2014 May

HPV stands for human papillomavirus, which is a virus from the papillomavirus family that affects human skin and the moist membranes that line the body, such as the throat, mouth, feet, fingers, nails, anus and cervix. There are at least 120 types of HPV. Some of them cause the kind of common warts you see on people’s hands and some of them cause plantar warts on the feet.

About 40 types of HPV, however, can infect the genital area — the vulva, vagina, cervix, rectum, anus, penis, or scrotum.

Genital HPV infections are very common. HPV is so common that about half of all men and more than 3 out of 4 women have HPV at some point in their lives. But most people who have HPV don’t know it.

For the purposes of understanding HPV better, let’s group it into two categories: low risk and high risk.

Here’s how it works: the papilloma viruses infect cells just beneath the skin which, like normal skin cells, move toward the surface, reach the upper layer, die and slough off, quite unnoticed by anyone. Papilloma is a fancy word for “raised bump,” so occasionally, the HPV-infected cells form lumps, which can be seen and felt. In reality, these are benign tumors. They are more commonly called genital warts.

Genital warts are warts that are located near or on the genital areas. In a female, that means on or near the vulva (the outside genital area), vagina, cervix, or anus. In a male, that means near or on the penis, scrotum, or anus.

Genital warts can look like bumps or growths. They can be flat or raised, single or many, small or large. They tend to be whitish or flesh colored. Sometimes, if left untreated, they can be shaped like a cauliflower. They are not always easy to see with the naked eye, and many times a person with genital warts doesn’t know that they’re there.

The warts can show up weeks or months after exposure to an infected sexual partner.

The types of HPV that can cause genital warts are NOT the same as the types of HPV that can cause cancer. Low-risk HPV strains, such as HPV-6 and 11, cause more than 90% of genital warts, which rarely develop into cancer. These, along with HPV-42, 43 and 44 are LOW risk for cancer of the cervix.

In the majority of cases, infected young females are not infected for long and there is no long-term consequence. The CDC says that over 70% of young female infections clear up within 12 months, while 90% do so within 24 months.

Not all of the 40 sexually transmitted HPV viruses cause serious health problems. But there are some types of HPV that may cause cell changes, which sometimes lead to cervical cancer and certain other genital and throat cancers. These are called high-risk types.

Very few warts are of the high-risk type. High-risk HPV strains include HPV-16 and 18, which cause about 70% of cervical cancers. Other high-risk HPV strains include 31, 33, 35, 39, 45, 51, 52, 58, and a few others.

Although most HPV infections go away within 8 to 13 months, some will not. HPV infections that do not go away can “hide” in the body for years and not be detected. That’s why it is impossible to know exactly when someone got infected, how long they’ve been infected, or who passed the infection to them.

In somewhere between 5% to 10% of cases, the infection persists and leads to high-risk type of HPV. This persistent long-term HPV infection raises the risk of developing precancerous lesions of the cervix. These can eventually, over a period of five to ten years, develop into cervical cancer. During this period, the progress can be treated and reversed with treatment for the pre-cancerous lesions. In some cases, treatment can lead to loss of fertility. However, in the majority of cases, cancer can be prevented.

As mentioned earlier, in 90% of cases the body’s own immune system destroys all the HPVs within 24 months. It is impossible to tell who might go on to develop health problems, including cancer.

These sexually transmitted HPV viruses are spread through contact with infected genital skin, mucous membranes, or bodily fluids, and can be passed through vaginal intercourse, anal intercourse and oral sex.
HPV can infect skin not normally covered by a condom, so using a condom does not fully protect someone from the virus.

You can get it from touching (hand to genital or genital to genital) an infected person’s lesions, which can transmit cells containing the virus.

Here’s an interesting fact regarding transmission of HPV: for many people, HPV is transmitted during their first 2 to 3 years of sexual contact.

Experts believe that when a wart is present, the virus may be more contagious. But HPV can still spread even if you can’t see warts. Many people don’t realize they’re infected with HPV and may have no symptoms, so neither sexual partner may realize that the virus is being spread.

In some rare cases, genital warts are transmitted from a mother to her baby during childbirth.

Warts can appear any time from several weeks to several months after a person has been exposed to them. Sometimes they might take even longer to appear because the virus can live in the body for a very long time before showing up as warts.

A few weeks or many months after infection, small groups of the genital warts, the size of a pinhead to begin with, appear on their own or in groups. They grow mostly on the head of the penis or anus. Occasionally, they appear in mouth, on the tongue or other parts of body or face, including the urethra and peri-anal area. Untreated, they can spread and get bigger to cauliflower-like warts.

External lesions may itch. A lesion on the skin may be either papillary (standing up from the skin) or flat. Lesions on the cervix can be seen only with the use of 5% acetic acid and magnification.

Not all warts look the same. They can be flat or raised above the surrounding skin. In moist areas, they have a softer surface and are known as exophytic warts. On skin that’s exposed to the air, the wart has a harder, “keratinized” surface. These are known as sessile or popular warts. Warts can be as small as a pinhead or as large as a sprout.

About 20 million people in the U.S. are infected with HPV at any time, according to the CDC. And three-fourths of sexually active people between ages 15 and 49 have been infected at some point in their lives, according to estimates from the American Social Health Association.

You’re more likely to get HPV if you:

• Have sex at an early age
• Have many sex partners
• Have a sex partner who has had multiple partners

While many people think HPV is mostly a problem for teens or young adults, HPV can infect men and women of any age. In fact, the latest statistics from the CDC found that:

• 19% of women 50 to 59 were infected with HPV virus
• 27% of women 20 to 24 were infected with HPV virus
• 45% of women 14 to 19 were infected with HPV virus

This has already been stated, but it’s important to read it again. Most HPV infections have no signs or symptoms. So someone can be infected and pass the disease on to another person without knowing.

Some people do get visible warts. Although warts might hurt, itch, or feel uncomfortable, most of the time they don’t. This is one reason why people may not know they have them.

Doctors can diagnose warts by examining the skin closely (sometimes with a magnifying glass) and using a special solution to make them easier to see.

Your doctor may take a tissue sample, (biopsy) and then examine it under the microscope (histology).

A common way to diagnose HPV in females is with a Pap smear (routine cervical cytology). This is a test that is performed during a gynecologic exam. In college-age females, probably no more than 10% of cervical lesions are truly pre-cancerous. It is extremely unlikely in college age women that HPV turns out to be malignant.

A colposcopy enables the operator to examine the surface of the cervix under magnification. Biopsies can be taken and if the labs show suspicious cells, it’s a simple matter to remove the offending tissue by freezing, burning or cutting off or a combination of these.

So here’s the thing about HPV: you can treat the symptoms but rarely get rid of the virus. The good news is that the lesions and warts can be eliminated. For many people, the virus is cleared from the body by itself! For others, viral particles remain in a latent form after treatment. However, (more good news), it is doubtful that simple presence of latent viral particles can result in transmission.

It is not possible to predict how long treatment will be needed. In some, two or three ‘shots’ of cryo-therapy suffices, while in others the warts just go on and on. Approximately 25% of cases return within 3 months.

However, in this particular lottery, everyone is a winner. Warts always eventually go away!

Here’s some really technical stuff about HPV treatment. Your doctor might use one or more of these procedures to remove the warts:

• LEEP (loop electrosurgical excision procedure): uses a metal prong, which literally burns the wart away.
• Freezing (cryotherapy) with liquid nitrogen: most commonly used. A jet of liquid nitrogen freezes the wart until it turns white. This is repeated at weekly intervals until the warts are gone. Freezing destroys the skin cell in which the virus resides. The cell dies; the virus dies. There are two theories to freezing warts: one freezes the wart and a small area around it, whereas the other limits the white frozen area to the wart.
• Aldara is a topical cream which is very effective.
• Laser is useful when there are many warts.
• Liquid N, TCA/BCA (tri and bichloracetic acid), and interferon: burns away the wart.
• Podophyllin: a plant extract, stops cells dividing, which means that the virus dies out. It has been replaced by podophyllotoxin. This is the first home treatment. It’s easy for the patient to apply as a cream or lotion – three times weekly, for 4 weeks.
• Imiquimod: an immune modulator is applied 3x a week, for 4 weeks (can be up to 16 weeks).
• 5-flouorocytosine is useful for warts that are difficult to reach, for example inside the urethra in the male.
• Proctoscopy: passing a metal cylinder through the anus to get at the warts. Not highly effective.

Yes, high-risk types of genital HPV can cause cancer of the cervix, vagina, vulva, anus, penis, and throat. The type of cancer HPV causes most often is cervical cancer.

Up to 50% of sexually active women develop HPV on their cervix. But as already stated, infection persists in up to only 10%. Perhaps 1 in five of those will need further treatment to prevent development of cancer.

Most HPV infections go away by themselves and don’t cause cancer. But abnormal cells can develop when high-risk types of HPV don’t go away. If these abnormal cells are not detected and treated, they can lead to cancer.

Most of us recover from HPV infections with no health problems at all. It is not fully known why some people develop long-term HPV infection, precancerous abnormal cell changes, or cancer. But we do know that women who have diseases that make it difficult for them to fight infections are at higher risk of cervical cancer. We also know that cigarette smoking increases the risk of cervical cancer.

There are two vaccines that have been shown to stop infection.

Although the vaccines were primarily designed to reduce the risk of cervical cancer in women, they also reduce the likelihood of genital warts in general and have some effect even on those already infected.

<b>Gardasil</b> protects against HPV type-16 and 18, and as we learned earlier, those are the high-risk strains, which cause 70% of cases of cervical cancer. It also protects against HPV types-6 and 11, the low-risk strains, which cause 90% of cases of genital warts.

<b>Cervarix</b> is another type of HPV vaccine that protects only against HPV types-16 and 18, the high-risk strains.

A patient’s prior exposure to HPV and age are two very important things to consider before s/he receives three doses of the vaccine. Unfortunately, Gardasil does not cure HPV. Gardasil does not work for a person who has already been exposed to the strains of the virus in the vaccine. As far as age goes, the vaccine is recommended for women and men between the ages of 9 and 26. Vaccinating a person before his or her first sexual encounter is thought to be most effective, although the vaccine can also be administered to someone who is sexually active.

If you choose to get the Gardasil vaccine, it is recommended that you have someone with you as you leave. It has been found that some people faint 20 minutes after the shot.

There are at least 120 types of HPVs. Below is a list of HPV virus types and what signs and symptoms or diseases they are linked to:

• 2, 7 – Common warts. Rough, raised bumps that generally affect the fingers, hands and around the nails. In the majority of cases their only problem is their appearance; however, they may sometimes bleed. Some patients may experience pain, but this is unusual.
• 1, 2, 4, 63 – Plantar warts. Small lesions that appear on the soles of the feet; they usually look like a cauliflower, with very small hemorrhages (petechiae) under the skin. When scratched they may bleed. Patients may feel pain when walking or standing. They can be similar to corns or calluses.
• 3, 10, 8 – Flat warts. Slightly raised, flat-topped lesions, which are darker than the skin around them. They may appear on the knees, elbows, wrists, hands, neck or face. Young adults, teenagers and younger children are usually affected.
• 6, 11, 42, 44 and some others – Anogenital warts. Small, flat cauliflower-like bumps, some may have stem-like protrusions. In females, the warts will usually appear on the vulva, but may also be found in the vagina, on the cervix, and near the anus. In males, they may appear on the penis, around the anus, and on the scrotum. They are rarely painful and do not typically cause discomfort.
• 6, 16, 18, 31, 53, 58 – Anal lesions
• Genital cancers

- 16, 18, 31, 45 are the highest risk
- 33, 35, 39, 51, 52, 56, 58, 59 are high or medium-risk
- 26, 53, 66, 68, 73, 82 – are probably high-risk
• 6, 7, 11, 16, 32 – Oral papillomas
• 16 – Oropharyngeal cancer
• 6,11 – Laryngeal papillomatosis
  

All sorts of lumps or bumps in the genital area get mistaken for warts and there are six other diagnoses that regularly cause confusion.Sebaceous cysts are pockets of secretion from sebaceous glands in the skin and occur almost anywhere. They vary in size from a small ballbearing to a billiard ball or larger.Folliculitis is literally an inflammation of a hair follicle. Any bit of skin that has hair follicles can develop folliculitis, which when infected becomes a boil.Skin tags are little extra bits of skin near the entrance to the vagina or around the anus.Molluscum contagiosum is sometimes mistaken for HPV.

Fordyce tubercles or ‘pearly papules’ appear as a ring of small, whitish bumps less than a millimeter across, encircling the glans penis just where it joins the shaft. They are normal variations but are often misdiagnosed as warts.

Vulval papillosis, a woman’s equivalent to Fordyce tubercles, are little fleshy bumps, also smaller than 1 mm across on the inside of the labia. Both vulval papillosis and Fordyce tubercles will not go away if subjected to anti-wart treatment.Any condition that can cause lumps or bumps on the skin will be confused with warts.

However, the conditions described above will account for 95% of the “warts” that turn out not to be warts.

In pregnancy, the immune system becomes less aggressive so as not to harm the unborn child, allowing warts to surface. Those who know they’ve had warts in the past and those with latent HPV infection may develop warts when they become pregnant. The good news is that the warts tend to regress, even without treatment, after the baby is born.The anogenital HPV types are usually confined to the nether regions. Very rarely, a mother with genital infection can pass this on during birth leading to laryngeal warts in her child.

Because HPV is so common and such a popular topic these days, there are a lot of key points to remember:

• Most HPV infections have no harmful effect at all.
• Most HPV cures itself without any medical intervention.
• There are more than 120 types, half of which cause genital warts.
• Approximately 3 out of 4 people will get them after having any kind of genital contact with someone who is infected.
• While there are 40 types of HPV that affect the genital area, some are low risk and some are high risk that cause most of the HPV-related diseases.
• Low risk strains are types-6 and 11 and cause about 90% of genital wart cases in males and females.
• High risk strains are types-16 and 18 and cause about 75% of cervical cancer cases, 70% of vaginal cancer cases, and up to 50% of vulvar cancer cases in females.
• If you have HPV, you should not be ashamed or afraid. Most people who have had sex have HPV at some point in their lives. And most infections go away on their own.
• The warts are actually (and properly) called ano-genital warts because they favor the back as well as the front. Warts can occur around the anus in both sexes without anal intercourse.
• It is the most common STI in the US.
• More than 5 million people are infected with it each year. 20 million people are currently living with it.
• The highest rates of genital HPV infections are found in adults between the ages of 18 to 28.
• Up to 80% of women will have been infected by the age of 25.
• At least 80% of sexually active women have been infected.
• Less than 5% of women aged 50 or older are still infected.
• HPV may be less common in young men but will infect well over 50%.
• Most of these men and women are unaware and unless they develop actual warts, will go their graves unaffected and oblivious.
• By the age of 50, only a small number, less than 5%, still carry the virus, unless they are still having many sexual partners. This statistic tells us that we eradicate it ourselves eventually.
• You cannot catch genital warts from towels or sheets.
• Keep in mind that a healthy immune system is usually able to clear the HPV virus, or at least suppress it, over time.
• Most men who contract HPV (of any type) never develop any symptoms or health problems.
• Unfortunately, there are no blood tests clinically available to diagnose a person for HPV prior to vaccination. Most of the time, patients are diagnosed when visible genital warts appear.
  

• Go Ask Alice! –
  Genital Warts, HPV, & Condyloma
• Gardasil – What is HPV?
• Planned Parenthood – Human Papillomavirus (HPV)
• WebMD – HPV/Genital Warts Health Center
• David Barstow – “Sexually Transmitted Infections (The Facts)”
• TeensHealth – Genital Warts
• What Is HPV (Human Papilloma Virus)?

DISCLAIMER: The information contained in this post is intended to inform readers and is not intended to replace specific advice from a health care professional.