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WARTS - ANOGENITAL
Anogenital warts (condylomas) are caused by human papillomavirus (HPV) with >90% of the lesions caused by genotypes 6 & 11.
Patients who present with visible warts may also be infected with high-risk HPVs (eg types 16 & 18) which can cause subclinical lesions that are associated with intraepithelial neoplasia, cervical cancer and anogenital cancer.
Many HPV infections are subclinical, transient, and clear spontaneously within 12 months but may also remain latent and reactivate after several years.

Prevention

  • Condoms provide limited protection against genital warts, cervical intraepithelial neoplasia (CIN) II and CIN III
  • Frequent cervical screening should start at appropriate age and be based on cytology since not all human papillomavirus (HPV) infection produce cervical cancer

Vaccines

  • Safe and highly effective in preventing HPV
  • Ideally given prior to sexual activity or exposure to the virus
  • Stable protection has been observed for 5 years
  • Not recommended for use during pregnancy

Quadrivalent HPV Vaccine

  • Contains HPV capsids of type 16, 18, 6 and 11
  • Studies show efficacy in preventing type-specific HPV infection

9-valent HPV Vaccine

  • Contains HPV types 6, 11, 16 and 18 similar to the quadrivalent HPV vaccine but also has five additional types: 31, 33, 45, 52 and 58  
  • For prophylactic use only and has no effect on active HPV infections or established disease

Follow Up

  • Patients undergoing therapy should be advised to return weekly for treatment until all the warts are removed in order to:
    • Monitor response to therapy, ie treatment response is mostly noted within 3 months of therapy
    • Assess need for changes in treatment modalities
    • Evaluate recurrence
    • Assess need for specialist referral
  • Patients whose original lesions have responded well to treatment but in whom new lesions are developing can continue with current regimen
  • Change in therapy is indicated if the patient is not tolerating current therapy, with severe side effects or <50% response to current treatment after 16 weeks for Imiquimod and 6 weeks for other modalities
  • Patients concerned about recurrence may be evaluated 3 months after successful treatment
    • Relapses should be treated according to the lesion types

Specialist Referral

  • Consider specialist referral in the following patients:
    • Large-volume disseminated disease
    • Intractable lesions
    • Immunocompromised patients
    • Pregnant patients
    • Children
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