Condylomata acuminata (genital warts): patient demographics and treating physicians

A Comprehensive Review of Treatment Approaches for Cutaneous and Genital Warts

Cutaneous and genital warts are common in both developed as well as developing countries. Human papillomavirus (HPV), which is a double-stranded DNA virus, is the causative agent of wart infection. Different types of HPV viruses are responsible for the different severity of diseases. Some types are associated with malignancy of the anal region and cervix. HPV is a common sexually transmitted disease in the United States. The incidence is most common in the younger age groups and the elderly population. Our main goal is to describe the different treatment modalities available for warts. Treatment modalities are divided into primary, secondary, and tertiary options. Topical medications, and physical excision of warts via cryotherapy, electrocautery, lasers, or photodynamic therapy are all common forms of treatment. Various clinical trials and randomized control trials have been seen as effective treatment against HPV infection. Higher remission rates are seen irrespective of different treatment options. Warts can be treated but the HPV virus cannot be completely removed. Older age, immunocompromised state, diabetes mellitus, and HIV are the predisposing factors for the disease. There is currently a large variety of medicines in use, all of which can differ significantly in terms of price, side-effect profiles, dosing regimens, length of therapy, and overall effectiveness. The best course of treatment has not yet been identified, and patients are often treated according to their unique needs.

Polymeric Nanoparticles and Chitosan Gel Loading Ketorolac Tromethamine to Alleviate Pain Associated with Condyloma Acuminata during the Pre- and Post-Ablation

This study describes the preparation and evaluation of two formulations, a hydrogel and a nanostructured system, containing ketorolac tromethamine as an anti-inflammatory agent for the local therapy against the inflammatory process derived from the surgical excision of Condyloma acuminata. Both formulations were physicochemically characterized. In vitro release profiles show that the nanoparticles release 92% ± 2.3 of the total ketorolac tromethamine encapsulated, while the chitosan gel releases 18.6% ± 0.2. The ex vivo permeation and distribution through human skin were also assayed and was observed how the main amount of ketorolac tromethamine is retained in the epidermis. In vivo studies were accomplished to evaluate the anti-inflammatory efficacy in mice which also involved the histological analysis to confirm the in vivo results. The nanoparticles present a significantly higher anti-inflammatory efficacy than chitosan gel. The tolerability of developed formulations was assessed by monitoring the biomechanical properties of the skin before and after application of both formulations. No statistical differences in trans-epidermal water loss and skin hydration with respect to the basal values were observed and the formulations exhibited higher anti-inflammatory activity compared to a reference ketotorlac tromethamine solution. Therefore, it can be concluded that both formulations can be proposed as outstanding candidates for offering a local anti-inflammatory therapeutical tool with potential clinical application.

The impact of genital warts on sexual function and sexuality-related distress in late adolescence

Adolescence is a transition period during which sexual experiences gain importance. Genital warts are sexually transmitted lesions that have been shown to negatively affect sexual perception. This study aimed to evaluate the impact of genital warts on female sexual function and sexuality-related distress in adolescence. A total of 90 female adolescents between the ages of 17 and 21 who had regular sexual intercourse with heterosexual partners were included in this prospective case-control study. Female Sexual Function Index, Arizona Sexual Experiences Scale, and Female Sexual Distress Scale-Revised scores of adolescents with genital warts (n = 45) were compared to healthy subjects (n = 45). Total Female Sexual Function Index and Arizona Sexual Experiences Scale scores revealed significant dysfunction in adolescents with genital warts (20.7 ± 4.13 (20.9) vs. 28.2 ± 3.51 (28.7), p < 0.0001; 17.1 ± 3.61 (17) vs. 13.02 ± 3.01 (13), p < 0.0001, respectively). Total Female Sexual Distress Scale-Revised score was significantly decreased in the presence of genital warts (23.82 ± 9.73 (23) vs. 8.8 ± 7.38 (6), p < 0.0001). Significant correlations were found between the total Female Sexual Distress Scale-Revised score and the total Female Sexual Function Index score, and the Arizona Sexual Experiences Scale score (r = -0.78, p < 0.0001; r = 0.68, p < 0.0001, respectively). This study revealed that genital warts have significantly unfavorable effects on sexuality in adolescence leading to sexual dysfunction as well as sexuality-related distress. Regarding to the present findings, promoting sexual health in addition to physical well-being may increase success in clinical management of genital warts.

Clinical and pathological aspects of condyloma acuminatum - review of literature and case presentation

Condyloma acuminatum (CA) is a pathology caused by the human papillomavirus (HPV). It is manifested by the appearance of warts in the vulvar, pubic, and anorectal regions, but can occur in other areas. It is a common disease that can be prevented by using measures such as condoms or vaccine. Topical, local, pharmacological, surgical, and excisional therapy options are available for this pathology. Macroscopically, it appears as a vegetative tumor, with a single implantation base that branches towards the periphery, with a cauliflower appearance. CA is defined microscopically by acanthosis, parakeratosis, papillomatosis and koilocytosis. Immunohistochemical studies can detect the presence of various HPV strains or viral antigens and can emphasize certain specific characteristics; e.g., in the case presented in this study, we observed that the tumor had a fulminant evolution due to a strong vascular base identified with anti-cluster of differentiation (CD) 34 antibody, by the existence of epithelial cells with a high degree of cell proliferation, as evidenced by the anti-Ki67 antibody, the inactivation of the tumor suppressor gene and the appearance of immunolabeling for the anti-p53 antibody, by the strong immunoreactivity for p63 which reveals the existence of cells with dysplastic and neoplastic transformation potential, but also by detecting the immunolabeling for p16^INK4a that is associated with the existence of HPV. Also, the tumor was immunoreactive for cytokeratin (CK) AE1/AE3, partially immunoreactive for CK5/6 in the basal layer and negative for CK7, which demonstrates the squamous epithelial origin of the described tumor. Subepithelial cells of the inflammatory system have been identified, such as macrophages immunolabeled with anti-CD68 antibody, T-lymphocytes immunolabeled with anti-CD3 antibody and rare B-lymphocytes immunolabeled with anti-CD20 antibody, which demonstrates the strong cellular response to remove the virus from the structure. Surgical and excisional treatment was helpful for the patient, because she was able to resume normal sexual activity and defecation, and on the other hand, microscopic studies showed the potential for malignant transformation of CA.

Topical and Systemic Retinoids for the Treatment of Genital Warts: A Systematic Review and Meta-Analysis

BACKGROUND

Genital warts, caused by the human papillomavirus, are a common sexually transmitted disease. The warts can regress spontaneously or exhibit a persistent clinical course. Various therapeutic modalities are available, yet none is curative, and there may be recurrences. Retinoids are considered the mainstay of therapy in many dermatologic diseases. Data on their use for genital warts are limited.

OBJECTIVE

To systematically review the published evidence on the efficacy and safety of retinoids for the treatment of genital warts.

METHODS

A systematic review and meta-analysis of all publications evaluating topical or systemic retinoids for the treatment of genital warts was performed. The primary outcome was complete response (CR); the secondary outcomes were recurrence rate and adverse events.

RESULTS

Six publications were evaluated, three randomized controlled trials and three prospective cohort studies, including a total of 141 patients with genital warts treated exclusively with retinoids (90% with isotretinoin). CR rates were 100% for systemic etretinate (3 out of 3 patients, 95% CI 28-81%) and 56% for isotretinoin (95% CI 28-81%; I2 = 84%). Topical etretinate did not induce CR. The most common side effect of topical agents was irritant contact dermatitis (36%) and that of systemic agents mucocutaneous disorders (80%). The relapse rate was 12% for oral isotretinoin and was unavailable for the other modalities.

CONCLUSIONS

Current data suggest that unlike topical retinoids, systemic retinoids are an effective and safe treatment for genital warts. Further studies are required to determine their specific role and the most effective regimen for each derivative.

Benign Anal Disease: Implementation of an Educational Program Across Specialties

BACKGROUND

Benign anal diseases, including hemorrhoids, fissures, abscesses, fistulas, and anal condylomata, affect 10%-15% of our population. Most patients seen by nonsurgical providers experience delayed treatment. We examined at our institution whether an educational session on anorectal diseases would benefit trainees from medical and surgical specialties.

MATERIALS AND METHODS

The study took place at Oregon Health & Science University, a primary institutional practice with 130 resident participants. An exploratory study using a 10-point pretest and posttest regarding these diseases was designed and administered to medical subspecialties, including general surgery (GS), emergency medicine, internal medicine, and family medicine, obstetrics/gynecology, and pediatric residents. Intervention was a 50-min presentation highlighting anatomy, history and physical findings, and disease treatment. The posttest was repeated after 6 mo to evaluate retention and overall satisfaction, and differences were evaluated.

RESULTS

With the exception of GS, posttest scores improved. Internal medicine improved most significantly. GS residents scored better on the pretest than other specialties; their posttest scores, however, declined. The survey demonstrated residents with prior education scored better on the pretest. PGY-1 and PGY-2 residents improved most on their posttest. On 6-mo retest, 17.6% of residents responded and posttest performance was 72%.

CONCLUSIONS

Nonsurgical residents have limited knowledge about benign anal diseases but demonstrate improvement after educational intervention. Surgery residents performed well, but demonstrate regression to the mean, common in test taking, but may also require a more advanced lecture. Formal institutional, regional, and national educational interventions are needed to improve the understanding of these diseases.

Cryotherapy of Genital Warts

Introduction:

Genital warts are a frequent form of sexually transmitted disease. Cryotherapy represents the first line of therapy. Healing occurs in 94%, and recurrence in 10% . Side effects are common during the treatment.

Aim:

The aim of this study is to determine the successfulness of cryotherapy of genital warts, frequency of recurrence, and side effects.

Patients and methods:

In a retrospective study, data from 50 women with genital warts who were treated in the Gynecological Centre “Dr Mahira Jahić” in Tuzla in a period from 2012–2018 were analyzed. Every woman was treated with cryotherapy. Treatments were repeated every 7 days, maximal number of treatments being 7. In processing of data, X2statistical method was used.

Results:

50% (N-25) of genital warts eliminated after 3 treatments with cryotherapy . Genital warts are eliminated in 78% (N-39) of women, while this treatment was unsuccessful in 18% (N-9). Recurrence after 3 months in 4% (N-2). Most common side effect was exudation in 78% (N-39), swelling in 72% (N-36) and pain in 66% (N-33). PAP smears in women with genital warts in 64% (N-34) of cases were inflammatory benign changes, while in 36% (N-18) mild abnormal changes in cells ASCUS and LSIL were found. LSIL lesions of cervix are more common (p<0,01) in women with genital warts of vulva.

Conclusion:

Cryotherapy is a method with a high success rate in healing of genital warts, and it decreases the concentration of HPV virus and removes the trigger that allows the development of cancer.

Cantharidin is Superior to Trichloroacetic Acid for the Treatment of Non-mucosal Genital Warts: A Pilot Randomized Controlled Trial

Condyloma Acuminatum is a sexually transmitted viral disease caused by the human papilloma virus (HPV). It is the most common viral sexually transmitted disease. In this randomized controlled trial, cantharidin was found to be more effective and better tolerated than trichloroacetic acid for the treatment of these lesions. Patients treated with cantharidin healed with less scarring than those treated with TCA (P<0.034), had less pain during treatment (P<0.01), and required fewer treatments to eradicate warts (P<0.01) when compared to Trichloroacetic acid.

Human papillomavirus (HPV) infection: a Mozambique overview

Human Papillomavirus is agent of the most common sexually transmitted disease which is able to infect mucosal and cutaneous membranes of the anogenital region, upper aerodigestive tract, and other head and neck mucosal regions. Although mainly HPV infection can be asymptomatic and transient, it may persist and give rise to various lesions such as warts, condyloma dysplasia and cancers depending on low or high risk type of HPV infection. Moreover, growing recent evidence suggests a role of this virus in male and female fertility. To date no effective prevention, test, treatment and control strategies are provided for people in developing countries despite the reported high incidence of HPV both in women and men. This paper reviews the more recent literature about HPV infection highlighting epidemiology, related pathologies and possible fertility effects of HPV in male and female with particular attention to the Mozambique context.

Comparison of methods for diagnostics and treatment of clinical manifestations of the papilloma viral infection

The article describes modern methods for diagnostics of clinical, subclinical and latent forms of the papilloma viral infection. The authors reviewed different methods of the destruction of anogenital warts and described their advantages and shortcomings. They provide the results of studies of the efficacy of Imiquimod for the treatment of anogenital warts.

Efficacy of combination therapy of oral zinc sulfate with imiquimod, podophyllin or cryotherapy in the treatment of vulvar warts

AIM

Zinc sulfate is beneficial in the treatment of epithelial warts. We conducted this study to compare the efficacy of combination therapy of oral zinc sulfate with conventional treatments in the treatment of vulvar warts.

MATERIAL AND METHODS

This study was a randomized controlled trial. The sample size was 42 in each group. Women aged 20-50 years were placed by the block randomized method into six groups: the podophyllin-, imiquimod- and cryotherapy-treated groups, and another three groups receiving 8-week combination therapy of 400 mg oral zinc sulfate with one of the above-mentioned treatments. Data were analyzed using anova and Fischer's exact test with spss16.

RESULTS

A total of 228 patients were recruited and completed the study in six treatment groups. No significant difference was observed in the response to treatment among these groups. Relapse after 6 months was significantly higher in the podophyllin-, imiquimod- and cryotherapy-treated patients compared to patients receiving these treatments in combination with oral zinc sulfate (P<0.05).

CONCLUSIONS

Combined therapy of oral zinc sulfate with conventional treatments of vulvar warts appears to reduce the relapse rate.

The impact of smoking on HPV infection and the development of anogenital warts

PURPOSE

The worldwide prevalence of human papillomavirus (HPV) infection is estimated at 9-13 %. Persistent infection can lead to the development of malignant and nonmalignant diseases. Low-risk HPV types are mostly associated with benign lesions such as anogenital warts. In the present systematic review, we examined the impact of smoking on HPV infection and the development of anogenital warts, respectively.

METHODS

A systematic literature search was performed using MEDLINE database for peer-reviewed articles published from January 01, 1985 to November 30, 2013. Pooled rates of HPV prevalence were compared using the χ (2) test.

RESULTS

In both genders, smoking is associated with higher incidence and prevalence rates for HPV infection, whereas the latter responds to a dose-effect relationship. The overall HPV prevalence for smoking patients was 48.2 versus 37. 5 % for nonsmoking patients (p < 0.001) (odds ratio (OR) = 1.5, 95 % confidence interval (CI) 1.4-1.7). Smoking does also increase persistence rates for high-risk HPV infection, while this correlation is debatable for low-risk HPV. The incidence and recurrence rates of anogenital warts are significantly increased in smokers.

CONCLUSIONS

Most current data demonstrate an association between smoking, increased anogenital HPV infection, and development of anogenital warts. These data add to the long list of reasons for making smoking cessation a keystone of patient health.

Human papillomavirus genotypes in genital warts in Latin America: a cross-sectional study in Bogota, Colombia

Epidemiological studies on benign lesions related to human papillomavirus (HPV) infection are scarce in Latin America. We enrolled 342 consecutive patients with lesions suspected of being genital warts (GW). All patients underwent confirmatory biopsy and GP5+/GP6+/- Reverse Line Blot HPV testing on frozen tissue. In 261 (81%) cases, the diagnosis was confirmed by histopathology and HPV was detected in 90.6% of men and 87.7% of women. HPV 6 was by far the most common type in both women (62%) and men (56%), followed by HPV 11 (∼20%). Co-infection with these two types occurred in 7% and 12% of women and men, respectively. HPV16 ranked third in prevalence, with 16% of patients testing positive. Twenty-five percent of cases tested positive for multiple HPV genotypes. Although HPV 6 and HPV 11 were the main types detected and no differences between men and women were observed, we found HPV 11 contributed more to GW aetiology compared with previous reports, showing a variability of HPV type distribution in GW across populations. This information is valuable baseline data in Latin America for future estimations of the burden of GW in men and women and shows the potential benefit obtainable by prophylactic vaccination against HPV types 6 and 11.

A surgical approach to giant condyloma (Buschke-Löwenstein tumour) with underlying superficial vulvar carcinoma: A case report

Anogenital warts (condyloma acuminatum or venereal warts) are a common sexually transmitted disease in males and females. Common clinical treatment of anogenital warts is conservative, however, in extreme cases conservative therapy is insufficient and surgical excision is required. Giant condyloma acuminata (Buschke-Löwenstein tumour) is an extremely rare clinical type of genital wart, characterised by aggressive down growth into underlying dermal structures. A 55-year-old female presented with cauliflower-like growth over the anogenital and sacral region, earlier diagnosed as condyloma acuminatum which was resistant to conservative therapy. During the period between 2005 and 2008 the patient underwent five surgical procedures. Due to the size and location of the tumour, gynaecological and plastic surgeons were involved in the procedures. In addition, definitive histology examination identified a superficial vulvar carcinoma.

The efficacy and safety of the quadrivalent human papillomavirus 6/11/16/18 vaccine gardasil

Human papillomavirus (HPV) infection causes cervical cancer, a significant portion of anal, genital, and oropharyngeal cancers, genital warts, and recurrent respiratory papillomatosis. In June 2006, a quadrivalent HPV-6/11/16/18 vaccine (Gardasil/Silgard) was licensed in the United States, and subsequently in the European Union (September 2006). It has since been approved in 121 countries, with >74 million doses distributed globally as of March 2011. As the incidence of HPV infection peaks 5-10 years after the onset of sexual activity, preadolescents and adolescents represent an appropriate target group to implement HPV vaccination programs so as to achieve the maximal public health benefit. In this article, we provide an overview of the prophylactic efficacy of the vaccine in young women who were found to be negative to at least one of the four vaccine HPV types, thus approximating sexually naive adolescents. Because adolescents are also at high risk for other infections which are preventable by currently available vaccines, the development of concurrent immunization strategies may lead to better compliance, thereby contributing to the overall goal of protection against preventable diseases. We also summarize concomitant administration studies with meningococcal, diphtheria, tetanus, and pertussis vaccines, which were conducted in adolescents aged 9-15 years. Prophylactic efficacy in other populations (males aged 16-26 years) is also summarized along with long-term safety and efficacy studies.

Efficacy and safety of imiquimod versus podophyllotoxin in the treatment of anogenital warts

BACKGROUND

Anogenital warts are a common sexually transmitted disease caused by human papillomaviruses. Despite the fact, that imiquimod and podophyllotoxin represent common topical agents, direct comparative studies lack. This work compares the effectiveness and safety of self-applied imiquimod 5% cream and podophyllotoxin 0.5% solution.

METHODS

Within 2 years, consecutive patients presenting with untreated anogenital warts were included in a randomized, open label trial. The primary endpoint was complete clearance at the end of treatment (4 weeks after the start with podophyllotoxin, 16 weeks after the start of imiquimod therapy). Side effects were evaluated as a secondary endpoint.

RESULTS

A total of 45 patients, 7 women and 35 men, of whom 5 were circumcised, concluded the treatment and were eligible for evaluation. The rates of clearance of baseline warts among treatment groups were 72% (95% confidence interval [CI], 52%-86%) in the podophyllotoxin group and 75% (95% CI, 53%-98%) in the imiquimod group. Statistically, clearance rates were identical (P=1). The differences in side effects between treatment groups were statistically not significant (P=0.24).

CONCLUSIONS

The current study, a direct comparison of both, confirms the previously obtained mathematical data, that imiquimod 5% cream and podophyllotoxin 0.5% solution have an identical beneficial effect on anogenital warts and are associated with identical and acceptable side effects. Both substances constitute effective and safe treatments of untreated anogenital warts in immunocompetent individuals.

Anal HPV infection in Slovenian men who have sex with men

Anal human papillomavirus (HPV) infection commonly affects men who have sex with men (MSM) and is associated with the development of anal cancer, with the highest prevalence in MSM who are positive for human immunodeficiency virus (HIV). The purpose of this study was to determine the prevalence of anal HPV infection and genotype distribution in Slovenian MSM and its correlation with behavioral patterns in order to predict the possible impact of quadrivalent HPV vaccine in this population. To our knowledge, this is the first study of prevalence and genotype distribution of anal HPV infection in MSM from any of the Eastern European countries. The study included 136 MSM who visited two outpatient offices from January 2007 through December 2008. All participants were clinically examined and tested for HIV, and anal swabs were taken for HPV testing. The results showed a high prevalence of anal HPV infection in both HIV-negative (75%) and HIV-positive (95%) MSM. Promiscuity and use of “poppers” (alkyl nitrites taken for recreational purposes through direct inhalation) were clearly associated with a higher prevalence of anal HPV infection. The four most common HPV genotypes were 6, 11, 16, and 18. The prevalence of anal HPV infection in Slovenian MSM is higher in comparison with other studies. Quadrivalent HPV vaccine could have great potential in this population.

Prevalence of human papillomavirus types 6, 11, 16 and 18 in young Austrian women - baseline data of a phase III vaccine trial

INTRODUCTION

Cervical cancer is the second most common cancer among women worldwide. In the absence of changing risk or intervention, it is projected that in comparison with 2002 there will be a 40% increase in the number of new cases of cervical cancer by 2020. HPV types 16 and 18 cause 70% of cervical cancers worldwide, 50% of high-grade cervical intraepithelial neoplasias and 25% of low-grade neoplasias. HPV types 6 and 11 are the causative agent of > 90% of genital warts. The aim of this study was to assess the baseline prevalence of infection with HPV 6, 11, 16 and 18 in young Austrian women.

METHODS

Austrian females aged 16-24 (n = 123) were enrolled in a double-blind, placebo-controlled, randomized phase III trial of a quadrivalent HPV (types 6, 11, 16, 18) vaccine (FUTURE I, ClinicalTrials.gov number NCT00092521). Healthy women who were not pregnant and had no prior history of genital warts or abnormal results on cervical cytologic testing and had fewer than five lifetime sex partners were eligible for enrollment. The study sub-population was recruited primarily from university settings.

RESULTS

Analysis of the sexual history of the Austrian subjects showed that 92.7% (114/123) were non-virgins and 46.3% were current smokers. At enrollment, 15 (13.5%) had positive serological or PCR tests for HPV 6, 11, 16 or 18. Serologically, 14 (12.3%) of women were positive to HPV 6, 11, 16 or 18: of these, 13 (11.4%) were positive for HPV 16, four (3.5%) were positive for HPV 18, and one (0.9%) for HPV 6. By PCR all were negative for HPV 6 and 11, whereas seven (6.1%) were positive for HPV 16 and one (0.9%) for HPV 18. Abnormal cytology was observed in 12 (10.3%) women.

DISCUSSION

Although the prevalence of vaccine HPV types among young Austrian women with fewer than five lifetime sexual partners was lower than in international data, we observed a high prevalence of abnormal cytology and smoking. These data suggest that a substantial number of Austrian women are at risk for HPV-related disease.

Assessing incidence and economic burden of genital warts with data from a US commercially insured population

OBJECTIVE

This study examined the incidence of and healthcare costs attributable to genital warts within a large US commercially insured, geographically dispersed population.

RESEARCH DESIGN AND METHODS

Using a retrospective cohort study design, this longitudinal analysis assessed administrative claims of integrated medical and pharmacy encounters from five Blue Cross Blue Shield health plans. Genital warts cases were identified using a methodology previously described by Insinga et al.

MAIN OUTCOME MEASURES

Age- and gender-specific incidence of genital warts per 1000 person-years in 2004, and duration-of-episode attributable direct medical costs (2004 US dollars) and healthcare resource utilization of cases diagnosed in 2002. Overall outcome measures were age- and gender-adjusted to the 2004 US civilian population.

RESULTS

Genital warts incidence in 2004 was 1.2/1000 females and 1.1/1000 males. Incidence was highest among females aged 20-24 (4.6/1000) and males aged 25-29 (2.7/1000). Projected overall incidence was over 340,000 cases in 2004. Mean duration-of-episode per incident case in 2002 was 95.4 days (males 116.3 days; females 69.7 days). Mean ambulatory visits per episode were 1.5 for females and 1.9 for males, with <1 drug prescription/episode. Mean costs were $647/episode ($745 males; $528 females). The 2004 estimated economic burden was $760 per 1000 individuals in the general population with the total exceeding $220 million.

LIMITATIONS

Only those genital warts cases that sought evaluation or for which the treating provider was covered by the health plan were captured in the study.

CONCLUSIONS

Genital warts represent a significant health and cost burden in the US. Adoption of novel healthcare technologies such as vaccines along with traditional interventions such as physician education of signs and symptoms, condom use and abstinence or limiting number of sexual partners may significantly help reduce the burden of genital warts.

Ultrasonic technology: a new treatment option for anal condylomata acuminata

PURPOSE

Treatment options for anal and perianal warts caused by human papillomavirus include topical application of cytotoxic substances or immunomodulators and ablative procedures. The objective of this prospective study was the evaluation of the ultrasound-driven Harmonic Scalpel (Ethicon Endo-Surgery, Norderstedt, Germany) for resection of anal and perianal condylomata acuminata.

METHODS

Eight men and three women (age range, 26-72 years) with anal and perianal condylomata acuminata were treated by a Harmonic Scalpel blade operating at a vibration frequency of 55.5 kHz and within a temperature range of 65 degrees C to 120 degrees C. Nine patients were treatment naïve, and two patients had recurrent disease. Follow-up ranged from 4 to 26 months.

RESULTS

Seven patients had perianal condylomata, two patients had exclusively intra-anal, and two patients had perianal and intra-anal warts. All condylomata were excised in a single-step procedure with complete clearing without injury of subepidermal layers. We observed no intraoperative or postoperative complications. No recurrences occurred during follow-up.

CONCLUSIONS

The Harmonic Scalpel has been an effective and safe method for the treatment of anal perianal human papillomavirus condylomata without recurrent warts. Subepidermal skin levels remained uninjured; thus, no complications or unsatisfactory cosmesis occurred.

Prophylactic HPV vaccines: new interventions for cancer control

Human Papillomavirus (HPV) infection causes cervical cancer, a significant portion of anal, vulvar, vaginal, and oropharyngeal cancers, genital warts, and recurrent respiratory papillomatosis (RRP). HPV 16 and 18 cause 70-90% of HPV-related cancers whereas HPV 6 and 11 cause 90% of RRP and genital wart cases. Together these four types cause 30-50% of all cervical intraepithelial neoplasia such as those detected by Papinicalou screening. In June 2006, a quadrivalent HPV (6, 11, 16, 18) vaccine was licensed in the United States, and subsequently in the European Union (September 2006), both following expedited review. We describe the primary objectives of the quadrivalent HPV vaccine clinical trial program including studies in females aged 9-45 and males aged 9-26. Planned long-term efficacy and safety evaluations, as well as programs to evaluate vaccine impact on oropharyngeal cancer are also described.

Earlier eradication of intra-anal warts with argon plasma coagulator combined with imiquimod cream compared with argon plasma coagulator alone: a prospective, randomized trial

PURPOSE

Despite the increasing incidence of condylomata acuminate, optimal treatment of anal warts is still undecided. This prospective, randomized study was designed to compare the efficacy of combined argon plasma coagulation and imiquimod cream vs. argon plasma coagulation alone in the management of intra-anal warts.

METHODS

From October 2002 to March 2005, 49 patients with intra-anal warts were randomly assigned to argon plasma coagulation plus imiquimod cream (n = 24) vs. argon plasma coagulation alone (n = 25). Therapeutic sessions were repeated until the elimination of the warts. Efficacy of therapy was defined as the time needed for eradication. All patients were followed up for a mean period of 12 months for signs of recurrence.

RESULTS

Elimination of warts was achieved earlier in patients receiving combination therapy compared with those receiving monotherapy with argon plasma coagulation (62.5 +/- 5.4 days vs. 91.2 +/- 6.4 days; P = 0.0016). A subgroup analysis performed in HIV-positive patients showed similar results (combination therapy 95 +/- 22.6 days; monotherapy 124.3 +/- 20.7 days; P = 0.033); however, in HIV-positive patients warts were eradicated later compared with HIV-negative patients (110.8 +/- 25.7 days vs. 65 +/- 25.4 days; P < 0.0001). No major complications were observed in our study population. After the follow-up period, recurrence of warts was evident in 22.7 percent of patients in the combination group compared with 34.7 percent of patients in the monotherapy group (P = 0.51). Recurrence was significantly higher in HIV-positive patients compared with HIV-negative patients (P = 0.0039).

CONCLUSIONS

Combination therapy with argon plasma coagulator plus imiquimod cream results in earlier clearance of intra-anal warts in both immunocompetent and immunocompromised patients; however, it does not affect the rate of recurrence.

Anogenital Warts Knowledge and Counseling Practices of US Clinicians: Results From a National Survey

OBJECTIVES

To examine messages US clinicians use when counseling patients diagnosed with anogenital warts.

STUDY DESIGN

In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts.

RESULTS

After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement.

CONCLUSIONS

Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

Human papillomavirus: the burden of infection

Vaccines for preventing human papillomavirus (HPV) infection are far along in clinical development and testing, and hold great promise for reducing HPV infections and HPV-associated disease. HPV is the most common sexually transmitted infection in the United States, affecting an estimated 75% of the U.S. population. HPV infection is highly prevalent in sexually active adolescents and young adults. Sexual activity is the most important risk factor for infection, with 64% to 82% of sexually active adolescent girls testing positive for HPV. Clinical manifestations of HPV infection include genital warts, cervical intraepithelial neoplasia (CIN), and invasive cervical cancer, all of which cause significant morbidity and, in the case of cervical cancer, mortality. The majority of HPV-associated disease is caused by 4 HPV types: HPV 6 and 11 are responsible for low-grade genital lesions and more than 90% of genital warts, and HPV 16 and 18 both account for approximately 70% of all high-grade CIN or dysplasia and invasive cervical cancer. Although current screening methods have proven effective in reducing cervical cancer incidence and associated mortality, more than 10,000 women are diagnosed annually and 4000 U.S. women die from the disease each year.

Assessing the annual economic burden of preventing and treating anogenital human papillomavirus-related disease in the US: analytic framework and review of the literature

The anogenital human papillomavirus (HPV) is estimated to be the most commonly occurring sexually transmitted infection in the US. Comprehensive estimates of the annual economic burden associated with the prevention and treatment of anogenital HPV-related disease in the US population are currently unavailable. The purpose of this paper is to (i) outline an analytic framework from which to estimate the annual economic burden of preventing and treating anogenital HPV-related disease in the US; (ii) review available US literature concerning the annual economic burden of HPV; and (iii) highlight gaps in current knowledge where further study is particularly warranted. Among eight US studies identified that describe the annual economic burden pertaining to one or more aspects of anogenital HPV-related disease, three met the review eligibility criteria (published between 1990 and 2004, examined multiple facets of annual anogenital HPV-related economic burden, and clearly articulated the data and methods used in the estimation process). All costs were adjusted to 2004 US dollars. Estimates of the annual direct medical costs associated with cervical cancer were comparable across studies (range 300-400 million US dollars). In contrast, there was a wide range across studies for estimates of the annual direct medical costs associated with cervical intraepithelial neoplasia (range 700 million US dollars-2.3 billion US dollars). Only one study reported direct medical costs for anogenital warts (200 million US dollars) and routine cervical cancer screening (2.3 billion US dollars). No studies examined direct medical costs attributable to HPV-related anal, penile, vaginal or vulvar cancers, or the work and productivity losses resulting from time spent receiving medical care, morbidity or mortality. Current economic burden estimates would suggest annual direct medical costs associated with the prevention and treatment of anogenital warts and cervical HPV-related disease of at least 4 billion US dollars. This figure would likely rise to at least 5 billion US dollars per year if direct medical costs associated with other disease entities caused by the sexual transmission of HPV were included, with further additions to the economic burden totalling in the billions of dollars if work and productivity losses were incorporated, a research priority for future studies.

Rate and predictors of new genital warts claims and genital warts-related healthcare utilization among privately insured patients in the United States

BACKGROUND

Little non-clinic-based data are available on incident genital warts rates and related healthcare use.

GOAL

: The goal of this study was to describe the incidence and predictors of genital warts and associated healthcare utilization patterns among a group of privately insured patients in the United States.

STUDY

Health claims were evaluated prospectively from 5,914,107 privately insured individuals.

RESULTS

The rate of new genital warts claims per 100,000 person-years at risk, age-standardized to the 2001 U.S. privately insured population, increased from 117.8 in 1998 to 205.0 in 2001. The highest rates were among 20- to 29-year-olds. The majority of claims came from dermatology and obstetrics/gynecology.

CONCLUSIONS

The incidence of genital warts, as measured by the rate of new claims, appears to be rising. Age associations with the rate of new genital warts claims differed by gender; these associations may be influenced by changes in health-seeking behavior, potentially driven by health awareness.

Genital and perianal warts: new treatment opportunities for human papillomavirus infection

Human papillomaviruses are among the most common sexually transmitted diseases in the United States. Genital warts are a common phenotypic expression of human papillomaviruses, affecting 1% of the population; therefore, the obstetrician/gynecologist will invariably be required to advise and treat patients with this clinical manifestation. Issues essential in the diagnosis, counseling, and management of patients with genital warts will be examined, including epidemiology, transmission, molecular biology, and host immune response. This review will also provide the health care professional with a thorough examination of the new patient-applied treatment opportunities for anogenital condyloma, in addition to an overview of current provider-administered therapies, to assist in patient management.

The health and economic burden of genital warts in a set of private health plans in the United States

We estimated the prevalence of and costs associated with genital warts among privately insured individuals from the perspective of a private health plan in the United States. Health care claims data were derived from a sample of 3,664,686 privately insured individuals. The database was limited to cases of disease for which an insurance claim was generated, with costs reflecting inpatient, outpatient, and pharmacy payments from all sources. We identified 5095 cases of genital warts (1.7 cases per 1000 person-years) billed through the health plans during 2000. The prevalences of and health plan costs associated with genital warts were highest among women aged 20-24 years (6.2 cases and $1692 in costs per 1000 person-years) and men aged 25-29 years (5.0 cases and $1717 in costs per 1000 person-years). On average, individual episodes of care for genital warts involved 3.1 physician visits and incurred costs of $436. These are the first age- and sex-specific estimates of the prevalence and cost of genital warts for a US health plan.