Cryotherapy

Report
Warts and All
Dr Daniela Brawley
ST4
Genitourinary medicine
23rd November 2010
Cases of genital warts/year in UK
Human Papilloma Virus

> 100 sub-types of HPV

HPV 6 and 11 cause 90% of genital warts

Most clear the infection in 9 months

HPV 16 and 18 risk for malignant change
–
Persistent infection with oncogenic sub-types
increases risk of malignant change
Prevalence

1% of population have visible warts

10% have active HPV infection

60% have cleared HPV
–

However can have long latent or lifelong phase
? Missed opportunity with quadrivalent HPV
vaccine (6/11/16/18)
Transmission

Sexual in majority of cases
–
–
Female to male 71% at 3 months
Male to female 54% at 3 months

Condoms can reduce risk but don’t eliminate

Increased risk if immunocompromised and/or
smoker
Diagnosis

Diagnosis is by examination under good light

Consider referral/biopsy if atypical or unsure

STI screening

Partner notification not necessary
STI screening

10-20% have co-existing STIs

Extensive warts – HIV indicator disease
–

Chlamydia/ Gonorrhoea
–
–

BHIVA 2008 HIV testing guidelines
Urine in males
Vulvovaginal/cervical swab in females
HIV/Syphilis
But first…
….what’s a normal lump?
Pearly penile papules

Normal anatomy

No treatment

Common presentation in young men

Reassure strongly that are normal
Vulval papillomatosis

Smooth and symmetrical

Easily confused with HPV

Don’t progress
–

review at 1 month
No treatment
Parafrenular glands

Symmetrical, small and smooth surface

No treatment required
Fordyce spots or sebaceous follicles

Glands in clusters

Prepuce, shaft of penis and vestibular area
of vulva

More obvious when skin is stretched

Reassurance
Sebaceous cysts

No treatment necessary unless become too
large or get infected

Reassurance

In men scrotal sebaceous cysts may occur
Lymphocoele

Hard swelling behind coronal surface

No treatment required

Usually resolves over time

Reassurance
And now…
other differentials
Molluscum contagiosum

Pox virus

Skin to skin contact, most likely sexual

Cryotherapy

STI screening including HIV especially if
extensive
Condyloma Lata of Secondary Syphilis

Refer GUM


Syphilis PCR and serology
Dark ground microscopy
STI screening

Penicillin and GUM follow-up

Now for warts….

Site, distribution and number

Morphology- keratinised or non keratinised

Patient features

Experience and equipment
–
Availability of cryotherapy
Treatments

Podophyllotoxin (warticon)

Cryotherapy

Imiquimod (aldara)

Smoking cessation
Excision

Warticon






Purified extract of podophyllin
Solution (0.5%) or cream (0.15%)
Non-keratinised warts, not perianal
3 days BD then 4 days rest for 4 weeks
Soreness and ulceration
NOT used in pregnancy
Cryotherapy

Necrosis of dermal-epidermal junction

Keratinised warts and intrameatal warts

Weekly application with “Halo” and “Freeze
and thaw” techniques

Safe in pregnancy
Aldara

Immune response modulator

Non formulary and expensive (£50/month)


Used for resistant/extensive warts
3 times a week for maximum 16 weeks

NOT used in pregnancy
Source: Sandyford ProtocolsExternal Anogenital Warts.
Clearance rates
TREATMENT
END OF
TREATMENT
>3 MONTHS
RECURRENCE
RATES (%)
Cryotherapy
63-88 (75)
63-92
0-39 (20)
Imiquimod
(Aldara)
50-62 (58)
50-62
13-19 (16)
Podophyllotoxin
(Warticon)
42-88 (65)
34-77
10-91 (50)
Surgical excision
89-93 (91)
36
0-29 (15)
Source: United Kingdom National Guideline on the Management of Anogenital
Warts, 2007. (BASHH)
Keratinised Warts

Cryotherapy first line

Imiquimod if not improving

Warticon less likely to be effective but can try
for 4 weeks
Non-keratinised warts

Warticon

Cryotherapy or imiquimod if not improving
Perianal warts

Cryotherapy first line

Imiquimod if not improving

Warticon can be used but not licensed

Proctoscopy not indicated unless immune
suppressed, or symptoms in anal canal
Extensive Sub-preputial warts

GUM referral

Imiquimod and cryotherapy

Surgical referral
20 week pregnant female
Warts in pregnancy





Cryotherapy
Warticon and Imiquimod contraindicated
Improve/resolve 6-8 weeks after delivery
Not an indication for Caesarean Section
Small risk of transmission both genital and
laryngeal papilloma
–
–
1 in 400
No reduction with c-section
Warts and Bowen’s Disease

Referral for biopsy of suspicious areas

Cryotherapy/ electrocautery

Circumcision
Warts and VIN

Referral for biopsy of suspicious areas

Localised surgical excision

Referral to Gynaecology
Features indicating biopsy

Atypical

Pigmentation

Flat warts

Older age groups

Immunosuppression including HIV

Heavy smokers
Extensive warts

Trial of imiquimod +/- cyrotherapy

Referral to Gynaecologist for surgical
removal

STI screening
Single wart at fourchette

Cryotherapy

Surgical excision
Extensive anal warts HIV positive gay
man





GUM referral
Syphilis PCR and serology
Cryotherapy and/or Imiquimod
Proctoscopy
Surgical referral
–
Risk of AIN
Meatal Warts

Cryotherapy
–
If can see extent of warts

Concern about causing urethral stenosis

Warn about symptoms of urethral
obstruction
Vaginal warts

Usually resolve with treatment of external
warts

Cryotherapy if not improving
Cervical warts

Usually resolve with treatment of external
warts

Ensure has had recent smear
–

No need for additional smears
If no external warts or no improvement with
treatment of external warts refer to
colposcopy
Summary points

Treat the patient in front of you

Offer STI testing

Smoking cessation

Refer if unsure, not improving or suspicious
features
Sandyford contacts

www.sandyford.org

0141 211 8130

[email protected]
Some final points…
Chlamydia/Gonorrhoea NAAT test
PREFERRED SAMPLE
VULVOVAGINAL SWAB
Tests for ulcers

Syphilis

Herpes type 1 and 2

Combined PCR test

Confirm with
syphilis serology
PRIMARY CARE VAGINAL DISCHARGE PROTOCOL
History
Low risk STI
Typical BV or VVC history
No symptoms of PID
High risk STI
Pregnant
Requests testing
Examination and pH
Examination, pH and
CT/GC NAAT
Exam
HVS
CT/GC NAAT
CT/GC NAAT
pH < 4.5
Treat for
VVC
pH > 4.5
Treat for BV
pH < 4.5
Treat for VVC
Await CT/GC
NAAT
Recurrence
Symptoms of PID
Postpartum
Gynaecological instrumentation
pH > 4.5
Treat for BV
Await CT/GC
NAAT
GUM referral if GC positive
or unresolved
BV- bacterial vaginosis
VVC- vulvovaginal candida
CT/GC NAAT- Chlamydia/Gonorrhoea molecular te
GUM- genitourinary medicine clinic

similar documents