1. GENITAL WARTS

2. Condyloma acuminata HPV

3. Human PapillomaVirus  Condyloma Acuminata represents the most common STI  Caused by a DNA virus that is a member of the Papovirus group- HPV  Most Commonly seen in Homosexual Male population

4. Human PapillomaVirus  19 % of patients with HIV have been found to have anal condyloma  It is recommended  that all patients with anal condyloma undergo HIV testing

5. Genital Warts (HPV)  There is NO cure for the virus.  can spread the virus to anyone you have sex with. . can still get HPV even when you use a condom.

6. Human Papillomavirus  Many types of Human Papillomavirus (HPV), some of which infect the genital area  Incubation period unclear  Can infect men, women, and newborns  The person can easily pass it on to sex partners 6 HPV

7. Genital HPV: Two Types  The types of HPV that infect the genital area are labeled “ low-risk” or “high-risk” depending on whether they can cause cancer or not.  Low-risk HPV types can cause genital warts.  High-risk HPV types can cause serious cervical lesions, cervical cancer, and other genital cancers. 7 HPV

8. CondylomataAcuminata  Over 40 subtypes of HPV  Most common 6 and 11  16, 18, 31, and 32 are associated with squamous cell carcinoma

9. TRANSMISSION  Genital warts are very contagious.  Infection is Acquired  oral,  vaginal, or  anal sex.

10. Epidemiology ·Genital warts caused by HPV 6 and 11 are the most common ·Direct contact with the lesion is believed to result in spread of the disease.

11. HPVHistology  Hyperplastic Epithelial Growth with irregular acanthosis and marked Hyperkeratosis

12. Epithelial Hyperplasia in a Condyloma When epithelia cells are infected by HPV, they undergo a transformation in which they divide continuously causing a buildup of abnormal tissue that eventually becomes a wart

13. Perinuclear Halos = Koilocytosis

14. soft, moist, or flesh colored appear in clusters that resemble cauliflower-like bumps, either raised or flat, small or large Features of CONDYLOMATA

15. cauliflower-like lesions

16. SymptomsofHPV  discharge,  pruritis,  difficulty with defecation,  anal pain,  tenesmus,  foul odor, and  rectal bleeding

17. Manifestations Warts are usually, small, discrete, elevated pink to grey vegetative excrescences · Soft, fleshy, cauliflower-like lesions on the skin, genitalia, perineum, and perianal regions.

18. For the cauliflower-like lesions, clinical presentation is enough. These must be differentiated from condyloma lata and molluscum contagiosum. cytology PCR immunofluorescence electron microscopy Diagnosis

19.  COMPLICATIONS  Cancer  cervical cancer.  vulvar cancer,  anal cancer, and  cancer of the penis (a rare cancer). .

20. LOCATION of GENITAL WARTS  Although genital warts are most often found on or inside the genitals, they can also be found on the mouth, eyelid, lip, nipple, and around the anus.

21. Male locations:GenitalWarts : Anal verge/canal just inside the opening of the urethra, frenulum, head of the penis, coronal ridge, inner surface of the foreskin, along the penile shaft.

26. Female locations:Genital Warts Opening to the vagina, inner third of the vagina, and cervix..

27. www.skinchoice.com

28. Condyloma Acuminata

31. Perianal Condyloma Acuminata

32. HPV Wartsonthe Thigh 32

33. Possible HPV on the Tongue 33

34. Condyloma on Tongue

35. HPV Penile Warts 35 Source: Cincinnati STD/HIV Prevention Training Center HPV

36. Genital Warts in a Woman 36 HPV Source: CDC/NCHSTP/Division of STD, STD Clinical Slides

37. Perianal Wart 37 Source: Cincinnati STD/HIV Prevention Training Center HPV

38. CondylomataAcuminata

43.  Successful therapy requires accurate diagnosis and eradication of all warts  All patients undergo anoscopy and genital examination  Once identified, there are many different treatments depending on disease progression  Each treatment has advantages and disadvantages

44. TreatmentModalities  1. Podophyllin-cytotoxic chemical agent very toxic to normal skin.Can only be used on external warts. .  Local complications include necrosis, fistula, and anal stenosis  Multiple treatments are usually required  Other caustic agents are available  Eg.Bichloracetic Acid

45. Immunotherapy  2.A Vaccine is created and the patient is vaccinated with six consecutive weekly injections

46. HPV Vaccine - Gardisil  Approved for use in women only, 9-26 Recommended at ages 11-12 Catch-up older patients 3 vaccine series (0,2,6 mo)  Efficacy varies, outcomes studied vary But efficacy in the 90+ percentile for reduction of type-specific dysplasia  Targets HPV 6/11,16/18 Based on primary capsid proteins

47. Immunomodulators (Imiquimod/Aldara)  3.Imidazoquinolines-a new class of immune-response modulators  Mechanism of action unknown, but thought to play a role in cytokine-induced activation of the immune system  Application 3/week qhs x 16weeks

48. CondylomataAcuminata  Two therapies that are more commonly practiced today are interferon injections and Aldara (imiquimod) cream  Both therapies are very potent with many side-effects  LFT ’ s should be checked routinely with interferon injections  Aldara should be used every other day, because it can burn normal tissue and make it necrotic

49. TopicalCytostatics  4. Chemotherapeutic agents such as 5-FU, Thiotepa and Bleomycin  Bleomycin is given as an intra-lesional injection q2-3weeks  70% success rate reported

50. Cryotherapy and Laser  5.Cryotherapy T - t h opi e ca r l a a pp p lica y tion of Liquid Nitrogen commonly used by dermatologists for the treatment of conventional warts  6.Laser Therapy- work through thermonecrosis  Success rate from 88-95%  Higher rate of recurrence seen than electrocoagulation  No difference in healing time, pain or scarring reported

51. Fulgaration/Electrocoagu lation  7.Fulgaration with excision of a portion to send to pathology  Gold Standard  Very Painful if done too deeply, should not be into the dermis or fat  Risk of stricture formation if a large area is to be treated  Less than 50% have full resolution after one treatment

52. Anal Condylomata Summary  External Condylomata without evidence of Internal Warts can usually be effectively treated by chemical means  If the response is unsatisfactory, physical destruction by electrocoagulation is the preferred approach  Obtaining tissue for pathologic confirmation, especially with respect to premalignant or malignant change is a a prudent philosophy

53. Secondary Syphilis - ClinicalManifestations  Represents hematogenous dissemination of spirochetes  Usually 2-8 weeks after chancre appears  Findings: rash - whole body (includes palms/soles) mucous patches condylomata lata - HIGHLY INFECTIOUS constitutional symptoms  Sn/Sx resolve in 2-10 weeks 53 Sores

54. Secondary Syphilis – Condylomata Lata 54 Sores Source: Florida STD/HIV Prevention Training Center

56. MOLLUSCUM CONTAGIOSUM  Molluscum contagiosum (MC) is a common, self-limited, benign viral infection of the skin caused by a member of the pox-virus group.  MC is transmitted by close personal contact including sexual contact

57. DIAGNOSIS   Diagnosis is usually done on clinical grounds alone by the typical appearance of the lesions.  Expression of materials stained with Giemsa, Wright or Gram stain reveals molluscum bodies.  Biopsy, which shows characteristic features of epidermal hyperplasia.

61. Complications:   Secondary infections  Eczematization  Conjunctivitis/keratitis from eyelid infection

62. DIFFERENTIAL DIAGNOSIS  Acne whiteheads Warts Pyoderma Cryptococcosis