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Warts and All. Dr Daniela Brawley ST4 Genitourinary medicine 23 rd November 2010. Cases of genital warts/year in UK. Human Papilloma Virus. > 100 sub-types of HPV HPV 6 and 11 cause 90% of genital warts Most clear the infection in 9 months HPV 16 and 18 risk for malignant change

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warts and all

Warts and All

Dr Daniela Brawley

ST4

Genitourinary medicine

23rd November 2010

human papilloma virus
Human Papilloma Virus
  • > 100 sub-types of HPV
  • HPV 6 and 11 cause 90% of genital warts
  • Most clear the infection in 9 months
  • HPV 16 and 18 risk for malignant change
    • Persistent infection with oncogenic sub-types increases risk of malignant change
prevalence
Prevalence
  • 1% of population have visible warts
  • 10% have active HPV infection
  • 60% have cleared HPV
    • However can have long latent or lifelong phase
  • ? Missed opportunity with quadrivalent HPV vaccine (6/11/16/18)
transmission
Transmission
  • Sexual in majority of cases
    • Female to male 71% at 3 months
    • Male to female 54% at 3 months
  • Condoms can reduce risk but don’t eliminate
  • Increased risk if immunocompromised and/or smoker
diagnosis
Diagnosis
  • Diagnosis is by examination under good light
  • Consider referral/biopsy if atypical or unsure
  • STI screening
  • Partner notification not necessary
sti screening
STI screening
  • 10-20% have co-existing STIs
  • Extensive warts – HIV indicator disease
    • BHIVA 2008 HIV testing guidelines
  • Chlamydia/ Gonorrhoea
    • Urine in males
    • Vulvovaginal/cervical swab in females
  • HIV/Syphilis
but first
But first…

….what’s a normal lump?

pearly penile papules
Pearly penile papules
  • Normal anatomy
  • No treatment
  • Common presentation in young men
  • Reassure strongly that are normal
vulval papillomatosis
Vulval papillomatosis
  • Smooth and symmetrical
  • Easily confused with HPV
  • Don’t progress
    • review at 1 month
  • No treatment
parafrenular glands
Parafrenular glands
  • Symmetrical, small and smooth surface
  • No treatment required
fordyce spots or sebaceous follicles
Fordyce spots or sebaceous follicles
  • Glands in clusters
  • Prepuce, shaft of penis and vestibular area of vulva
  • More obvious when skin is stretched
  • Reassurance
sebaceous cysts
Sebaceous cysts
  • No treatment necessary unless become too large or get infected
  • Reassurance
  • In men scrotal sebaceous cysts may occur
lymphocoele
Lymphocoele
  • Hard swelling behind coronal surface
  • No treatment required
  • Usually resolves over time
  • Reassurance
and now
And now…

other differentials

molluscum contagiosum
Molluscum contagiosum
  • Pox virus
  • Skin to skin contact, most likely sexual
  • Cryotherapy
  • STI screening including HIV especially if extensive
condyloma lata of secondary syphilis
Condyloma Lata of Secondary Syphilis
  • Refer GUM
  • Syphilis PCR and serology
  • Dark ground microscopy
  • STI screening
  • Penicillin and GUM follow-up
now for warts
Now for warts….
  • Site, distribution and number
  • Morphology- keratinised or non keratinised
  • Patient features
  • Experience and equipment
    • Availability of cryotherapy
treatments
Treatments
  • Podophyllotoxin (warticon)
  • Cryotherapy
  • Imiquimod (aldara)
  • Smoking cessation
  • Excision
warticon
Warticon
  • Purified extract of podophyllin
  • Solution (0.5%) or cream (0.15%)
  • Non-keratinised warts, not perianal
  • 3 days BD then 4 days rest for 4 weeks
  • Soreness and ulceration
  • NOT used in pregnancy
cryotherapy
Cryotherapy
  • Necrosis of dermal-epidermal junction
  • Keratinised warts and intrameatal warts
  • Weekly application with “Halo” and “Freeze and thaw” techniques
  • Safe in pregnancy
aldara
Aldara
  • Immune response modulator
  • Non formulary and expensive (£50/month)
  • Used for resistant/extensive warts
  • 3 times a week for maximum 16 weeks
  • NOT used in pregnancy
clearance rates
Clearance rates

Source: United Kingdom National Guideline on the Management of Anogenital

Warts, 2007. (BASHH)

keratinised warts
Keratinised Warts
  • Cryotherapy first line
  • Imiquimod if not improving
  • Warticon less likely to be effective but can try for 4 weeks
non keratinised warts
Non-keratinised warts
  • Warticon
  • Cryotherapy or imiquimod if not improving
perianal warts
Perianal warts
  • Cryotherapy first line
  • Imiquimod if not improving
  • Warticon can be used but not licensed
  • Proctoscopy not indicated unless immune suppressed, or symptoms in anal canal
extensive sub preputial warts
Extensive Sub-preputial warts
  • GUM referral
  • Imiquimod and cryotherapy
  • Surgical referral
warts in pregnancy
Warts in pregnancy
  • Cryotherapy
  • Warticon and Imiquimod contraindicated
  • Improve/resolve 6-8 weeks after delivery
  • Not an indication for Caesarean Section
  • Small risk of transmission both genital and laryngeal papilloma
    • 1 in 400
    • No reduction with c-section
warts and bowen s disease
Warts and Bowen’s Disease
  • Referral for biopsy of suspicious areas
  • Cryotherapy/ electrocautery
  • Circumcision
warts and vin
Warts and VIN
  • Referral for biopsy of suspicious areas
  • Localised surgical excision
  • Referral to Gynaecology
features indicating biopsy
Features indicating biopsy
  • Atypical
  • Pigmentation
  • Flat warts
  • Older age groups
  • Immunosuppression including HIV
  • Heavy smokers
extensive warts
Extensive warts
  • Trial of imiquimod +/- cyrotherapy
  • Referral to Gynaecologist for surgical removal
  • STI screening
single wart at fourchette
Single wart at fourchette
  • Cryotherapy
  • Surgical excision
extensive anal warts hiv positive gay man
Extensive anal warts HIV positive gay man
  • GUM referral
  • Syphilis PCR and serology
  • Cryotherapy and/or Imiquimod
  • Proctoscopy
  • Surgical referral
    • Risk of AIN
meatal warts
Meatal Warts
  • Cryotherapy
    • If can see extent of warts
  • Concern about causing urethral stenosis
  • Warn about symptoms of urethral obstruction
vaginal warts
Vaginal warts
  • Usually resolve with treatment of external warts
  • Cryotherapy if not improving
cervical warts
Cervical warts
  • Usually resolve with treatment of external warts
  • Ensure has had recent smear
    • No need for additional smears
  • If no external warts or no improvement with treatment of external warts refer to colposcopy
summary points
Summary points
  • Treat the patient in front of you
  • Offer STI testing
  • Smoking cessation
  • Refer if unsure, not improving or suspicious features
sandyford contacts
Sandyford contacts
  • www.sandyford.org
  • 0141 211 8130
  • dbrawley@nhs.net
preferred sample
PREFERRED SAMPLE

VULVOVAGINAL SWAB

tests for ulcers
Tests for ulcers
  • Syphilis
  • Herpes type 1 and 2
  • Combined PCR test
  • Confirm with syphilis serology
slide68

PRIMARY CARE VAGINAL DISCHARGE PROTOCOL

CT/GC NAAT

BV- bacterial vaginosis

VVC- vulvovaginal candida

CT/GC NAAT- Chlamydia/Gonorrhoea molecular test

GUM- genitourinary medicine clinic