Viral infections-Human papillomaviruses infection

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Humanpapilomavirus infection genital & non-genital warts C/P, Dx, histopathological picture, DDx, Rx, prevention.

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Viral infections-Human papillomaviruses infection

  1. 1. VIRAL DISEASES
  2. 2. Major Types of viruses thatMajor Types of viruses that affect the skin:affect the skin:  HUMAN PAPILLOMAVIRUSESHUMAN PAPILLOMAVIRUSES  HUMAN HERPESVIRUSESHUMAN HERPESVIRUSES  OTHER VIRAL DISEASESOTHER VIRAL DISEASES
  3. 3. HUMAN PAPILLOMAVIRUSESHUMAN PAPILLOMAVIRUSES  Papovavirus  dsDNA,  icosahedral in shape  Naked (non-enveloped)  Resistant to drying, freezing, and solvents  Human papillomaviruses include at least 200 types200 types that infect the skin and mucosa  Most types cause specific typesspecific types of warts and favor certain anatomic locationscertain anatomic locations  Infections are described as clinical, subclinical & latent
  4. 4. Viral replication mainly within the granular layer of the epidermis
  5. 5. Classification  Nongenital warts  Anogenital warts
  6. 6. Classification  Nongenital warts  Anogenital warts 1. Commonwarts (Verruca vulgaris) 2. Filiform warts 3. Butcher's warts 4. Flat warts (Verruca plana) 5. Palmoplantar warts a) Mosaic warts b) Myrmecial warts 6. Periungual wart 7. Oral warts 8. Epidermodysplasia verruciformis 9. Focal epithelial hyperplasia (Heck disease). 10.Verrucous cyst (plantar cysts)
  7. 7. Classification  Nongenital warts  Anogenital warts 1. Condylomata acuminata 2.2. Bowenoid papulosisBowenoid papulosis 3.3. Buschke-LBuschke-Lööwenstein tumorwenstein tumor 4.4. Erythroplasia of QueyratErythroplasia of Queyrat
  8. 8. Clinical variant depend on: 1. Anatomic location 2. Morphology 3. Histopathology 4. HPV subtype
  9. 9. In clinical practice, subtyping is generally only performed routinely on Papanicolaou smears. Subtyping does not usually change management of cutaneous lesions.
  10. 10. NONGENITAL WARTS
  11. 11. NONGENITAL WARTS  Mode of TransmissionMode of Transmission: via direct person-to- person contact or indirect contact with contaminated surfaces/objects.  Prevalence:Prevalence: of increase in incidence among school- aged children 20% in school children but may arise at any age.  Sex:Sex: Male-to-female ratio approaches 1:1.  Incubation period:Incubation period: ranges from 1-6 months  Latency period:Latency period: of up to 6m-3 years or more.
  12. 12. NONGENITAL WARTS  Numerous warts or persistent/progressive warts should prompt consideration of immunosuppression or defects in cellular immunity.  Malignant change in nongenital warts is rare but has been reported and is termed verrucous carcinoma.  A third or more self-regress within one years.
  13. 13. 1. Verruca vulgaris (Common warts)1. Verruca vulgaris (Common warts)  HPV TYPE:HPV TYPE: most common HPV 22  RISK FACTORS:RISK FACTORS: 1. Frequent trauma/disruption to the normal epithelial barrier. 2. Frequent emersion of hands in water.  SITESSITES: Any site but usually located on the hands  Spread by autoinnoculation  Natural history is for spontaneous resolution, half by 1 year and two thirds by 2 years
  14. 14.  PRESENTATIONPRESENTATION: Present as asymptomatic elevated, rough, grayish hyperkeratotic, exophytic or dome shaped papules or plaques range from smaller than 1 mm to larger than 1 cm with punctate black dots (thrombosed capillaries/pathognomonic) that may require paring to see.
  15. 15. 1. Verruca vulgaris/Histopathology
  16. 16. 1. Verruca vulgaris/Histopathology ‘church spire’ papillomatosis
  17. 17. Pap smear with group of normal cervical cells on left andPap smear with group of normal cervical cells on left and HPV-infected cells showing features typical ofHPV-infected cells showing features typical of koilocytes: enlarged (x2 or x3) nuclei andkoilocytes: enlarged (x2 or x3) nuclei and hyperchromasia.hyperchromasia.KOILOCYTES MAY HAVE THE FOLLOWING CELLULAR CHANGES:KOILOCYTES MAY HAVE THE FOLLOWING CELLULAR CHANGES: 1.A clear area around the nucleus, known as a perinuclear halo. 2.Nuclear enlargement (two to three times normal size) 3.A darker than normal staining pattern in nucleus (Hyperchromasia) 4.Irregularity of the nuclear membrane contour KoilocytosisKoilocytosis (pathognomonic feature of HPV infection)
  18. 18. 1. Verruca vulgaris/Histopathology 1. Orthokeratosis 2. Parakeratosis 3. Hypergranulosis 4. Acanthosis. 5. Koilocytosis 6. ‘Church spire’ papillomatosis 7. Elongated rete ridges that slope inwards (point radially toward lesion center) 8. Dilated dermal papillary capillaries
  19. 19. 1. Verruca vulgaris/DDx 1. Seborrheic keratosis, 2. Actinic keratosis, 3. Cutaneous horn, 4. SCC (especially periungual), 5. Trichilemmoma, 6. Spitz nevus. 7. Lichen Planus 8. Prurigo Nodularis
  20. 20. 2. Filiform warts2. Filiform warts
  21. 21. 2. Filiform wartsFiliform warts  long slender growths, usually seen on the face around the lips, eyelids, or nares /scalp  Filiform warts may appear similar to common warts but tend to have prominent papillomatosis.
  22. 22. 2. Filiform warts / Histopathology
  23. 23. 3. Butcher's warts3. Butcher's warts  HPV type 7  Seen in people who frequently handle raw meat. Their morphology is similar to common warts, with a higher prevalence of hyperproliferative cauliflower-like lesions. They are seen most commonly on the hands.
  24. 24. 3. Butcher's warts /Histopathology  Prominent acanthosis, hyperkeratosis, and papillomatosis.  Small vacuolized cells with centrally located shrunken nuclei may be seen in clusters within the granular layer rete ridges.
  25. 25. 4. Verruca plana (Flat/Plane Warts)4. Verruca plana (Flat/Plane Warts)  HPV TYPE:HPV TYPE: HPV 3,3, 1010  SITESSITES: Face, neck, dorsa of hands, shins and knees  Children and young adults. Men who shave and women who shave their legs  Koebnerization => linear distribution  Highest rate of spontaneous remission which usually is heralded by inflammation.
  26. 26.  They are characterized as flat-topped, slightly elevated flesh-colored papules or slightly pinkpink or brownbrown that may be smooth or slightly hyperkeratotic. They range from 1-5 mm or more, and numbers range from a few to hundreds of lesions that may become grouped or confluent. 4. Verruca plana (Flat/Plane Warts)
  27. 27. 4. Verruca plana /Histopathology  Resemble common warts but the features tend to be muted.  Cells with prominent perinuclear vacuolization around pyknotic, strongly basophilic, centrally located nuclei may be in the granular layer. These may be referred to as "owl's eye cells."
  28. 28. Histopathology of verruca plana showing the typical cytopathic effect on keratinocytes called as koilocytes having a perinuclear halo referred to as "owl-eye appearance”
  29. 29. 1. Common warts 2. Small seborrheic keratoses 3. Lichen Planus 4. Lichen Nitidus 5. Molluscum Contagiosum 6. Epidermodysplasia verruciformis 4. Verruca plana DDx
  30. 30. 5. Verruca Palmaris/Plantaris5. Verruca Palmaris/Plantaris (Palmoplantar warts)(Palmoplantar warts)  HPV type 11  usually are found on weight-bearing areas (pressure points), such as the metatarsal head and heel.  Frequently several lesions are seen  Plantar warts can be painful, and extensive involvement on the sole of the foot may impair ambulation.
  31. 31. Deep plantar warts also are termed myrmecia.
  32. 32.  MOSAICMOSAIC WART:WART: plaque of closely grouped warts. When the surface is pared, the angular outlines of tightly compressed individual warts are seen, relatively asymptomatic.  MYRMECIAL WART:MYRMECIAL WART: sloping sides and a central depression occurs as deep, often inflamed and tender papules or plaques. They begin as small shiny papules and progress to deep endophytic, sharply defined, round lesions with a rough keratotic surface, surrounded by a smooth collar of calloused skin; may be confused with callus, (no black dots) 5. Verruca Palmaris/Plantaris (Palmoplantar warts)
  33. 33. Verrucae plantaresVerrucae plantares Photo after the shaving of the hyperkeratotic surface
  34. 34. 5. Palmoplantar warts /Histopathology  Similar to common warts except that most of the lesion lies deep to the plane of the skin surface.  BasophilicBasophilic nuclear inclusions and basophilic parakeratotic cells loaded with virions may be in the upper layers of the epidermis.  Endophytic epidermal growth often has the distinctive feature of polygonal, refractile- appearing, eosinophiliceosinophilic, cytoplasmic inclusions composed of keratin filaments, forming ringlike structures.
  35. 35. 5. Palmoplantar warts DDx 1. Corns 2. Punctate palmoplantar keratoderma 3. Arsenical keratoses, 4. SCC 5. Amelanotic melanoma. 6. Plantar cyst
  36. 36. 6. Periungual warts6. Periungual warts  Myrmecia arising around nails. They tend to be periungual &/or subungual.  Difficult to Rx  May lead to permanent nail dystrophy
  37. 37. 7. Oral warts7. Oral warts  Buccal, gingival, and labial mucosae as well as tongue and hard palate  Small, soft, mucosal-colored to whitewhite, slightly elevated papillomatous papules.  DDx:DDx: 1. Verrucous proliferative leukoplakia, 2. Heck’s disease 3. Early SCC, 4. Bite fibroma.
  38. 38. 8. Epidermodysplasia verruciformis8. Epidermodysplasia verruciformis  A rare inherited disorder or acquired immunosuppression (e.g. HIV infection)  Characterized by widespread HPV infection and cutaneous SCCs  Most commonly inherited as and AR trait  HPV-5, HPV-8 and many other “unique” types  Presents in childhood (inherited form) and continues throughout life
  39. 39. 8. Epidermodysplasia verruciformis  Skin lesions include flat, wart-like lesions of the dorsal hands, extremities, and face  SCCs develop in 30-60% of pts, most often on sun exposed areas.  Actinic background  DDx:DDx: flat warts or tinea versicolor  Surgery, radiation is contraindicated  Strict sun avoidance
  40. 40. Histopathological view: Koiliocytes and moderate dysplasia Distinctive histopathology with expanded gray-blue cytoplasm within the keratinocytes Of the upper stratum spinosum.
  41. 41. 9. Focal epithelial hyperplasia9. Focal epithelial hyperplasia (Heck disease)(Heck disease)  HPV types 13 and 32  HPV infection occurring in the oral cavity, usually on the lower labial mucosa. The lesions appear as sessile multiple flat- topped or dome-shaped pink-pink-whitewhite papules. They usually are 1-5 mm, with some lesions coalescing into plaques. They are seen most frequently in children of American Indian or Inuit descent.
  42. 42. 10. Cystic warts (plantar10. Cystic warts (plantar epidermoid cysts)epidermoid cysts)  HPV type 60  A cystic wart appears as a nodule on the sole usually is smooth with visible rete ridges but may become hyperkeratotic. If the lesion is incised, cheesy material may be expressed.  The etiology of these lesions is uncertain. One theory is that a cyst forms, originating from the eccrine duct, and secondary HPV infection occurs. Another theory is that the epidermis infected with HPV becomes implanted into the dermis, forming an epidermal inclusion cyst.
  43. 43. Anogenital Warts (venereal wart, Condyloma acuminatum)
  44. 44. 1. Condylomata Acuminata1. Condylomata Acuminata  Anogenital infection with HPV.  Most common sexually transmitted disease.  If present in children may be acquired through: 1. Vertical transmission perinatally 2. Via the same routes as nongenital warts direct & indirect contact (digital inoculation or autoinoculation, fomite or social nonsexual contact). 3. Sexual abuse should be considered if >3 years of age  May be subclinical (closely linked with cancer especially of the cervix) or latent  Numerous genital warts may appear during pregnancy
  45. 45. 1. Condylomata Acuminata  HPV types:HPV types: o HPV-6, HPV-11 (benign lesions- low risk) o HPV-16 and HPV-18 (cancer- high risk or oncogenic type)
  46. 46. 1. Condylomata acuminata/CP  Appear as lobulated papules that are frequently multifocal range from discrete, sessile, smooth- surfaced papilloma to large cauliflower-like lesions skin-coloredskin-colored to pinkpink to brownbrown.  Intraurethral condylomata may present with terminal hematuria, altered urinary stream, or urethral bleeding  They may coalesce to form huge fungating plagues causing discomfort and irritation.  The vaginal and anorectal mucosae may be affected.  Other sexually transmitted disease may be present
  47. 47. 1. Condylomata Acuminata/ DDx 1. Seborrheic keratosis 2. Skin tag 3. Molluscum contagiosum 4. Bowenoid papulosis 5. SCC 6. Pearly penile papules 7. Free sebaceous glands 8. Condyloma lata.
  48. 48. 2. Bowenoid papulosis2. Bowenoid papulosis  HPV-16 may behave similar to other genital warts  Similar to condylomata acuminata.  Singly or in multiples  Primarily in the anogenital region. pinkpink to red-brownbrown smooth- flat to warty papules or plaques.  May progress to invasive SCC
  49. 49. Bowenoid papulosis of the anus positive for high-risk HPV in a homosexual male
  50. 50. 2. Bowenoid papulosis/2. Bowenoid papulosis/Histopathology  Numerous mitoses scattered throughout the epidermis (which distinguishes it from condyloma acuminatum) keratinocytes may show less atypia than in an SCC
  51. 51. 3. Buschke-L3. Buschke-Lööwenstein tumorwenstein tumor (Giant condyloma acuminatum)(Giant condyloma acuminatum)  HPV-6  A rare, aggressive wart-like growth that is a verrucous carcinomaverrucous carcinoma  Cauliflower-like deeply infiltrating giant condyloma acuminata fistulas and/or abscesses may be present.  Most often occurs on the glans penis or prepuce of an uncircumcised male  May invade deeply, and rarely metastases
  52. 52. Buschke-Löwenstein Tumor
  53. 53.  Well-demarcated pink to red plaque  Favors the glabrous skin. 4. Erythroplasia of Queyrat (Intraepithelial4. Erythroplasia of Queyrat (Intraepithelial neoplasia/Squamous Cell Carcinoma In Situ)neoplasia/Squamous Cell Carcinoma In Situ)
  54. 54. A well demarcated velvety plaque of the prepuce positive for high-risk HPV
  55. 55. Diagnosis of Verruca
  56. 56. Diagnosis of Verruca - Primarily on the basis of clinical findings. A. Laboratory Studies B. Clinical Procedures C. Histologic Findings
  57. 57. Diagnosis of Verruca A.Laboratory Studies B.Office Procedures C.Histologic Findings 1) Immunohistochemical detection of HPV structural proteins may confirm the presence of virus in a lesion/ low sensitivity. 2) Viral DNA identification using Southern blot hybridization is a more sensitive and specific technique used to identify the specific HPV type present in tissue. PCR may be used to amplify viral DNA for testing.
  58. 58. Diagnosis of Verruca A.Laboratory Studies B.Office Procedures C.Histologic Findings Paring of warts may reveal minute black dots, which represent thrombosed capillaries.
  59. 59. Management of Warts
  60. 60. Treatment of Warts  Aims of therapy are: 1) To remove the wart; 2) Not to produce scarring; 3) To induce lifelong immunity to prevent recurrence.  Consider benign neglect  Depends on the type of wart and the age of the patient  Allow 2-3 months of therapy  Do not abandon any treatment too quickly
  61. 61. Treatment of Warts  Two basic approaches  Destruction and/or Induction of local immune reactions
  62. 62. Management of Warts  MEDICAL TREATMENT “5”MEDICAL TREATMENT “5” I. Topical agents II. Systemic agents III.Intralesional injections IV.Photodynamic therapy V. Alternative treatments
  63. 63. Management of Warts  SURGICAL TREATMENT “5”SURGICAL TREATMENT “5” I. Cryotherapy II. Electrosurgery III.Lasers. IV.Curettage V. Surgical excision
  64. 64. MEDICAL TREATMENTMEDICAL TREATMENT
  65. 65. Management of Warts  MEDICAL TREATMENT “5”MEDICAL TREATMENT “5” I. Topical agents II. Systemic agents III.Intralesional injections IV.Photodynamic therapy V. Alternative treatments 1. Keratolytics 2.2. TTrichloacetic acid 3.3. TTretinoin 4.4. PodophyllPodophyllin 5.5. PodophyllPodophyllotoxin 6. Imiquimod (Aldara)® 7.7. CChemotherapeutichemotherapeutic agent/agent/5-fluorouracil 8.8. CCantharidin 9.9. CContact allergens 10.10. CCidofoviridofovir
  66. 66. Management of Warts  MEDICAL TREATMENT “5”MEDICAL TREATMENT “5” I. Topical agents II. Systemic agents III.Intralesional injections IV.Photodynamic therapy V. Alternative treatments 1. Systemic retinoids (acitretin and isotretinoin) 2. Cimetidine 3. Intravenous cidofovir
  67. 67. Management of Warts  MEDICAL TREATMENT “5”MEDICAL TREATMENT “5” I. Topical agents II. Systemic agents III.Intralesional injections IV.Photodynamic therapy V. Alternative treatments 1. Bleomycin 2. Interferon alpha 3. Intralesional immunotherapy using injections of Candida, PPD, mumps/MMR.
  68. 68. Management of Warts  MEDICAL TREATMENT “5”MEDICAL TREATMENT “5” I. Topical agents II. Systemic agents III.Intralesional injections IV.Photodynamic therapy V. Alternative treatments ALA
  69. 69. Management of Warts  MEDICAL TREATMENT “5”MEDICAL TREATMENT “5” I. Topical agents II. Systemic agents III.Intralesional injections IV.Photodynamic therapy V. Alternative treatments 1. Occlusion/Adhesio- therapy 2. Heat treatment 3. Hypnotic suggestion 4. Garlic 5.5. Tea tree oilTea tree oil
  70. 70. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 1.1. KeratolyticsKeratolytics: Salicylic acid 10-50% is a first-line therapy used to treat warts / more cost-effective. 2.2. TTrichloroacetic acid (30-80%)richloroacetic acid (30-80%): causes tissue necrosis. 3.3. TTretinoinretinoin is a topical retinoic acid that primarily is used to treat acne. It has been successful in treating flat warts. 4.4. PodophyllPodophyllin:in: is a cytotoxic compound used more commonly in the treatment of genital warts more effective in treating warts on occluded or moist surfaces, such as the mucosa or under the prepuce. as a crude extract, usually in 25 % in tincture of benzoin. 5.5. PodophyllPodophyllotoxin 0.5%otoxin 0.5% solution or gel purified podophyllin is applied by the patient twice a day for 3 consecutive days of each week in 4- to 6-week treatment cycles.
  71. 71. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 1.1. KeratolyticsKeratolytics: Salicylic acid 10-50% is a first-line therapy used to treat warts / more cost-effective. 2.2. TTrichloroacetic acid (80%)richloroacetic acid (80%): causes tissue necrosis. 3.3. TTretinoinretinoin is a topical retinoic acid that primarily is used to treat acne. It has been successful in treating flat warts. 4.4. PodophyllPodophyllin:in: is a cytotoxic compound used more commonly in the treatment of genital warts more effective in treating warts on occluded or moist surfaces, such as the mucosa or under the prepuce. as a crude extract, usually in 25 % in tincture of benzoin. 5.5. PodophyllPodophyllotoxin 0.5%otoxin 0.5% solution or gel purified podophyllin is applied by the patient twice a day for 3 consecutive days of each week in 4- to 6-week treatment cycles.
  72. 72. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 1.1. KeratolyticsKeratolytics: Salicylic acid 10-50% is a first-line therapy used to treat warts / more cost-effective. 2.2. TTrichloroacetic acid (30-80%)richloroacetic acid (30-80%): causes tissue necrosis. 3.3. TTretinoinretinoin is a topical retinoic acid that primarily is used to treat acne. It has been successful in treating flat warts. 4.4. PodophyllPodophyllin:in: is a cytotoxic compound used more commonly in the treatment of genital warts more effective in treating warts on occluded or moist surfaces, such as the mucosa or under the prepuce. as a crude extract, usually in 25 % in tincture of benzoin. 5.5. PodophyllPodophyllotoxin 0.5%otoxin 0.5% solution or gel purified podophyllin is applied by the patient twice a day for 3 consecutive days of each week in 4- to 6-week treatment cycles.
  73. 73. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 1.1. KeratolyticsKeratolytics: Salicylic acid 10-50% is a first-line therapy used to treat warts / more cost-effective. 2.2. TTrichloroacetic acid (30-80%)richloroacetic acid (30-80%): causes tissue necrosis. 3.3. TTretinoinretinoin is a topical retinoic acid that primarily is used to treat acne. It has been successful in treating flat warts. 4.4. PodophyllPodophyllin:in: is a cytotoxic compound used more commonly in the treatment of genital warts more effective in treating warts on occluded or moist surfaces, such as the mucosa or under the prepuce. as a crude extract, usually in 25 % in tincture of benzoin. 5.5. PodophyllPodophyllotoxin 0.5%otoxin 0.5% solution or gel purified podophyllin is applied by the patient twice a day for 3 consecutive days of each week in 4- to 6-week treatment cycles.
  74. 74. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 1.1. KeratolyticsKeratolytics: Salicylic acid 10-50% is a first-line therapy used to treat warts / more cost-effective. 2.2. TTrichloroacetic acid (30-80%)richloroacetic acid (30-80%): causes tissue necrosis. 3.3. TTretinoinretinoin is a topical retinoic acid that primarily is used to treat acne. It has been successful in treating flat warts. 4.4. PodophyllPodophyllin:in: is a cytotoxic compound used more commonly in the treatment of genital warts more effective in treating warts on occluded or moist surfaces, such as the mucosa or under the prepuce. as a crude extract, usually in 25 % in tincture of benzoin. 5.5. PodophyllPodophyllotoxin 0.5%otoxin 0.5% solution or gel purified podophyllin is applied by the patient twice a day for 3 consecutive days of each week in 4- to 6-week treatment cycles.
  75. 75. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 6.6. Imiquimod (Aldara)®:Imiquimod (Aldara)®: is an immune response modifier approved for the treatment of genital warts. 7.7. CChemotherapeutic agent 5-Fluorouracilhemotherapeutic agent 5-Fluorouracil. It has been reported to be effective in treating warts when used under occlusion daily for up to 1 month. 8.8. CCantharidin:antharidin: is an extract of the blister beetle that causes epidermal necrosis and blistering. 9.9. CContact sensitizersontact sensitizers e.g. diphencyclopropenone (DCP) 10.10. CCidofoviridofovir is an antiviral agent used for the treatment of CMV infection in HIV patients. gel applied 1-2 times per day. This remains an investigational drug for warts
  76. 76. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 6.6. Imiquimod (Aldara)®:Imiquimod (Aldara)®: is an immune response modifier approved for the treatment of genital warts. 7.7. CChemotherapeutic agent 5-Fluorouracilhemotherapeutic agent 5-Fluorouracil. It has been reported to be effective in treating warts when used under occlusion daily for up to 1 month esp. bowenoid papulosis 8.8. CCantharidin:antharidin: is an extract of the blister beetle that causes epidermal necrosis and blistering. 9.9. CContact sensitizersontact sensitizers e.g. diphencyclopropenone (DCP) 10.10. CCidofoviridofovir is an antiviral agent used for the treatment of CMV infection in HIV patients. gel applied 1-2 times per day. This remains an investigational drug for warts
  77. 77. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 6.6. Imiquimod (Aldara)®:Imiquimod (Aldara)®: is an immune response modifier approved for the treatment of genital warts. 7.7. CChemotherapeutic agent 5-Fluorouracilhemotherapeutic agent 5-Fluorouracil. It has been reported to be effective in treating warts when used under occlusion daily for up to 1 month. 8.8. CCantharidin:antharidin: is an extract of the blister beetle that causes epidermal necrosis and blistering. 9.9. CContact sensitizersontact sensitizers e.g. diphencyclopropenone (DCP) 10.10. CCidofoviridofovir is an antiviral agent used for the treatment of CMV infection in HIV patients. gel applied 1-2 times per day. This remains an investigational drug for warts
  78. 78. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 6.6. Imiquimod (Aldara)®:Imiquimod (Aldara)®: is an immune response modifier approved for the treatment of genital warts. 7.7. CChemotherapeutic agent 5-Fluorouracilhemotherapeutic agent 5-Fluorouracil. It has been reported to be effective in treating warts when used under occlusion daily for up to 1 month. 8.8. CCantharidin:antharidin: is an extract of the blister beetle that causes epidermal necrosis and blistering. 9.9. CContact sensitizersontact sensitizers e.g. diphencyclopropenone (DCP) 10.10. CCidofoviridofovir is an antiviral agent used for the treatment of CMV infection in HIV patients. gel applied 1-2 times per day. This remains an investigational drug for warts
  79. 79. MEDICAL TREATMENTMEDICAL TREATMENT I.I. Topical agents 6.6. Imiquimod (Aldara)®:Imiquimod (Aldara)®: is an immune response modifier approved for the treatment of genital warts. 7.7. CChemotherapeutic agent 5-Fluorouracilhemotherapeutic agent 5-Fluorouracil. It has been reported to be effective in treating warts when used under occlusion daily for up to 1 month. 8.8. CCantharidin:antharidin: is an extract of the blister beetle that causes epidermal necrosis and blistering. 9.9. CContact sensitizersontact sensitizers e.g. diphencyclopropenone (DCP) 10.10. CCidofoviridofovir is an antiviral agent used for the treatment of CMV infection in HIV patients. gel applied 1-2 times per day. This remains an investigational drug for warts
  80. 80. MEDICAL TREATMENTMEDICAL TREATMENT II.II. Systemic agents 1.1. RetinoidsRetinoids are synthetic vitamin A analogs. The limiting side effects include liver function abnormalities, increased serum lipid levels, and teratogenicity. 2.2. CimetidineCimetidine is a type-2 histamine receptor antagonist commonly used to treat peptic ulcer disease. Because of its immunomodulatory effects at higher doses. 3.3. Intravenous cidofovirIntravenous cidofovir used for the treatment of extensive, disfiguring, and refractory warts. This should be used with caution because of the risk of nephrotoxicity
  81. 81. MEDICAL TREATMENTMEDICAL TREATMENT II.II. Systemic agents 1.1. RetinoidsRetinoids are synthetic vitamin A analogs. The limiting side effects include liver function abnormalities, increased serum lipid levels, and teratogenicity. 2.2. CimetidineCimetidine is a type-2 histamine receptor antagonist commonly used to treat peptic ulcer disease. Because of its immunomodulatory effects at higher doses. 3.3. Intravenous cidofovirIntravenous cidofovir used for the treatment of extensive, disfiguring, and refractory warts. This should be used with caution because of the risk of nephrotoxicity
  82. 82. MEDICAL TREATMENTMEDICAL TREATMENT II.II. Systemic agents 1.1. RetinoidsRetinoids are synthetic vitamin A analogs. The limiting side effects include liver function abnormalities, increased serum lipid levels, and teratogenicity. 2.2. CimetidineCimetidine is a type-2 histamine receptor antagonist commonly used to treat peptic ulcer disease. Because of its immunomodulatory effects at higher doses. 3.3. Intravenous cidofovirIntravenous cidofovir used for the treatment of extensive, disfiguring, and refractory warts. This should be used with caution because of the risk of nephrotoxicity
  83. 83. MEDICAL TREATMENTMEDICAL TREATMENT III. Intralesional injectionsIII. Intralesional injections 1.1. BleomycinBleomycin is a chemotherapeutic agent that inhibits DNA synthesis in cells and viruses. Cure rates have ranged from 33-92%. 2. Interferon-alfa is a naturally occurring cytokine with antiviral, antibacterial, anticancer, and immunomodulatory effects. Cure rates of 36- 63% have been reported. 3. Intralesional immunotherapy using injections of Candida, PPD, mumps/MMR.
  84. 84. MEDICAL TREATMENTMEDICAL TREATMENT III. Intralesional injectionsIII. Intralesional injections 1. Bleomycin is a chemotherapeutic agent that inhibits DNA synthesis in cells and viruses. Cure rates have ranged from 33-92%. 2.2. Interferon-alfaInterferon-alfa is a naturally occurring cytokine with antiviral, antibacterial, anticancer, and immunomodulatory effects. Cure rates of 36- 63% have been reported. 3. Intralesional immunotherapy using injections of Candida, PPD, mumps/MMR.
  85. 85. MEDICAL TREATMENTMEDICAL TREATMENT III. Intralesional injectionsIII. Intralesional injections 1. Bleomycin is a chemotherapeutic agent that inhibits DNA synthesis in cells and viruses. Cure rates have ranged from 33-92%. 2. Interferon-alfa is a naturally occurring cytokine with antiviral, antibacterial, anticancer, and immunomodulatory effects. Cure rates of 36- 63% have been reported. 3.3. Intralesional immunotherapyIntralesional immunotherapy using injections of Candida, PPD, mumps/MMR.
  86. 86. MEDICAL TREATMENTMEDICAL TREATMENT IV.IV. Photodynamic therapy  5-Aminolevulinic acid (ALA) is a photosensitizer that has been successfully used topically kept under occlusion for 5h, then followed by photoactivationphotoactivation with redred light-emitting diodes at 2- to 3-week intervals or with blueblue light to treat flat warts
  87. 87. MEDICAL TREATMENTMEDICAL TREATMENT V. Alternative treatmentsV. Alternative treatments 1.1. AdhesiotherapyAdhesiotherapy is performed by applying duct tape to the wart daily. This method is painless and inexpensive. 2.2. HypnosisHypnosis has been used to treat refractory warts with prepubertal children more likely to respond than adults. 3.3. HyperthermiaHyperthermia involves immersing the involved surface in hot water (45ºC) for 30-45 minutes, 2-3 times per week. 4.4. Raw garlic clovesRaw garlic cloves have been demonstrated to have antiviral activity. This can be rubbed onto the wart nightly, followed by occlusion. 5.5. Tea tree oilTea tree oil possesses antimicrobial properties and when applied topically has also been reported as successful
  88. 88. MEDICAL TREATMENTMEDICAL TREATMENT V. Alternative treatmentsV. Alternative treatments 1.1. AdhesiotherapyAdhesiotherapy is performed by applying duct tape to the wart daily. This method is painless and inexpensive. 2.2. HypnosisHypnosis has been used to treat refractory warts with prepubertal children more likely to respond than adults. 3.3. HyperthermiaHyperthermia involves immersing the involved surface in hot water (45ºC) for 30-45 minutes, 2-3 times per week. 4.4. Raw garlic clovesRaw garlic cloves have been demonstrated to have antiviral activity. This can be rubbed onto the wart nightly, followed by occlusion. 5.5. Tea tree oilTea tree oil possesses antimicrobial properties and when applied topically has also been reported as successful
  89. 89. MEDICAL TREATMENTMEDICAL TREATMENT V. Alternative treatmentsV. Alternative treatments 1.1. AdhesiotherapyAdhesiotherapy is performed by applying duct tape to the wart daily. This method is painless and inexpensive. 2.2. HypnosisHypnosis has been used to treat refractory warts with prepubertal children more likely to respond than adults. 3.3. HyperthermiaHyperthermia involves immersing the involved surface in hot water (45ºC) for 30-45 minutes, 2-3 times per week. 4.4. Raw garlic clovesRaw garlic cloves have been demonstrated to have antiviral activity. This can be rubbed onto the wart nightly, followed by occlusion. 5.5. Tea tree oilTea tree oil possesses antimicrobial properties and when applied topically has also been reported as successful
  90. 90. MEDICAL TREATMENTMEDICAL TREATMENT V. Alternative treatmentsV. Alternative treatments 1.1. AdhesiotherapyAdhesiotherapy is performed by applying duct tape to the wart daily. This method is painless and inexpensive. 2.2. HypnosisHypnosis has been used to treat refractory warts with prepubertal children more likely to respond than adults. 3.3. HyperthermiaHyperthermia involves immersing the involved surface in hot water (45ºC) for 30-45 minutes, 2-3 times per week. 4.4. Raw garlic clovesRaw garlic cloves have been demonstrated to have antiviral activity. This can be rubbed onto the wart nightly, followed by occlusion. 5.5. Tea tree oilTea tree oil possesses antimicrobial properties and when applied topically has also been reported as successful
  91. 91. MEDICAL TREATMENTMEDICAL TREATMENT V. Alternative treatmentsV. Alternative treatments 1.1. AdhesiotherapyAdhesiotherapy is performed by applying duct tape to the wart daily. This method is painless and inexpensive. 2.2. HypnosisHypnosis has been used to treat refractory warts with prepubertal children more likely to respond than adults. 3.3. HyperthermiaHyperthermia involves immersing the involved surface in hot water (45ºC) for 30-45 minutes, 2-3 times per week. 4.4. Raw garlic clovesRaw garlic cloves have been demonstrated to have antiviral activity. This can be rubbed onto the wart nightly, followed by occlusion. 5.5. Tea tree oilTea tree oil possesses antimicrobial properties and when applied topically has also been reported as successful
  92. 92. SURGICAL TREATMENTSURGICAL TREATMENT
  93. 93. SURGICAL TREATMENTSURGICAL TREATMENT I. CryosurgeryI. Cryosurgery  Liquid nitrogen (-196ºC) is the most effective method of cryosurgery. Apply liquid nitrogen using a cotton bud applicator or cryospray to the recommended 1-2 mm rim of normal skin tissue around the wart. Repeat every 1-4 weeks for approximately 3 months, as needed. Warn patients about pain and possible blistering after treatment.
  94. 94. SURGICAL TREATMENTSURGICAL TREATMENT II. ElectrosurgeryII. Electrosurgery  Electrodesiccation and curettageElectrodesiccation and curettage, it is painful, more likely to scar, and HPV can be isolated from the plume smoke potentially infectious  20% recur within few months.
  95. 95. SURGICAL TREATMENTSURGICAL TREATMENT III. LasersIII. Lasers  This is an expensive treatment, and is reserved only for large or refractory warts. Multiple treatments may be required. Local or general anesthesia may be necessary. 1.1. Carbon dioxideCarbon dioxide lasers have successfully treated resistant warts; however, the procedure can be painful and leave scarring. 2.2. Pulse dyePulse dye laser targets the blood vessels that feed warts with decreased risk of scarring 3.3. Nd:YAGNd:YAG laser may be used for deeper, larger warts.
  96. 96. SURGICAL TREATMENTSURGICAL TREATMENT IV. CurettageCurettage  Avoid using curettage in most circumstances because of the risks of koebnerization and recurrence.
  97. 97. SURGICAL TREATMENTSURGICAL TREATMENT V. Surgical excisionV. Surgical excision  Avoid using surgical excision in most circumstances because of the risks of scarring and recurrence.
  98. 98. Prevention
  99. 99. Prevention HPV Vaccines  Two vaccines are available to prevent infection by some HPV types: Gardasil, and Cervarix. Both protect against initial infection with HPV types 16 and 18, which cause most of the HPV associated cancer cases. Gardasil also protects against HPV types 6 and 11, which cause 90% of genital warts.
  100. 100. References  Bolognia Dermatology Essentials.  Bolognia Dermatology 2nd ed.  http://www.dermnetnz.org  http://en.wikipedia.org  http://www.ijdvl.com  http://emedicine.medscape.com
  101. 101. Thank U

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