Papillomavirus Follow-up

  • Author: John D Shanley, MD, MPH; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Dec 29, 2011
 

Further Outpatient Care

  • Because human papillomaviruses (HPVs) reside in the basal layer of the epidermis in a latent state, recurrences are common and retreatment is often necessary. For genital neoplasia, careful follow-up is mandatory.
  • High-risk (oncogenic) DNA testing is appropriate as routine cervical cancer screening in conjunction with cervical cytology in women aged 30 years and older. In women with negative cytology results but positive HPV results, repeat both tests in 12 months. When results of both cytology and HPV testing are negative, repeat both tests at 3-year intervals.
  • Treatment of cervical intraepithelial neoplasia, grade 1 may be monitored safely with serial cytology, HPV DNA detection, and colposcopy in reliable patients. Perform PAP tests every 6 months and colposcopy every 2 years. Treatment options include carbon dioxide laser ablation or excision, cryotherapy for lesions of 2 quadrants or less, cone biopsy, or loop excision.
  • For anal and rectal lesions in the context of HIV infection, frequent follow-up is essential.
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Deterrence/Prevention

  • In 2006, the FDA approved the HPV vaccine Gardasil (Merck and Co.). This vaccine is a quadrivalent vaccine that contains the major capsid protein, L1, for HPV types 6, 11, 16, and 18. Types 6 and 11 are associated with genital warts, while types 16 and 18 are associated with more than 70% of cervical malignancy cases. The vaccine is produced via recombinant technology to synthesize viruslike particles (VLPs) that are formed when L1 is expressed in vitro. VLPs are morphologically identical to the HPV but lack the viral genome. The vaccine is administered with a proprietary adjuvant of amorphous aluminum hydroxyphosphate sulfate. The vaccine is administered intramuscularly at 0, 2, and 6 months. The most common adverse effects include local irritation (swelling, pain, redness, itching) and fever. It is not approved for use in pregnant women.
  • In October 2009, the FDA approved the use of the quadrivalent vaccine for prevention of genital warts in males aged 9-26 years.[4] Also in 2009, a bivalent HPV vaccine against types 16 and 18 was licensed for routine use in females aged 9-26 years. Either vaccine is now recommended for use in females.[5]
  • Clinical trials have demonstrated a high degree of efficacy in preventing cytological changes due to HPV or clinical disease. The vaccine induces antibody responses that are 80-100 times that of natural infection.
  • The Advisory Committee on Immunization Practices gave provisional recommendations for immunization of females beginning at age 11 or 12 years. Catch-up vaccination was recommended for females aged 13-26 years.
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Prognosis

HPV infection primarily involves the basal epithelial cells. As a result, recurrences are common. Spontaneous regressions are also common.

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Patient Education

For excellent patient education resources, visit eMedicine's Warts Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Warts, Genital Warts, Plantar Warts, Cervical Cancer, Birth Control Overview, and Birth Control FAQs.

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Contributor Information and Disclosures
Author

John D Shanley, MD, MPH  Professor Emeritus, University of Connecticut; Professor of Preventive Medicine, Stony Brook Medical Center

John D Shanley, MD, MPH is a member of the following medical societies: American Association for the Advancement of Science, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey D Band, MD  Professor of Medicine, Oakland University William Beaumont School of Medicine; Director, Division of Infectious Diseases and International Medicine, Corporate Epidemiologist, William Beaumont Hospital; Clinical Professor of Medicine, Wayne State University School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Charles V Sanders, MD  Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References

  1. Hariri S, Unger ER, Sternberg M, Dunne EF, Swan D, Patel S, et al. Prevalence of genital human papillomavirus among females in the United States, the national health and nutrition examination survey, 2003-2006. J Infect Dis. Aug 2011;204(4):566-73. [Medline].

  2. [Guideline] FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. May 28 2010;59(20):626-9. [Medline]. [Full Text].

  3. Recommendations on the Use of Quadrivalent Human Papillomavirus Vaccine in Males - Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. Dec 23 2011;60:1705-8. [Medline].

  4. FDA. FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. May 28 2010;59(20):626-9. [Medline].

  5. FDA. FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. May 28 2010;59(20):630-2. [Medline].

  6. Ault KA. Human papillomavirus infections: diagnosis, treatment, and hope for a vaccine. Obstet Gynecol Clin North Am. Dec 2003;30(4):809-17. [Medline].

  7. Beutner KR, Ferenczy A. Therapeutic approaches to genital warts. Am J Med. May 5 1997;102(5A):28-37. [Medline].

  8. Burd EM. Human papillomavirus and cervical cancer. Clin Microbiol Rev. Jan 2003;16(1):1-17. [Medline].

  9. Carr J, Gyorfi T. Human papillomavirus. Epidemiology, transmission, and pathogenesis. Clin Lab Med. Jun 2000;20(2):235-55. [Medline].

  10. Cox JT. History of the use of HPV testing in cervical screening and in the management of abnormal cervical screening results. J Clin Virol. Jul 2009;45 Suppl 1:S3-S12. [Medline].

  11. Fazel N, Wilczynski S, Lowe L, Su LD. Clinical, histopathologic, and molecular aspects of cutaneous human papillomavirus infections. Dermatol Clin. Jul 1999;17(3):521-36, viii. [Medline].

  12. Huang CM. Human papillomavirus and vaccination. Mayo Clin Proc. Jun 2008;83(6):701-6; quiz 706-7. [Medline].

  13. Huh WK. Human papillomavirus infection: a concise review of natural history. Obstet Gynecol. Jul 2009;114(1):139-43. [Medline].

  14. Koutsky L. Epidemiology of genital human papillomavirus infection. Am J Med. May 5 1997;102(5A):3-8. [Medline].

  15. Sedlacek TV. Advances in the diagnosis and treatment of human papillomavirus infections. Clin Obstet Gynecol. Jun 1999;42(2):206-20. [Medline].

  16. Siddiqui MA, Perry CM. Human papillomavirus quadrivalent (types 6, 11, 16, 18) recombinant vaccine (Gardasil). Drugs. 2006;66(9):1263-71; discussion 1272-3. [Medline].

  17. Tjalma WA, Arbyn M, Paavonen J, van Waes TR, Bogers JJ. Prophylactic human papillomavirus vaccines: the beginning of the end of cervical cancer. Int J Gynecol Cancer. Sep-Oct 2004;14(5):751-61. [Medline].

  18. Wiley DJ, Douglas J, Beutner K, Cox T, Fife K, Moscicki AB, et al. External genital warts: diagnosis, treatment, and prevention. Clin Infect Dis. Oct 15 2002;35(Suppl 2):S210-24. [Medline].

 
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Verrucous warts in a patient with HIV infection.
Plantar warts.
Flat wart.
Table 1. Association of HPV Types With Morphology and Site of Skin Lesions
LesionLocationHPV Genotype
Common wartMostly hands2, 4
Plantar wartBottom of feet1
Mosaic wartHands and feet2
Flat wartArms, face, knees3, 10, 28, 41
Butcher wartHand7
Extragenital Bowen diseaseUpper and lower extremities, head2, 3, 5, 16, 18, 20, 31, 33, 34, 54, 56, 58, 61, 62, 73
Macular plaques of epidermodysplasia verruciformisLight-exposed areas5, 8, 9, 12, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 36, 47, 50
Table 2. HPV Types Associated With Anogenital Lesions
LesionsHPV Genotype
Genital warts6, 11
Flat condylomata6, 11, 16, 18, 31
Cervical intraepithelial neoplasia16, 18, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 56
Bowen disease6, 11
Buschke-Löwenstein tumors6, 11
Vulvar intraepithelial neoplasia16 (occasionally 6, 11)
Cervical cancer16, 18 (strong association)
31, 33, 35, 45, 51, 52, 56 (moderate association)
6, 11, 42, 43, 44 (weak association)
Penile intraepithelial neoplasia16, 18
Anal intraepithelial neoplasia16 (rarely 6, 11, 18, 33)
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