Dr Annabel Mead
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Clinical
Aboriginal Health
Sexual HealthHuman Papilloma Virus
Table of Contents |
Introduction
DNA probing has identified more than 70 types of Human Papilloma Virus (HPV), and types 6, 11, 16, 18, 31, 33 and 35 seem to be closely associated with anogenital infection. Increasing awareness of how certain types are linked to anogenital cancer means HPV is a potential threat to health, rather than being just a nuisance STD.
Dr Annabel Mead, gmc@nor.com.au
Transmission
Genital warts are seen in up to 10% of sexually active women, and
sub-clinical disease is found in 30-40% of women. HPV is transmitted
by direct skin to skin contact, although the assumption that genital
infection has to be by sexual contact cannot be upheld medico
legally. The possible role of fomites is not well researched yet.
Anogenital warts in children, however, should always prompt
exploration of the possibility of sexual abuse.
Factors in development of clinical HPV
Host immune function appears to play an important role in the
appearance of clinical lesions HIV infection, transplant patients,
steroid therapy and pregnancy all have an effect. Individual
susceptibility and viral load also play a role, and smoking has a
marked effect.
Malignant progression
HPV DNA is found in 90% of anogenital cancers, generally types 16,
18, 31 and 33. Again, immune suppression and smoking increase the
risk of malignant transformation markedly.
Diagnosis
Inspection of perianal area, gluteal folds, vagina and urethral
orifice (using an auroscope) is necessary. Pap smear should always
be performed, and colposcopy is useful. Biopsies may be required to
differentiate warts from pre-neoplasia or neoplastic lesions.
Differential diagnoses include pearly penile papules, skin tags,
vaginal papillae, condylomata lata and Molluscum contagiosum.
Treatment
Podophyllin 25% in tinc. Benz. Co. is popular but has variable
potency, a limited shelf-life (six months) and carries the risk of
toxicity. Podophyllotoxin 0.5% is better, and self application twice
daily for three days at weekly intervals is effective. Cryotherapy is
equally effective, using 2x freeze-thaw cycles at 7-10 day intervals.
It is more painful, but Emla cream 10 minutes before is helpful.
Laser/diathermy under general anaesthetic is useful for large,
confluent or widespread warts. Lesions should be stable for four
weeks (in case of subsequent cropping). Recurrence rate in new skin
is 10-60% after initial therapy, and patients should be counselled
about this.
HPV in pregnancy
Perinatal transmission from mothers with clinical vulvar lesions
has been well documented, but laryngeal papillomatosis in the neonate
occurs in less than 1% of susceptible vaginal births. The
transmission potential of maternal subclinical HPV is unknown.
Lesions will often worsen during pregnancy, and an attempt at
treatment should be made. Podophyllin is contra-indicated, but
cryotherapy is useful.
Goonellabah NSW 2477
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