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VULVA: HUMAN PAPILLOMAVIRUS INFECTIONS & VULVAR INTRAEPITHELIAL NEOPLASIA
HPV TREATMENT
Cryosurgery, electrosurgery, laser ablation, topical acids, retinoin, interferon, and conservative surgical excision have been used successfully. Laser vaporization is precise and effective therapy that causes little scarring. Topical therapy with immunomodulators may be effective if surface keratin is minimal. Risk assessment including age and immune status is also an important part of planning therapy. Other modalities used include Efudex, Condylox, Aldara, and Podophyllin.
| AGENT |
ACTION |
COST |
HEALING |
SCAR |
CLEARANCE
RATES |
RECURRENCE |
Cryosurgery
>more info |
Surgical
|
Low
|
4 days-4 wks |
Little
|
68% -90%
|
38%
|
Electrosurgery
>more info |
Surgical
|
Low
|
2-6 wks
|
Possible |
|
|
Laser Ablation
>more info |
Surgical |
High |
2-4 wks |
Little |
27-82% |
7-72% |
Topical acids
>more info |
Chemical/
Cytotoxic |
Low |
1-2 wks |
Little |
70-81% |
NA |
Podophyllin
>more info |
Chemical/
Cytotoxic |
Low |
1-2 wks |
Little |
32-79% |
27-65% |
Pododphyllotoxin
>more info |
Chemical/
Cytotoxic |
Low |
1-2 wks |
Little |
45-88% |
31-60% |
5-Fluorouracil
>more info |
Chemical/
Cytotoxic |
|
|
|
30%-50%
|
|
Interferon
>more info |
Immuno-
therapy |
High |
None |
None |
Intralesional
32-60%
Systemic
17-21% |
65-67%
Not reported |
Imiquimod
(Aldara)
>more info |
Immuno-
therapy |
Low |
2-3 wks |
Rarely |
72-84%
(female) |
5-19%
(female) |
Surgery
>more info |
Surgical Excision (see also laser ablation) |
***Post Laser Instructions
- Apply ice for the first 12-24 hours. Leave the ice on for 30 minutes, then let the skin warm up again prior to replacing the ice.
- Take a Sitz bath three times per day with warm water and instant ocean, sea salt or Epsom salts.
- Dry area well thereafter with a hair dryer set on low.
- Apply Silvadene cream (if patient not allergic to sulfa), Carrington’s gel, or Bacitracin afterwards.
- Cleanse area with salt water solution after each void or bowel movement if soiled.
- For symptomatic relief, you may use warm tea bags or lightly apply witch hazel in between Sitz baths.
- You will be given oral pain medication as well as a stool softener to prevent constipation.
- If you develop extreme redness around the lasered area or a foul discharge, then contact your health care provider.
Long-Term Follow-Up Care and Prevention
Self-examination supplemented by periodic exams by health care providers are recommended to assess for recurrence of HPV disease on external areas.
If a patient does not respond to a given product by the fourth week, you should switch to another form of therapy and consider a biopsy to rule out other diseases.
Comparison of FDA-approved products for treatment of external genital warts
Product
|
Packaging |
Dosing regimen |
Mechanism
of action |
Treatment limitations
by labeling |
Margin
of safety |
Pregnancy category |
Relative
cost* |
Imiquimod
(Aldara™) |
5% topical cream in 0.25-g sachets’ 12 sachets/box |
tiw at night for < 16 weeks self-applied |
Cytokine induction; immune response modifier |
< 20 cm2 |
Wide |
B |
$-$$ |
Podofilox
(Condylox™) |
0.5% solution 3.5-mL vials; 0.5% gel in 3.5-g tubes |
bid X 3 days consecutively, rest X 4 days |
Antimitotic, locally inflammatory |
< 10 cm2 and < 0.5 g/day |
Wide |
C |
$-$$ |
Interferon-a: Leukocyte- Derived
(Alferon-N™) |
5 MIU/1.0 mL vial for injection |
0.05 mL/wart intralesionally biw X < 8 weeks |
Nonspecific antiviral Immuno-stimulatory
(?) |
< 5 MIU or < 20 warts |
Moderate |
C |
$$$$ |
Recombinant
(Intron-A™) |
1.0 MIU/0.1 mL 0.5 or 1.0 mL vials for injection |
0.1 mL/wart Intralesionally tiw X <3 weeks |
Nonspecific antiviral Immuno-stimulatory
(?) |
< 5 MIU or < 5 warts |
Moderate |
C |
$$$$ |
*”Relative cost” includes estimates of cost of office visits, cost of drug, primary efficacy, recurrence rates following complete clearance, and need for additional treatment with failure.
IN: NEW APPROACHES TO MANAGEMENT OF EXTERNAL GENITAL WARTS
Based on May 17, 1999 meeting in Philade lphia. Ralph M Richart, Program Chair. Panel: Alex Ferencxy, Kenneth F Trofatter, Stephen K Tyring. Sponsored by The College of Physicians and Surgeons of Columbia University.
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