HPV Infection and Treatment Quiz

HPV Infections

• HPV infections are common mucocutaneous conditions.
• HPV causes proliferative diseases of keratinocytes.
• Cutaneous warts are common in children and adolescents; they do not typically degenerate.
• Genital warts (condylomas) are sexually transmitted diseases caused by HPV.
• Genital warts can lead to cervical cancer in adults.
• There is no specific antiviral treatment for HPV.

Course Plan

• The course covers introduction, pathogenesis (pathogen and transmission), epidemiology, diagnosis (clinical forms, differential diagnosis, intraepithelial neoplasms, and paraclinical), treatment and prophylaxis, and conclusion.

Learning Objectives

• Recognize cutaneous wart lesions.
• Recognize genital wart lesions.
• Understand treatment of lesions based on the global approach for sexually transmitted diseases.

Introduction

• HPV infections are common mucocutaneous conditions, causing proliferative diseases in keratinocytes.
• Cutaneous warts (or condylomas) are common in children and adolescents, but do not typically result in degeneration (not cancerous).
• Genital warts, caused by the human papillomavirus, can cause cervical cancer in adults.

Pathogenesis: Pathogen and Transmission

• HPV is a small circular, double-stranded DNA virus.
• HPV does not have an envelope; it is resistant and has a particular tropism for skin and squamous mucosa.
• HPV infection leads to the replication and transcription of viral genes.
• HPV can cause immune evasion, regulation of p53, and regulation of Rb.

Virology

• HPV virus has a unique structure with a capsid. HPV exists as double-stranded DNA virus.
• HPV does not have an envelope, making it resistant to environmental factors.
• HPV has specific tissue tropism; it preferentially infects skin and squamous mucosa.

Genotypes

• Over 200 genotypes of HPV have been identified.
• HPVs are categorized as high or low risk for carcinogenesis (cancer development).
• Genotypes 1, 2, 3, and 4 are associated with cutaneous warts.
• Genotypes 6, 11, 42, 43, and 44 are associated with condylomas acuminata (low-risk).
• Genotypes 16 and 18 are associated with high-risk condylomas causing cervical dysplasia, cervical cancer.

Transmission

• Warts: Transmission can be direct through minimal skin abrasions or indirect via contaminated surfaces. Self-inoculation also spreads lesions.
• Condylomas: Transmission occurs primarily sexually and vertically (mother-to-child). Self-inoculation further spreads lesions.

Microtrauma and Viral Life Cycle

• Microtrauma allows for penetration of the virus into basal cells.
• Viral DNA enters the nucleus, initiating a latent period.
• Replication of the virus occurs in superficial layers, potentially leading to visible lesions.
• HPV life cycle closely links to the proliferation and differentiation of epithelial cells.

Epidemiology

• Prevalence of viral warts is around 7-12%.
• Cutaneous warts are common in children and young adults, often transmitted via microtrauma in swimming pools or fitness clubs.
• High-risk professions (butchers, veterinarians, fishmongers) have a higher prevalence of hand warts (often caused by HPV7).
• Genital warts (condylomas) are increasingly common in developed countries.
• Sexual transmission is the primary mode in young adults, while child sexual abuse can also be a factor.
• HPV infections can contribute to cervical intraepithelial neoplasia (CIN) and cervical cancer.
• Immunocompromised patients (organ transplant recipients, HIV, and immunosuppressant users) experience more frequent and aggressive HPV infections, with an increased risk of degeneration.

Clinical Diagnosis: Skin Lesions

• Common warts: Cauliflower-like, rough, papillomatous, hyperkeratotic, ranging from 1 mm to 1 cm or more. Common on the dorsal surface of hands and fingers, sometimes around fingernails.
• Common Flat Warts: Small, yellow to skin-colored papules with a smooth or finely pitted surface; commonly found on the back of the hands and limbs and may spontaneously regress.
• Filiform Warts: Clusters of fine fronds growing from a narrow base; typically found on the face.
• Palmar-Plantar Warts (Myrmecia): Deep (endophytic) wart, painful on pressure. Characterized by a thick keratotic rim surrounded by yellow hyperkeratotic skin, with breaks in skin markings. Often spotted with black dots (microhemorrhages).
• Mosaic Warts: Less common, superficially growing, non-painful flat warts; often found in grouped patches, characterized by a large keratotic patch with multiple warts.

Clinical Diagnosis: Mucosal Lesions (Condylomas)

• Condyloma Acuminata: Skin-colored, fleshy, or grayish spots or papules, frequently coalescing into a cauliflower-like shape. Asymptomatic in men. In women, potential for itching, discomfort, increased vaginal discharge, and bleeding. Common genital area.
• Flat Condylomas: Isolated macules (flat spots) that potentially coalesce and may be difficult to detect without acetic acid application to make them more visible (white color). Requires close follow-up including cytologic smears and potential biopsy for accurate diagnosis.
• Papular Condylomas: Pinkish or pigmented papules that may be smooth or have a slightly rough keratotic surface; often isolated or coalesced. Differentiated using acetic acid and inspection.
• In both genders, examination can detect possible anorectal extension, indicating the need for proctological examination.

Early Diagnosis

• Dermoscopy aids in early diagnosis.
• Atypical skin lesions warrant pathological examination and HPV genotype testing.
• Acetic acid application (3-5%) aids in detecting early genital warts.

Special Clinical Forms

• Giant Buschke-Loewenstein condylomas are giant wart proliferations in the anogenital area. They can invade locally and transform into squamous cell carcinoma.

HPV Infections in Immunocompromised Patients

• Immunocompromised individuals (e.g., organ transplant recipients, HIV-positive patients, those on immunosuppressants) experience more frequent, severe, and potentially cancerous HPV infections. These infections are often profuse (large quantity).

Treatment and Prophylaxis

• No specific antiviral treatment for HPV infections exists.
• Treatment focuses on eliminating visible lesions.
• Recurrence is possible (approximately 30%).
• The virus persists in healthy epidermis after lesion removal.

Local Medical Treatments

• Keratolytic acids like TCA and salicylic acid are used to destroy lesions.
• Cryotherapy (liquid nitrogen) is a physical method for lesion destruction.
• Chemical destruction uses agents like podophyllotoxin, imiquimod, and 5-fluorouracil. Electrocoagulation is a surgical technique.

Preventive Treatment

• Vaccination (e.g., Gardasil) is a preventive approach against HPV infection by stimulating immunity for HPV infection.
• Gardasil is highly immunogenic, producing high levels of antibodies, and shows significant effectiveness even with a 5-year follow-up.

HPV Vaccination Schedule (Morocco)

• HPV vaccination is integrated into the national vaccination program in Morocco for girls aged 11.

Conclusion

• HPV infections are frequent public health concerns.
• Diagnosis is often straightforward with simple clinical examination.
• Spontaneous regression is possible; however, recurrence and potential degeneration, especially with certain HPV types (16 and 18), remain concerns.
• Cervico-vaginal smears are crucial for screening.
• Vaccination is a critical preventive measure.

Test your knowledge on human papillomavirus (HPV) infections, treatments, and vaccination strategies. This quiz covers important aspects such as risk of recurrence, transmission, and HPV types associated with warts and degeneration. Perfect for health professionals and students interested in infectious diseases.