How to treat human papilloma viruses
Treatment for human papilloma viruses
The classic standard therapy for genital warts has been based on the assumption that the grossly visible warty tissue needed to be destroyed and that the virus resided only where the warts existed. The recognition of subclinical disease in addition to overt disease and the association with genital neoplasia forces a re-evaluation of the standard approach. HPV infection must be regarded as having the potential for infecting the entire genital tract, and only very early disease tends to be localized. Therapy is also complicated by the fact that HPV may be present in normal skin and in colposcopically, cytologically and histologically normal epithelium. Wart recurrence after any therapy is common and whether a virologic ‘cure’ can be accomplished is unknown. Practically all clinical trials address only overt visible disease. Wart recurrence after therapy is difficult to assess. It is not known whether recurrence indicates failure of therapy, failure to treat all areas involved, resistant virus or reinfection. Most recurrences are seen within 3 months of therapy. If disease is present for six months despite repetitive attempts at therapy, it is called resistant and persistent. Therapy uses agents that are keratolytic (podophyllin, tri- or bichloracetic acid, 5-fluorouracil (5-FU)); physical agents (electric cautery, laser therapy, cryotherapy) and immunotherapy (vaccine, interferon inducers). Since the classic standard approach must be modified to account for subclinical infection and the frequent presence of HPV throughout the genital tract, no single or combination of agents has emerged as standard treatment at this time.
Currently available treatments for visible genital warts are patient-applied therapies: podofilox (Condylox) and imiquimod (Aldara); and provider-administered therapies: cryotherapy, podophyllin resin, trichloroacetic acid (TCA), bichloroacetic acid, interferon (Intron, Alferon), and surgery. Most patients have one to ten genital warts with a total wart area of 0.5 to 1.0 cm2, which is amenable to most treatment modalities. Factors that may influence selection of treatment include wart size, wart count, anatomic site, wart morphology, patient preference, financial cost of treatment, and clinician’s experience. It is important to have a treatment plan or protocol since many patients will require a course of therapy rather than a single treatment. The treatment should be no worse than the disease. In general, warts on moist surfaces and/or located in intertriginous areas respond better to topical treatment such as TCA, podophyllin, podofilox and imiquimod than do warts on drier surfaces. After utilization of provider-administered treatments, if there has not been significant improvement after three treatment sessions, or complete clearance after six treatment sessions, the treatment modality should be changed. The risk-benefit ratio of treatment should be evaluated throughout the course of therapy in order to avoid over-treatment. Providers should be knowledgeable about, and have available to them, at least one patient applied and one provider administered modality. When employed properly, complications of wart treatment are rare but can occur. Scarring in the form of persistent hypo- or hyperpigmentation may occur with ablative modalities. Depressed or hypertrophic scars are rare but can occur especially when the patient has not had sufficient time to heal between treatments. Overly aggressive treatment can result in disabling chronic pain syndrome such as vulvodynia or hypoesthesia of the treatment.
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Tags: HPV, human papilloma virus, podofilox, podophyllin, TCA
