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.
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.
Prognosis
HPV infection primarily involves the basal epithelial cells. As a result, recurrences are common. Spontaneous regressions are also common.
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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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].
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| Lesion | Location | HPV Genotype |
| Common wart | Mostly hands | 2, 4 |
| Plantar wart | Bottom of feet | 1 |
| Mosaic wart | Hands and feet | 2 |
| Flat wart | Arms, face, knees | 3, 10, 28, 41 |
| Butcher wart | Hand | 7 |
| Extragenital Bowen disease | Upper and lower extremities, head | 2, 3, 5, 16, 18, 20, 31, 33, 34, 54, 56, 58, 61, 62, 73 |
| Macular plaques of epidermodysplasia verruciformis | Light-exposed areas | 5, 8, 9, 12, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 36, 47, 50 |
| Lesions | HPV Genotype |
| Genital warts | 6, 11 |
| Flat condylomata | 6, 11, 16, 18, 31 |
| Cervical intraepithelial neoplasia | 16, 18, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 56 |
| Bowen disease | 6, 11 |
| Buschke-Löwenstein tumors | 6, 11 |
| Vulvar intraepithelial neoplasia | 16 (occasionally 6, 11) |
| Cervical cancer | 16, 18 (strong association) |
| 31, 33, 35, 45, 51, 52, 56 (moderate association) | |
| 6, 11, 42, 43, 44 (weak association) | |
| Penile intraepithelial neoplasia | 16, 18 |
| Anal intraepithelial neoplasia | 16 (rarely 6, 11, 18, 33) |

