is one of the most commonly used therapeutic modalities to treat anogenital warts (AGWs), but this treatment was not clearly established in the recent international recommendations.

OBJECTIVE

To compare the efficacy and safety of cryotherapy versus other AGW treatments.

METHODS

Through a systematic search of 12 electronic databases, we identified 11 randomized controlled trials, screened from database inception through October 2016, that met the inclusion criteria (including immunocompetent adults with AGWs receiving cryotherapy in 1 of the comparison groups). Primary endpoint was complete clearance of AGW. Risk-for-bias assessment was based on Cochrane Handbook recommendations. Meta-analyses used Review Manager v5.3 software.

RESULTS

Cryotherapy efficacy did not appear to differ from that of trichloroacetic acid, podophyllin, or imiquimod. Electrosurgery was weakly associated with better AGW clearance than cryotherapy (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.65-0.99). Cryotherapy was associated with more immediate low-level adverse events (erythema, stinging, or irritation; RR 3.02, 95% CI 1.38-6.61) and immediate pain requiring oral analgesics (RR 2.11, 95% CI 1.07-4.17) but fewer erosions (RR 0.57, 95% CI 0.36-0.90).

LIMITATIONS

All but 1 randomized-controlled trial had a high risk for bias.

CONCLUSION

With low-level quality of the evidence, cryotherapy is an acceptable first-line therapy to treat AGWs.

Predictors of Adults' Knowledge and Awareness of HPV, HPV-Associated Cancers, and the HPV Vaccine: Implications for Health Education

High human papillomavirus (HPV) prevalence and low HPV vaccine uptake are significant public health concerns. Disparities in HPV-associated cancers and HPV vaccine uptake rates suggest the need for additional research examining factors associated with vaccine acceptance. This study assessed HPV awareness and knowledge and identified sociodemographic characteristics associated with HPV knowledge at the population level. Data from adult men ( n = 1,197) and women ( n = 1,906) who participated in the National Cancer Institute's 2014 Health Information National Trends Survey were analyzed. Multivariable regression was used to identify predictors of four HPV knowledge categories: (1) general knowledge, (2) cervical cancer knowledge, (3) "other" cancer knowledge (i.e., anal, oral, penile), and (4) vaccine knowledge. Significant gender differences in awareness and knowledge of HPV and the HPV vaccine were revealed. Most participants (>70%) knew that HPV could cause cervical cancer, but fewer (14.9% to 31.5%) knew of the association between HPV and "other" cancers. Women were more likely to report that a health care provider recommended vaccination. Significant predictors of general HPV and HPV vaccine knowledge included gender, education, income, race, and other sociodemographic characteristics. Age and income predicted cervical cancer knowledge. Knowledge of "other" HPV-associated cancers was predicted by having a child under 18 years in the household and relationship status. HPV knowledge appears to be socially patterned. Low HPV knowledge among men and some racial minorities suggests a need for further intervention. Health education should emphasize risks of noncervical HPV-associated cancers. Patient-provider communication that includes education, counseling, and clear recommendations favoring vaccination may improve uptake.

Impact of quadrivalent human papillomavirus vaccine on genital warts in an opportunistic vaccination structure

OBJECTIVE

Genital warts are the most common sexually transmitted disease and have a detrimental impact on quality of life. Genital warts could be prevented by prophylactic HPV vaccination. The objective was to study real-life benefit of opportunistic HPV vaccination on age and gender specific incidence of genital warts.

METHODS

We performed a register-based population cohort study from publicly funded health-care provider in Israel. The incidence of genital warts was assessed during three time frame intervals: 2006-2008 (pre-vaccination effect period) 2009-2012 (early post-vaccination effect period) and 2013-2015 (late post-vaccination effect period), with an average annual number of members of 1,765,481, 1,906,774 and 2,042,678 in the years 2006-2008, 2009-2012 and 2013-2015, respectively.

RESULTS

Among females, annual incidence of genital warts per 100,000 women decreased from 210.43 to 161.71 (OR 0.76, 95%CI 0.71-0.82, p<0.001) and to 146.8 (OR 0.69, 95%CI 0.66-0.72, p<0.001) between pre-vaccination period and early and late post-vaccination periods, respectively. Among males, annual incidence of genital warts per 100,000 men decreased from 262.85 to 232.40 (OR 0.88, 95%CI 0.83-0.93, p<0.001) and to 234.01 (OR 0.88, 95%CI 0.86-0.91, p<0.001) between pre-vaccination period and early and late post-vaccination periods, respectively.

CONCLUSIONS

There is a potential benefit in reducing incidence of genital warts even in opportunistic HPV vaccination structure. This information may be relevant for health-care providers in countries where national immunization programs do not include HPV vaccines.

Immunostaining for High-Risk Human Papillomavirus in Condyloma Lesions in Immunocompromised Patients

BACKGROUND

Human papillomavirus (HPV) is the underlying infectious cause of condyloma acuminata (CA) and high-risk types of HPV can cause cancer. Condyloma may undergo malignant degeneration, particularly in immunosuppressed patients. The presence of high-risk HPV in CA is a risk factor for developing malignancy; however, determining which patients with condyloma are clinically at risk can be difficult. High-risk HPV can now be localized within CA using routine immunohistochemical stains.

METHODS

We examined HPV (cocktail, 16, 18) immunohistochemical staining of CA and the relevant clinical history from immunocompromised patients and compared them with age- and sex- matched immunocompetent patients with biopsied CA.

RESULTS

HPV was detected in 9 of the 12 specimens from immunocompromised patients (75%), and 6 of the 12 specimens from the age- and sex-matched comparison patients (50%). HPV-16 was detected in 7 of the 12 specimens from immunocompromised patients (58%), and 4 of the 12 specimens from comparison patients (33%). HPV-18 was not detected in any of the 21 specimens from immunocompromised or comparison patients for which the stain was available.

CONCLUSION

High-risk HPV is found within CA lesions, more often in immunocompromised patients, and confirming the presence of these HPV types with stains in high-risk patient populations may help guide the clinician in treatment and surveillance in certain cases.

Vaccination to prevent human papillomavirus infections: From promise to practice

In an essay, Paul Bloem and Ikechukwu Ogbuanu discuss the public health implications of HPV vaccination.

Sinecatechins and imiquimod as proactive sequential therapy of external genital and perianal warts in adults

This review about the proactive sequential therapy (PST) of external genital and perianal warts (EGW) is based on the most current available clinical literature and on the broad clinical experience of a group of international experts, physicians who are well versed in the treatment of human papillomavirus-associated diseases. It provides a practical guide for the treatment of EGW, including epidemiology, etiology, clinical appearance, and diagnostic procedures for these viral infections. Furthermore, the treatment goals and current treatment options, elucidating provider- and patient-applied therapies, and the parameters driving treatment decisions are summarized. Specifically, the mode of action of the topical treatments sinecatechins and imiquimod, as well as the PST for EGW to achieve rapid and sustained clearance is discussed. The group of experts has developed a treatment algorithm giving healthcare providers a practical tool for the treatment of EGW which is very valuable in the presence of many different treatment options.

Effectiveness of HPV vaccines against genital warts in women from Valencia, Spain

OBJECTIVES

To assess the effectiveness of the HPV vaccines in preventing genital warts in young women.

DESIGN

Population-based study using health databases.

SETTING

Valencian Community (Spain).

PARTICIPANTS

All girls and women aged 14-19years who were registered in the Valencian Community between January 2009 and December 2014 (n=279,787).

MAIN OUTCOME MEASURES

Incident cases of genital warts were defined as the first activation of diagnosis code ICD-9-CM 078.11 (Condyloma acuminatum) in primary care and outpatient clinics during the study period.

RESULTS

There were 612 cases of genital warts. The overall incidence rate was 75.8/100,000 person-years (95% CrI 69.7-81.8). There was a decrease in genital warts when female candidates to be vaccinated with quadrivalent HPV vaccine reached the age of 18 (in 2012), compared to previous years. Incidence of genital warts in unvaccinated women and those who received the bivalent vaccine was higher than in girls and women who received the quadrivalent HPV vaccine. The effectiveness of a three-dose regimen of the quadrivalent HPV vaccine was 77% (95 CrI: 66-85%), whereas that of a single dose was 61% (95 CrI: 20-87%). No effectiveness was seen with a full vaccination course with the bivalent HPV vaccine.

CONCLUSIONS

Three doses of the quadrivalent HPV vaccine were effective against genital warts in our population. Moreover, with low vaccine coverage the incidence of genital warts decreased only in the vaccinated.

Decline in hospitalization for genital warts in the Veneto region after an HPV vaccination program: an observational study

BACKGROUND

Human papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region (Italy) from 2004 to 2015.

METHODS

All patients with GWs were identified in the hospital discharge records of all public and accredited private hospitals that related to Veneto residents and contained the ICD9-CM code 078.11 associated with a genital surgical procedure (vulval/vaginal warts, penile warts and anal warts). Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period.

RESULTS

An annual rate of 11.8 per 100,000 population (8.6 per 100,000 males, and 14.8 per 100,000 females) was found, corresponding to 6076 hospitalizations for condyloma (53.3% vulval/vaginal, 35.8% anal, 8.3% penile, and 2.6% both penile or vulval/vaginal and anal). Among females, the rate of overall GWs remained stable to 2007 (19.1 per 100,000), then dropped significantly, reaching a rate of 11.3 per 100,000 in 2015 (average annual percent changes [AAPC]: -6.1%; 95% CI: -8.4; -3.7). For males, the overall rate increased over the study period (from 6.4 per 100,000 in 2004 to 10.8 per 100,000 in 2015; AAPC: 3.8%; 95% CI: 1.2; 6.4). Among the potentially vaccinated females (12- to 20-year-olds) there was a 62.1% decrease in the number of vulval/vaginal warts from the years 2010-2012 to the years 2013-2015 due to an increase in the HPV coverage rate. A similar reduction among males was observed in the same period and the same age group for penile warts (-68.2%).

CONCLUSION

GWs have an important impact on the health services and data suggest that GW-related hospitalization rates rapidly decline in a population with a high HPV vaccination coverage (about 75%). Further efforts should be made to better clarify the epidemiological picture regarding HPV-related diseases, with particular regard to sexual behavior.

Human Papillomavirus Vaccine Update

Rates of cancers attributable to human papillomavirus (HPV) are rising. A safe and extremely effective vaccine is available to prevent many of these cancers. Studies have shown that health care providers' recommendation to immunize is the most important factor in parents' decision. Parents of all adolescent boys and girls should receive a strong and unequivocal recommendation to vaccinate their child against HPV at the 11- or 12-year-old well child visit. Ideally, adolescents complete their HPV vaccine series by their 13th birthday, leading to greater immune response and protection before most adolescents are exposed to sexually transmitted HPV.

Prevalence and incidence of external genital warts in a sample of Italian general female population

Background

The Human papillomavirus is the most common sexually transmitted virus worldwide. The objective of this study was to estimate: 1) the prevalence and the incidence of external genital warts (eGW) in a sample of women attending community outpatient clinics and 2) the total number of eGW cases in the Italian female population aged 15–64 years.

Methods

A prospective study was performed for a 12-month period between 2009 and 2010, among a sample of women attending community gynecological outpatient clinics located throughout Italy. Demographic data, for every woman aged 15–64 years, were collected. For women diagnosed with eGW, behavioral and clinical data were recorded. Prevalence of eGW was calculated as the proportion between the number of women with eGW and that of women visiting any of the participating gynecologists; incidence of eGW was calculated as the proportion between the number of women with a new diagnosis of eGW and that of women visiting any of the participating gynecologists. Standardized prevalence by age was used to estimate the number of eGW cases occurring in the Italian female population aged 15–64 years.

Results

In 2009–2010, 44 community gynecologists were included in the network. In one-year period, 16,410 women visited any of the participating gynecologists; 63 women were diagnosed with eGW, corresponding to a prevalence of 3.8 cases per 1,000 women per year (95%CI: 2.9-4.9). The incidence of eGW was 3.0 cases per 1,000 women per year (95%CI: 2.2-3.9). Women aged 15–24 years showed both the highest prevalence and incidence. Prevalence and incidence significantly decreased by increasing age group (p <0.001), and were higher in Southern Italy compared to Central-Northern Italy. The estimated number of women with eGW among women aged 15–64 years in Italy, in 2010, was approximately 69,000.

Conclusions

These data show a high prevalence and incidence of eGW among young women in Italy, stress the effectiveness of community clinical networks in investigating STI epidemiology among women from the general population, confirm the relevance of HPV vaccination programs among adolescents, and underscore the need of promoting safe sex, implementing early diagnosis, treatment and prevention of genital warts.

Four sexually transmitted infections (STIs) in Belgian general practice: first results (2013-2014) of a nationwide continuing surveillance study

OBJECTIVES

To describe and explore data from the surveillance of chlamydia, syphilis, gonorrhoea and genital warts by the Belgian Network of Sentinel General Practices (SGP) over the first 2 years (2013 and 2014) and to estimate the incidence of these 4 sexually transmitted infections (STIs). A special focus is put on data quality.

DESIGN

Retrospective observational study.

SETTING

General practices from the nationwide representative SGP network.

OUTCOME MEASURES

Agreement between data distributions by year, agreement between SGP-based incidence and incidence based on mandatory notification, missingness of patient age or gender and incompleteness of sexual risk history of patients.

RESULTS

306 new STI episodes were reported from 298 patients, corresponding with an episode-based incidence of 91.9/100 000 (95% CI 81.9 to 102.8) general practice patients, with almost half of it due to chlamydia. The incidence of chlamydia in men was significantly higher in 2014 than in 2013. Population characteristics were similarly distributed in 2013 and 2014. The SGP-based incidence of gonorrhoea and syphilis in Flanders were in agreement with the incidence based on mandatory notification of cases. Patient age or gender was missing from 35 episodes (11.4%). Independent determinants of missingness of patient age or gender were the Flemish region (OR 3.46; 95% CI 1.02 to 11.73) and genital warts infection (OR 2.23; 95% CI 1.07 to 4.63). An incomplete sexual risk history was reported for 54.6% STI episodes. The odds for an incomplete sexual history were higher for older patients (OR 1.72; 95% CI 1.06 to 2.76) and for patients infected with syphilis, gonorrhoea or co-infection(s) (OR 1.71; 95% CI 1.03 to 2.83).

CONCLUSIONS

Incompleteness of reports about patients with STI sexual risk histories is important from the perspective of quality of data and of quality of care. Together with the low rates of both HIV testing and discussion of partner notification, this suggests that a general practice guideline is needed.

Clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic evaluation

BACKGROUND

Typically occurring on the external genitalia, anogenital warts (AGWs) are benign epithelial skin lesions caused by human papillomavirus infection. AGWs are usually painless but can be unsightly and physically uncomfortable, and affected people might experience psychological distress. The evidence base on the clinical effectiveness and cost-effectiveness of treatments for AGWs is limited.

OBJECTIVES

To systematically review the evidence on the clinical effectiveness of medical and surgical treatments for AGWs and to develop an economic model to estimate the cost-effectiveness of the treatments.

DATA SOURCES

Electronic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Web of Science) were searched from inception (or January 2000 for Web of Science) to September 2014. Bibliographies of relevant systematic reviews were hand-searched to identify potentially relevant studies. The World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov were searched for ongoing and planned studies.

REVIEW METHODS

A systematic review of the clinical effectiveness literature was carried out according to standard methods and a mixed-treatment comparison (MTC) undertaken. The model implemented for each outcome was that with the lowest deviance information criterion. A de novo economic model was developed to assess cost-effectiveness from the perspective of the UK NHS. The model structure was informed through a systematic review of the economic literature and in consultation with clinical experts. Effectiveness data were obtained from the MTC. Costs were obtained from the literature and standard UK sources.

RESULTS

Of 4232 titles and abstracts screened for inclusion in the review of clinical effectiveness, 60 randomised controlled trials (RCTs) evaluating 19 interventions were included. Analysis by MTC indicated that ablative techniques were typically more effective than topical interventions at completely clearing AGWs at the end of treatment. Podophyllotoxin 0.5% solution (Condyline(®), Takeda Pharmaceutical Company Ltd; Warticon(®) solution, Stiefel Laboratories Ltd) was found to be the most effective topical treatment evaluated. Networks for other outcomes included fewer treatments, which restrict conclusions on the comparative effectiveness of interventions. In total, 84 treatment strategies were assessed using the economic model. Podophyllotoxin 0.5% solution first line followed by carbon dioxide (CO2) laser therapy second line if AGWs did not clear was most likely to be considered a cost-effective use of resources at a willingness to pay of £20,000-30,000 per additional quality-adjusted life-year gained. The result was robust to most sensitivity analyses conducted.

LIMITATIONS

Limited reporting in identified studies of baseline characteristics for the enrolled population generates uncertainty around the comparability of the study populations and therefore the generalisability of the results to clinical practice. Subgroup analyses were planned based on type, number and size of AGWs, all of which are factors thought to influence treatment effect. Lack of data on clinical effectiveness based on these characteristics precluded analysis of the differential effects of treatments in the subgroups of interest. Despite identification of 60 studies, most comparisons in the MTC are informed by only one RCT. Additionally, lack of head-to-head RCTs comparing key treatments, together with minimal reporting of results in some studies, precluded comprehensive analysis of all treatments for AGWs.

CONCLUSIONS

The results generated by the MTC are in agreement with consensus opinion that ablative techniques are clinically more effective at completely clearing AGWs after treatment. However, the evidence base informing the MTC is limited. A head-to-head RCT that evaluates the comparative effectiveness of interventions used in clinical practice would help to discern the potential advantages and disadvantages of the individual treatments. The results of the economic analysis suggest that podophyllotoxin 0.5% solution is likely to represent a cost-effective first-line treatment option. More expensive effective treatments, such as CO2 laser therapy or surgery, may represent cost-effective second-line treatment options. No treatment and podophyllin are unlikely to be considered cost-effective treatment options. There is uncertainty around the cost-effectiveness of treatment with imiquimod, trichloroacetic acid and cryotherapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005457.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Ano-Genital Warts and HIV Status- A Clinical Study

INTRODUCTION

Ano-Genital Warts (AGW) like other Sexually Transmitted Diseases (STD) is associated with Human Immunodeficiency Virus (HIV) infection. This study of AGW was done in HIV positive and HIV negative patients.

AIM

To study the risk factors and clinical presentations of ano-genital warts in HIV positive and negative patients.

MATERIALS AND METHODS

A comparative, cross-sectional, descriptive study of 25 HIV positive and 25 HIV negative (n=50) AGW patients between 15-60 years of both sex was conducted in Dr. D. Y. Patil Hospital and Research Centre from July 2014 to July 2016.

RESULTS

Significant association of HIV positivity (p<0.05) was observed between age group of 15-30 years and HIV negative status (p<0.05) in age group of 31-45 years. HIV positive status significantly higher in patients with self-admitted multiple sexual partners (p<0.01), homosexuality (p<0.05) and presentation with anal warts (p<0.01). HIV negative status correlated significantly with single sexual partner admission (p<0.01) and hetero-sexuality (p<0.05). Gender did not show significant association with number of sexual partners or HIV positivity. Extra-genital or only genital warts had no association with HIV status. Co-STDs though more in number in ser-positive group, did not show any significant association with HIV positivity (p>0.05). No patient presented with changes of malignancy. Four were adolescents below 19 years. Two patients had atypical presentations of giant condylomata i.e., Buschke-Lowenstein Tumour (BLT).

CONCLUSION

HIV positivity was significantly associated with the risk factors of age below 30 years, homo sexuality and multiple sexual partners. Anal warts were significantly common in HIV positive patients. Four adolescents with AGW underline the need for high risk behaviour counselling. No patient had malignant ano-genital warts. Follow up of these patients with Human Papilloma Virus (HPV) sub-typing is necessary.

Surgical Management of Giant Genital Condyloma Acuminata by Using Double Keystone Flaps

Condyloma acuminata in the external genitalia (genital warts) is a sexually transmitted disease that is often caused by human papillomavirus (HPV). We report a case of giant genital condyloma acuminata in a 35-year-old male patient with HIV comorbidity treated by wide surgical excision. Excision defect was covered with split thickness skin graft (STSG) and double keystone flaps. There was no complication after surgery. Ten months following surgery, there was no new condyloma lesion and the patient had normal voiding and erectile functions.

Green tea extract for external anogenital warts

Catephen (Kora Corporation Ltd) is a herbal medicinal product consisting predominantly of catechins (sinecatechins) extracted from Camellia sinensis (L.) O. Kuntze folium (green tea leaf) formulated as a topical preparation for the treatment of external genital and perianal warts (condylomata acuminata).(1) Marketing authorisation for an ointment containing 0.1g of green tea extract per gram (10%) was granted by the Medicines and Healthcare products Regulatory Agency (MHRA) under the mutual recognition procedure in February 2015.(2) Here, we consider the evidence for Catephen ointment in the management of external genital and perianal warts and its place within current management strategies.

The Expanded Impact of Human Papillomavirus Vaccine

Human papilloma virus (HPV) infection is the most common sexually transmitted infection in the United States. Some infections will result in anogenital warts and anogenital or oropharyngeal cancers. Preventing HPV infection is a public health priority to reduce cancer and HPV-associated complications. Prevention through vaccination is the most cost-effective and lifesaving intervention to decrease the burden of HPV-related cancers and other HPV-associated diseases. It is critical for pediatricians to make a strong recommendation for early and timely vaccination and completion of the 3-dose series. The goal of early vaccination is to immunize before first exposure to HPV virus.

[CONDYDAV: A multicentre observational study of patients presenting external genital warts in France]

BACKGROUND

Since 2007 in France, human papilloma virus (HPV) vaccination has been licensed for use as a vaccine against HPV 6, 11, 16 and 18. The impact on the epidemiology of external genital warts (EGWs) in a large population remains unclear.

OBJECTIVES

To determine epidemiologic and clinical features of patients presenting EGWs in France in the era of HPV vaccination.

PATIENTS AND METHODS

In this prospective, observational study, we analyzed clinical features and treatments between January 1st, 2012 and March 31, 2012 for patients consulting for EGWs at 15 STI clinics throughout France.

RESULTS

A total of 372 men and 111 women were included; mean age 31.2 years. The women were younger than the men (31.7 and 28.9 years respectively P<0.05). Among the patients, 416 (85.7%) were heterosexual, 13 bisexual and 54 (11.2%) homosexual, including one female. Males reported more sexual partners in the last 12 months (more than 3 partners in 32.6% versus 11.9%, P<0.01). Among the men, 230 had involvement of the penis alone and 46 had involvement of the anus alone. Seventy-six patients had EGWs of the anus, and of these 26 were MSM. In females, 76 had an infection of the vulva alone and 22 co-infection of the vulva and anus. MSM and females were at higher risk than heterosexual males for anal involvement (P<0.0001 and P=0.004, respectively). Three women had been vaccinated: two with Gardasil^® and one with Cervarix^®. Cryotherapy was the preferred treatment.

CONCLUSION

With the advent of HPV vaccination, a global strategy for the prevention and treatment of EGW should be implemented.

Human Papillomavirus and Genital Warts: A Review of the Evidence for the 2015 Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines

To provide updates for the 2015 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines on human papillomavirus (HPV) and anogenital warts (AGWs), a review of the literature was conducted in key topic areas: (1) epidemiology and burden of disease; (2) transmission and natural history; (3) diagnosis and management of AGWs; (4) occupational exposure of healthcare workers; (5) anal cancer screening among men who have sex with men (MSM); and (6) HPV vaccine recommendations. Most sexually active persons will have detectable HPV at least once in their lifetime; 14 million persons are infected annually, and 79 million persons have prevalent infection. HPV is transmitted frequently between partners; more frequent transmission has been reported from females to males than from males to females. A new formulation of imiquimod (3.75% cream) is recommended for AGW treatment. Appropriate infection control, including performing laser or electrocautery in ventilated rooms using standard precautions, is recommended to prevent possible transmission to healthcare workers who treat anogenital warts, oral warts, and anogenital intraepithelial neoplasias (eg, cervical intraepithelial neoplasia). Data are insufficient to recommend routine anal cancer screening with anal cytology in persons living with human immunodeficiency virus (HIV)/AIDS or HIV-negative MSM. An annual digital anorectal examination may be useful for early detection of anal cancer in these populations. HPV vaccine is recommended routinely for 11- or 12-year-olds, as well as for young men through age 21 years and young women through age 26 years who have not previously been vaccinated. HPV vaccine is also recommended for MSM, people living with HIV/AIDS, and immunocompromised persons through age 26 years.

Associations of Anogenital Low-Risk Human Papillomavirus Infection With Cancer and Acquisition of HIV

α-Mucosal human papillomavirus (HPV) types are implicated in a range of clinical conditions and categorized as "low-risk" (LR) and "high-risk" (HR) types according to their degree of association with cervical cancers. The causative role of LR HPV infection in the development of anogenital warts and in low-grade squamous intraepithelial lesions is well established. In addition, there is a growing body of evidence that infection with LR HPV types may be associated with an elevated risk of cancers and potentiation of coinfections. Prospective and case-control studies consistently report a higher risk of anogenital cancers in men and women with a history of anogenital warts. Based on currently available evidence, this higher risk may be due to shared exposure to HR HPV types or an underlying immune impairment, rather than a direct role of LR HPV types in subsequent cancer risk. Data also suggest that infection with LR HPV, HR HPV, or both may increase the risk of HIV acquisition, although the relative contribution of different HPV types is not yet known. There is also evidence implicating HPV clearance, rather than HPV infection, in increased risk of HIV acquisition.

Low- and high-risk human papillomavirus genotype infections in intra-anal warts in HIV-positive men who have sex with men

BACKGROUND

Anogenital warts are often presumed to represent nondysplastic or low-grade anal intraepithelial neoplasia (LGAIN). We previously demonstrated that up to 20% of intra-anal warts in HIV-positive men who have sex with men (MSM) contain regions of high-grade AIN (HGAIN).

OBJECTIVES

To determine the causative human papillomavirus (HPV) types of low- and high- grade dysplastic areas in warts from HIV-positive MSM.

METHODS

A total of 42 intra-anal warts from 41 HIV-positive MSM were graded as nondysplastic, LGAIN or HGAIN. Whole-tissue sections (WTS) were analysed with the SPF10 polymerase chain reaction/LiPA25 HPV genotyping system. If the WTS contained multiple HPV types, dysplastic regions were isolated by laser capture microdissection (LCM) for HPV genotyping.

RESULTS

Overall, 38 of 42 (91%) WTS tested positive for HPV DNA. Of these, 23 (61%) contained a single HPV type and 15 (39%) contained multiple HPV types. All LCM-selected regions contained no more than one HPV type. Ten of 42 (24%) WTS contained HGAIN disease, of which six (60%) were associated with a high-risk HPV (hrHPV) genotype. Twenty-three of 42 WTS contained LGAIN disease, of which two (9%) were associated with hrHPV. AIN lesions containing hrHPV types were identified using p16 staining.

CONCLUSIONS

LGAIN lesions can be caused by high-risk HPV genotypes and vice versa. We therefore recommend routine follow-up and treatment of all dysplastic intra-anal warts for HIV-positive MSM.

A Comparative Study of Potassium Hydroxide versus CO2 Laser Vaporization in The Treatment of Female Genital Warts: A Controlled Clinical Trial

BACKGROUND

Genital warts are the most common viral sexually transmitted disease affecting 1% of the population. A prospective, open-label controlled trial was performed to compare topical 5% potassium hydroxide (KOH) solution with CO2 laser in the treatment of female genital warts.

METHODS

Seventy patients were enrolled in the study after convenience sampling. Right-sided lesions of the patients were treated by CO2 laser every 3 weeks. The left-sided lesions of the same patients were treated by topical 5% KOH solution twice a day using a toothpick with cotton wrap on the tip. The patients were visited at 3, 6, and 9 weeks after initiation of the treatment and followed up for 6 months after the last visit.

RESULTS

Out of seventy patients, sixty three completed the study and were analyzed. A total of 56 KOH treated-patients (88.9%) showed complete response. On the other hand, 56 laser-treated patients (88.9%) presented complete clearing of the lesion. There was not any difference in response to both modalities of treatment. Complications of KOH solution and CO2 laser were 24% and 19% respectively (P>0.05), but serious adverse events were not observed. The patients under KOH treatment displayed a recurrence rate of 11.1% (7 cases), while the same patients with CO2 laser therapy demonstrated a recurrence rate of 7.9% (5 cases) (P=0.54).

CONCLUSION

Topical 5% KOH solution was as effective as CO2 laser in the treatment of female genital warts. There was not any serious complication in the application of KOH solution. This could be used as a new treatment for genital warts.

TRIAL REGISTRATION NUMBER

IRCT201412207848N1.

Impact of HPV vaccination on anogenital warts and respiratory papillomatosis

Human papillomavirus (HPV), the most common sexually transmitted infection in the US and worldwide, can cause cancers, anogenital warts (AGW), and recurrent respiratory papillomatosis (RRP) in men, women, and children. Global incidence of AGW ranges from 160-289 cases per 100,000 person-years and peaks in young men and women in the third decade of life. RRP has an estimated incidence of 3 per 1 million person-years in children. Pre-licensure trial efficacy, modeling and time-trend ecological studies have shown a significant short-term impact of 4vHPV vaccine. In girls aged 15-19 years, a previously published meta-analysis indicated that genital warts decreased significantly by 31%; stratified analysis revealed more substantial reductions in populations with high (≥50 %) vs. low (<50 % ) vaccination coverage (61% vs. 14%). Longer-term monitoring will reveal whether this impact continues under 9vHPV programs, and whether current declines in AGW are mirrored by declines in RRP.