​Kembara Xtra - Medicine - Condylomata Acuminata

​Kembara Xtra - Medicine - Condylomata Acuminata 
The human papillomavirus (HPV) is the causative agent of the soft, fleshy, skin-colored lesions known as condylomata acuminata. These lesions are also generally referred to as genital warts.
– Warts can appear singly or in groups (a single wart is referred to as a "condyloma," while multiple warts are referred to as "condylomas" or "condylomata"); they can be small or large; they most commonly appear on the anogenital skin (penis, scrotum, introitus, vulva, perianal area); they can also occur in the anogenital tract (vagina
HIV-related factors to consider:
There should be no difference in the treatment of external genital warts for people who are HIV-positive.
– It's possible that the lesions will get bigger or more numerous.
- There is a possibility that they will not respond to treatment as favorably as immunocompetent individuals

Pediatric Considerations Despite the fact that children can become infected through other means (such as the transfer of a wart from one child's hand to another child's hand or a protracted latency period), it is important to consider the possibility of sexual abuse if the condition is observed in a child.

It is recommended by the American Academy of Pediatrics that any school-aged child who presents with lesions be assessed for possible abuse and screened for other sexually transmitted diseases (STDs).
 
Things to Think About When Expecting

It is common for warts to become larger during pregnancy, but they typically disappear on their own following the delivery of the baby. It is believed that vertical transmission leads to infection in newborns. Incidence is controversial. In cases of maternal condylomata, an emergency cesarean section may not be required.

It has been discovered that a cervical infection is a risk factor for giving delivery prematurely.

There have been very few documented occurrences of laryngeal papillomas that were caused by HPV transmission during the delivery process. Even though it is uncommon, the illness is extremely dangerous.
Getting vaccinated against HPV while pregnant is not recommended.
The treatment of trichloroacetic acid (TCA) during pregnancy is contentious, but options include cryotherapy, electrocautery, surgical excision, and topical trichloroacetic acid (TCA).
There is insufficient evidence to determine whether or whether imiquimod, sinecatechins, podophyllin, or podofilox are safe to use during pregnancy.


The HPV types 6 and 11 are related with 90% of cases of condylomata acuminata, according to epidemiology (incidence and prevalence). Highly contagious; the incubation time can range from one to eight months. May be found in warts and may be associated with high-grade intraepithelial dysplasia in immunocompromised states such as HIV. Types 16, 18, 31, 33, and 35 may be found. Incubation periods may range from one to eight months. Initial infections could very likely go undiagnosed, which means that what appears to be a "new" outbreak could actually be a recurrence of an infection that was acquired many years ago.
The majority of people are between the ages of 15 and 30.
The majority of infections are short-lived and go away on their own within two years in most cases. The ratio of males to females is 1:1.
Incidence
One research population found that the incidence of genital warts reduced by 35% (from 0.94% per year to 0.61% per year) in females 21 years old between 2007 and 2010, when HPV vaccines were first introduced. The incidence of genital warts decreased by 19% in males 21 years old during the same time period.
Prevalence
The most prevalent form of sexually transmitted infection (STI) in the United States that is caused by a virus. The majority of sexually active men and women will, at some point in their lives, have contracted a genital HPV infection, which is typically asymptomatic.
It is estimated that 6.2 million people in the United States may contract genital HPV each year.
It is estimated that 10–20% of sexually active women are now infected with HPV. The peak age range for HPV infection is 17–33 years. Studies in men reveal a similar prevalence.
Recurrence of lesions and accelerated growth of lesions are favored by pregnancy as well as immunosuppression.

Causes and effects: etiology and pathophysiology 

The DNA molecule that makes up HPV is circular and double-stranded. There are more than 120 different subtypes of HPV. The forms of HPV that are responsible for genital warts are not linked to anogenital malignancies.

Risk Factors Typically acquired via unprotected sexual activity Young adults and adolescents Multiple sexual partners; short interval between meeting new sex partner and first intercourse Not using protective barriers Young age of beginning sexual activity History of other sexually transmitted infections Risk Factors Typically acquired through unprotected sexual activity 
Immunosuppression can be caused by a number of factors, including HIV, smoking cigarettes, using oral contraceptives, and radiation therapy.

Prevention 

Either sexual continence or exclusive monogamy
The purpose of the HPV vaccination is to protect against HPV infections as well as malignancies that are connected with HPV. This vaccine is aimed at adolescents prior to the time in their lives when they are at the greatest risk of being exposed to HPV. The vaccine does not treat infections that have already occurred:
– If the HPV vaccine series is started before the 15th birthday, a 2-dose schedule (beginning at 0 and ending at 6 to 12 months) will have the same level of efficacy as a 3-dose plan (beginning at 0 and ending at 1 to 2, 6 months). The 9-valent HPV (9vHPV; Gardasil 9) vaccine protects against the two most prevalent HPV serotypes (types 6 and 11, which are responsible for the majority of anogenital warts) as well as the two most cancer-promoting types (16 and 18) and types 31, 33, 45, 52, and 58. This vaccine also protects against the other HPV serotypes listed.
– The HPV vaccines known as Gardasil and Gardasil 9 are licensed for use in females and males between the ages of 9 and 45 years old. These vaccines are quadrivalent (4vHPV) and 9vHPV, respectively.
– Since 2006, the Advisory Committee on Immunization Practices (ACIP) has suggested that girls receive routine vaccination at the age of 11 or 12 years, and since 2011, this recommendation has been extended to boys.
The use of condoms is effective to some degree; nonetheless, warts can be easily disseminated by lesions that are not covered by a condom (for example, forty percent of infected men have warts on their scrotums).
Complete and total abstinence till therapy is finished

Conditions That Often Occur Together 
Over ninety percent of cases of cervical cancer are linked to HPV types 16, 18, 31, 33, and 35. Sixty percent of cases of oropharyngeal and anogenital squamous cell carcinomas are linked to HPV.
● STIs (e.g., gonorrhea, syphilis, chlamydia), AIDS


Providing an Account of History 

Discuss your sexual history, the methods of birth control you've used, and other aspects of your lifestyle.
The vast majority of warts have no symptoms, but those that do can include itching, burning, redness, discomfort, and bleeding.
Large warts can create obstructive symptoms in the anus (when defecating) or the vaginal canal (when engaging in sexual activity or giving birth). This might result in vaginal discharge.

Clinical Examination 
Although lesions frequently have the appearance of being rough and warty with many fingerlike projections, they can also be soft, sessile, and smooth.
Large lesions resemble cauliflower and can grow to be more than 10 centimeters in diameter.
● Most common sites: penis, vaginal introitus, and perianal region
It is possible for the warts to bleed or irritate the surrounding tissue, and they can appear anywhere on the anogenital epithelium or in the anogenital tract. Warts frequently appear in clusters.

Condylomata lata, also known as flat warts of syphilis, lichen planus, and normal sebaceous glands are included in the differential diagnosis.
Seborrheic keratosis, molluscum contagiosum, keratomas, micropapillomatosis, scabies, Crohn disease, skin tags, melanocytic nevi, vulvar intraepithelial neoplasia, and squamous cell carcinoma are some of the skin conditions that can be caused by seborrheic keratosis.

Findings from the Laboratory The majority of the time, a clinical diagnosis is determined via an unaided visual assessment of the lesions.
Biopsy Acetowhitening test: Subclinical lesions can be observed by putting moistened gauze soaked with 5% acetic acid (vinegar) to the afflicted area for 5 minutes. This procedure is called the acetowhitening test. When viewed via a 10x hand lens or colposcope, warts look like very small white papules. Because of its limited specificity, the Centers for Disease Control and Prevention (CDC) advises against the routine use of this test to screen for HPV mucosal infection. The shining white appearance of the skin shows foci of epithelial hyperplasia, which is a subclinical infection.
Initial Tests (lab, imaging)
In most cases, this step is not necessary for diagnosis
In order to rule out the possibility of condylomata lata, serologic tests for syphilis may be beneficial.

Additional screening for sexually transmitted infections

There is a possibility that a Pap smear is required.

Additional Examinations, as well as Other Important Factors
For lesions that do not respond to treatment, a biopsy might be recommended since squamous cell carcinoma can sometimes look like condylomata or even coexist with them.


Diagnostic Methods and Other Procedures

It is extremely rare for a biopsy to be beneficial when highly specialized identification methods are used. One example of this would be the detection of HPV DNA by polymerase chain reaction.
Colposcopy, antroscopy, anoscopy, and urethroscopy are all possible diagnostic procedures that may be necessary to identify abnormalities in the anogenital tract.
It is debatable whether or not men who have sex with other men (also known as MSM) should get anal Pap smear screening.


Management 

Change therapy if there is no improvement after three treatments, clearance is not complete after six treatments, or the therapy's duration or dosage exceeds the guidelines of the manufacturer. Approximately thirty percent of cases resolve on their own within four months.
Screening and counseling of potential partners as necessary

First and foremost, medication
There is no one treatment for genital warts that is optimal for all patients or manifestly superior to the other available treatments.
Recommendations for the treatment of external genital warts, as applied by the patient:
- Podofilox (Condylox): antimitotic activity; apply 0.5% solution or gel to warts twice daily (allowing them to dry in between applications) for three days in a row at home, followed by four days without treatment; may repeat up to four total cycles; maximum of 0.5 mL/day or area less than 10 cm2
– Imiquimod (Aldara) is an immune booster that can be used as a self-treatment by applying a 5% cream to the affected area once daily before night and three times weekly until the warts disappear for a maximum of 16 weeks. After six to ten hours, you can remove the product by washing it off with soap and water. It has been shown that imiquimod reduces the effectiveness of condoms and diaphragms; hence, patients should avoid having sexual intercourse while the cream is still on their skin.
– Sinecatechins (Veregen), an extract from green tea that acts as an immune booster and antioxidant; apply a 0.5-centimeter strand of the ointment three times daily for up to 16 weeks. Don't bother washing off afterward.
Recommendations for the treatment of external genital warts, applied by the provider:
- Cryotherapy is a treatment for warts that involves applying liquid nitrogen to the warts for two bursts of roughly 10 seconds each (or for however long is necessary to freeze the wart without causing considerable expansion significantly deeper or lateral to the wart), with thawing in between. This treatment typically requires between two and three sessions per week.
- Podophyllin at concentrations ranging from 10 to 25% in tincture of benzoin. Directly apply the medication to the warts, and allow it to air dry in the office before wearing clothing. Remove with water in one to four hours. Repeat once every week at the office until all of the food is gone.
- TCA: 80% solution. Use solely on warts; use powder or talc to remove any acid that has not reacted. Ideal for isolated lesions in pregnancy, repeat in office at weekly intervals; recommended for exophytic cervical warts Biopsy to rule out high-grade squamous intraepithelial lesion (SIL) is recommended for exophytic cervical warts.

The following treatments are recommended for vaginal warts: cryotherapy, trichloroacetic acid (TCA), or bichloroacetic acid (BCA) 80–90% 

Cryotherapy or podophyllin 10–25% diluted in compound tincture of benzoin are the treatments that are recommended for urethral meatus warts.
The following treatments are recommended for anal warts: cryotherapy, TCA or BCA 80–90%, or surgery. Intraanal warts should be sent to a specialist. (3)[A]
Things to Think About When Expecting
Cryotherapy, surgery, or the TCA; drugs that should not be taken during pregnancy include podophyllin, podophyllotoxin, sinecatechins, interferon, and imiquimod. 

Intralesional interferon, photodynamic therapy, and topical cidofovir are the second line of treatment. 

Surgical Procedures It may be necessary to remove larger warts using surgical excision, laser therapy, or electrocoagulation (which may also include infrared therapy):
– A word of caution: the use of a laser therapy could produce smoke plumes that are contaminated with HPV. The Centers for Disease Control and Prevention (CDC) advises positioning a smoke evacuator no more than two inches away from the actual surgery site.
Masks are highly suggested, with N95 being the most effective option. 
The fulgurating CO2 laser can be used to treat lesions that are located intraurethrally, externally (penile and perianal), anatomically, and orally. Oral or external penile or perianal lesions can also be treated surgically or with electrocautery.

Keep in Touch 

No restrictions, except for sexual contact
Monitoring of the Patient
Patients ought to be examined once every one to two weeks till the lesions clear up.
Patients should return for a follow-up appointment three months after their treatment has been finished.
Warts that don't go away need to be biopsied.
● Sexual partners require supervision.

Please provide information on the prevention of sexually transmitted infections and the usage of condoms.
It is difficult to know how or when a person acquired an HPV infection; a diagnosis in one spouse does not show sexual infidelity in the other partner. Explain to patients that it is difficult to know how or when a person acquired an HPV infection.
Ensure that women are aware of how important it is to adhere to the guidelines for getting regular Pap smears.

The prognosis is that the infection will continue to exist indefinitely in asymptomatic individuals, that treatment does not significantly reduce the infectious potential of the virus, and that warts may clear up with treatment or disappear on their own.
However, recurrences are common, especially in the first three months, and it's possible that you'll need to undergo more treatments.

Complications 
Cervical dysplasia (which probably does not occur with type 6 or 11, which are the most common causes of warts) Malignant change: The progression of condylomata to cancer happens very rarely, if at all; nonetheless, squamous cell carcinoma may coexist in larger warts.
Obstruction of the urethra, vagina, or anum as a result of therapy

It is likely that greater levels of HPV activity are to blame for the higher prevalence of high-grade dysplasia and cancer in the anal canal among HIV-positive individuals when compared to HIV-negative patients.

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