Million N presented a seminar on HPV-induced warts. The presentation covered the classification, epidemiology, transmission, pathogenesis, clinical manifestations, diagnosis, management and prevention of HPV-induced warts. HPV can cause skin warts and genital warts. Warts are benign skin growths caused by HPV. Treatment depends on the type and location of warts, and may include cryotherapy, topical medications, surgical removal or vaccination. Patient education is important to prevent transmission of HPV.

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COLLAGE OF MEDICINE AND
HEALTH SCIENCE
DEPARTMENT OF DERMATOLOGY
Modulator: Dr. Tadele ( Dermatologist )
Presenters
1. Million N.
Seminar presentation on HPV induced
WARTS
BY Million N( B pharm, nutritionist)

2. OUTLINES
Introduction
Classification
Epidemiology
 risk factors
Transmission
Pathogenesis
Clinical manifestations
Differential dx
Management
Prevention and pt education
Reference
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3. What is HPV?
Human Papillomavirus (HPV)
Human papillomaviruses are a group of more than 100 viruses.
viruses infect the skin and mucous membranes.
They are called papillomaviruses because certain types may cause papillomas (or
warts), which are benign tumors.
The most common clinical manifestation of these viruses is warts (verrucae).
HPV;-
More than 60 cutaneous types
Can lead to skin warts
40 mucosal types; high risk and low risk
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4. HPV
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characteristic proliferative lesions
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5. Classifications of HPV
• Two categories of HPV exist:
 low-risk (benign)HPV lesions and
 high-risk (neoplastic )HPV lesions.
The low-risk strains are responsible for;
genital warts,
recurrent respiratory papillomatosis (RRP),and
low-grade cervical lesions.
Types 6 and 11account for more than 90%.
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6. Cont…
high grade strains;
Type 16,18,31,33 and 35 are found as
coinfection with HPV 6 and 11 and
HAVE a potential for precancerous changes.
 are associated with foci of intraepithelial
neoplasia (HIV infection)( Cervical ca, anal ca,
penile ca, and lung ca).
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7. Cont…
frequently affected sites: penis, vulva,
vagina, cervix, perineum, and perianal area.
 Epidermal manifestation attributed to epidermotropic
human papilloma virus.
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8. Disease types
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9. epidemiology
HPV found world wide spreading ,
Cutaneous verrucae occur most commonly in children and young adults.
Genital HPV infections are very common among sexually active
individuals.
74 percent of new infections occur among young people age 15–24yrs.
Because of this its assumed to be a STD.
also more common among certain occupations such as handlers of meat,
poultry, and fish.
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10. Predisposing conditions
atopic dermatitis
decreased cell-mediated immunity
Sexual habit
AIDS, organ transplantation)
Born in underdeveloped countries
Trauma to the skin( laceration/ maceration )
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11. HPV Transmission
reservoir for HPV appears to be individuals with clinical or
subclinical infection.
Direct skin-to-skin contact
– Usually, but not always sexual contact
 Infected birth canal
 Fomites (very rare)
The incubation period following exposure is approximately two to
six months.
Spontaneous remission of warts occurs(2/3)
Recurrence is common
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12. Warts
are skin growths that are caused by the
human papillomavirus (HPV).
HPV stimulates quick growth of cells on the
skin's outer layer.
 common warts appear on the fingers, near
the fingernails, on the hands or genital area .
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13. Types of Warts
Verrucae/warts
location
genital plantar palmar
morphology
flat mosaic filiforms
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Lesions may occur singly, in groups, or as coalescing lesions forming plaques.
BY Million N( B pharm, nutritionist)

14. Cont….
• Plantar warts;-flesh-colored or light brown lumps ,
tiny black dots(on the soles of the feet).
• Genital warts;-can appear in the pubic area, on the
genitals, in or around the anus, and/or in the vagina.
• Flat warts: -
more common in teens and children than in adults.
are smoother, flatter, and smaller than other warts
they generally occur on the face.
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15. Cont…
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16. Genital Warts
• Flat, papular or pedunculated growth on genital
mucosa( HPV).
• Usually asymptomatic but can be painful or pruritic.
Sites:
 introitus in women
 under foreskin of uncircumcised penis
 shaft of circumcised penis
 Anogenital epithelium: cervix, vagina, urethra, perineum,
perianal
skin and scrotum
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17. Clinical Types
External Warts
 Single, multiple papules or
plaque,
 Flat ,verrucous,pedunculate
d
 Reddish or brown smooth
raised papules
 Dome-shaped lesions on
keratinized skin
Internal Warts
 Affect mucous membranes
 Discomfort, pain, bleeding,
difficult intercourse.
According to the
Alexandria
university
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18. HPV is a sexually transmitted disease and HPV can cause genital warts.
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19. Cont…
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20. Giant Condyloma
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21. (anogenital warts )
 Cauliflower-like appearance
 Skin-colored,( pink or hyper pigmented)
 keratotic on skin and non-keratinized on mucosal
surfaces.
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22. Pathogenesis
HPV infection…..
 at the basal cell layer of
stratified Squamous epithelial
cells.
 Stimulate cellular
proliferation in (epithelium
and infected cells).
 interaction between viral
proteins and cellular proteins
occurs(p53) and pRb
(retinoblastoma gene
product).
Skin Papilloma
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23. Pathogenesis
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24. Clinical manifestations
Majorly asymptomatic.
Painless bumps, pruritus and discharge( chief
complaints).
multiple lesions rather than a single wart
Urethral bleeding or urinary obstruction
Vaginal bleeding during pregnancy
Coital bleeding ( discomfort)also may occur
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25. DX for Genital Warts
Can be detected in a clinical exam;
– History
– Visual exam
– Pap smears
– DNA testing
confirmed by biopsy and is indicated if:
1) the diagnosis is uncertain
2) the lesions do not respond to standard therapy
3) the disease worsens during therapy
4) the lesion is atypical
5) the patient has comprised immunity
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26. Histopathology
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27. Differential Diagnosis
 Pearly White Papules
 Molluscum Contagiosum
hairlike projections
Condyloma
Lata
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28. Cont….
Lichen planus and lichen nitidus(flat-topped papules of
lichen planus and globoid papules )
Seborrheic keratosis( stuck on appearance, with horn cysts ,
often pigmented).
 Acrochordon( skin tags) pedunculated flesh-colored
papules that lack the roughness of warts.
 Clavus – Commonly called a corn.
 Squamous cell carcinoma (lesions have irregular growth, ulceration,
or resist therapy,)
 Traumatic black heel(Dried dark erythrocytes deposited in the
epidermis).
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29. management
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30. Factors that may influence
selection of treatment
Wart size
Wart number
Anatomic site of wart
 Wart morphology
Patient preference
Cost of treatment
Adverse effects
Provider experience
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31. Human Papilloma Virus (HPV) Vaccine
Two vaccines currently developed:
a) Gardasil – protects against HPV types 16, 18,
6 and 11( released in 2006) ( 9-26yrs)( more effective).
b) Cervarix – protects against HPV types 16 and
18,( effective for previously un exposed women).
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32. Recommended Regimens f or
External Geni t al Warts
a) Podofilox 0.5% solution or gel:
Antimitotic drug that destroys wart
Twice a day for 3 days, followed by 4 days of
no therapy/ four cycles.
The total wart area treated should not exceed
10 cm2/ podofilox limited to 0.5 mL per day.
 Most patients experience mild/moderate pain
or local irritation after treatment.
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33. Cont….
b) Imiquimod 5% cream:
Topically active immune enhancer that
stimulates
production of interferon and other cytokines.
Three times a week for up to 16 weeks.
The treatment area should be washed with soap
and water 6--10 hours after the application.
Moderate erythema, erosions and tenderness.
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34. Cont….
C) Podophyllin resin 10%-25% in a
compound tincture of benzoin:
 Cytotoxic, antimitotic.
A small amount should be applied to each
wart and allowed to air dry.
D)Trichloroacetic acid (TCA) 80%--90%.
• Destroy warts by chemical coagulation of the
protein( CURRENTLY not used ..necrosis).
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35. Cont….
Salicylic acid
Liquid nitrogen
Tretinion
Cantharidin
Cimetidine
5-FU
Snip or shave excision( anesthetizing)
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36. Other options
Cryotherapy is freezing the abnormal cells
with liquid nitrogen( EN).
 Conization, also known as a cone biopsy,
removes the abnormal areas.
 LEEP or Loop Electrosurgical Excision
Procedure is when abnormal cells are
removed with a painless electrical current.
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37. Algorithm
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38. prevention
avoid exposure
avoid touching warts
Using slippers or other footwear
Tools used for paring down warts should not used
and shared
hair-bearing areas with warts should be shaved
Nutrition and hygiene should be explained.
Patient education ( basics and beyond the basics).
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39. Reference
• Alexandria university, dermatology guidelines
• Harrison principles of internal medcn…20th
edn.
• Up-to-date 21.6
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40. GALATOOMAA!!
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