Introduction

• Human papillomavirus (HPV) DNA typing has

demonstrated over 90 genotypes, of which HPV-
6, HPV-11, HPV-16 and HPV-18 most commonly
infect the genital tract through sexual
transmission.
• Benign genotypes (HPV-6 and 11) that cause
anogenital warts.
• Genotypes such as 16 and 18 that are associated
with dysplastic conditions and cancers of the
genital tract.
 Viral warts
• Transmission is by direct virus contact, in living or
shed skin, and is encouraged by trauma and
moisture (e.g. swimming pools).
• Genital warts are spread by sexual activity and
show a clear relationship with cervical and intra-
epithelial cancers of the genital area.
• HPV-16 and 18 appear to inactivate tumour
suppressor gene pathways  SCC of the cervix or
intra-epithelial carcinoma of the genital skin.
• Common warts are initially smooth, skin-coloured
papules, which become hyperkeratotic and ‘warty’.
• They are most common on the hands but can occur on
the face, genitalia and limbs, and are often multiple.
• Plantar warts (verrucae) have a slightly protruding
rough surface and horny rim and are often painful on
walking.
• Paring reveals capillary loops that distinguish plantar
warts from corns.
• Other varieties of wart include:
• • mosaic warts: mosaic-like sheets of warts
• • plane warts: smooth, flat-topped papules,
usually on
• the face and backs of hands; they may be
• pigmented and therefore misdiagnosed
• • facial warts: often filiform
• • genital warts: may be papillomatous and
exuberant.
 Management
• Most viral warts resolve spontaneously, although this may take
years and active treatment is therefore often sought.
• Treatments are destructive. Salicylic acid or salicylic/ lactic acid
combinations and regular wart paring for several months is the first
approach.
• Cryotherapy is usually the next step and is repeated 2–4-weekly.
• However, caution is required, particularly on the hands, as over-
vigorous cryotherapy can lead to scarring, nail dystrophy and even
tendon rupture.
• Periungual and subungual warts can be problematic, and nail
cutting and electrodessication may help.
• Several other therapies have been used for recalcitrant warts,
including systemic retinoids, intralesional bleomycin or interferon
injections, and contact sensitisation with, for example,
diphencyprone.
• Imiquimod and PDT may also be beneficial, particularly for multiple
warts in immunosuppressed patients.
 Anogenital warts
• Anogenital warts caused by HPV may be single or
multiple, exophytic, papular or flat.
• Perianal warts, whilst being more commonly found
in MSM, are also found in heterosexual men and in
women.
• In pregnancy, warts may dramatically increase in size
and number, making treatment difficult.
• C-section is required if it is large enough to
obstruct labor.
 Management
• The use of condoms can help prevent the transmission of HPV to non-infected
partners, but HPV may affect parts of the genital area not protected by
condoms.
• A variety of treatments are available for established disease, including the
following:
 Podophyllotoxin, 0.5% solution or 0.15% cream (contraindicated in
pregnancy), applied twice daily for 3 days, followed by 4 days’ rest, for up to
4 weeks is suitable for home treatment of external warts.
 Imiquimod cream (contraindicated in pregnancy), applied 3 times weekly
(and washed off after 6–10 hours) for up to 16 weeks, is also suitable for
home treatment of external warts.
 Cryotherapy using liquid nitrogen to freeze warty tissue is suitable for
external and internal warts but often requires repeated clinic visits.
 Hyfrecation – electrofulguration that causes superficial charring – is suitable
for external and internal warts. Hyfrecation results in smoke plume which
contains HPV DNA and has the potential to cause respiratory infection in the
operator/patient. Masks should be worn during the procedure and adequate
extraction of fumes should be provided.
 Surgical removal. Refractory warts, especially pedunculated perianal lesions,
may be excised under local or general anaesthesia.
Cervix carcinoma
 Screening
• In Malaysia, all women who are, or who have been
sexually active, between the ages of 20 and 65 years,
are recommended to undergo Pap smear testing. If
the first two consecutive Pap results are negative,
screening every three years is recommended.
 Diagnosis
• The diagnosis of micro-invasive cervical cancer
should be based on histological examination
of removed tissue, preferably a cone that
includes the entire lesion of the cervix
colposcopic directed biopsy of suspicious
lesions is preferred histological confirm of
cervical cancer is mandatory.
 Investigation for invasive cervical CA
• Once invasive cervical cancer is diagnosed, the
following investigations are recommended: ·
 Blood tests - Full blood count ,Liver function test ,
Renal profile
 Imaging - Intravenous urography (IVU) , Chest X-
ray
• CT scan is desirable especially for stages III and IV,
as it may reveal paraortic nodes, as well as the size
of the primary tumour. Patients who have had a CT
scan need not have an IVU. MRI of the pelvis is
preferable, but may not be always practical in our
context.
Management for abnormal
cervical smear
HPV vaccination
• There are two types of vaccine:
 A bivalent vaccine (Cervarix) offers protection against
HPV types 16 and 18, which account for approximately
75% of cervical cancers in the UK.
 A quadrivalent vaccine (Gardasil) offers additional
protection against HPV types 6 and 11, which account
for over 90% of genital warts.
• Both types of vaccine have been shown to be highly
effective in the prevention of cervical intra-epithelial
neoplasia in young women, and the quadrivalent
vaccine has also been shown to be highly effective in
protecting against HPV-associated genital warts
 References
• CPG malaysia : MANAGEMENT OF CERVICAL
CANCER
• Davidson priciple & practice of medicine