Medical Care: A variety of medical treatments exists for condyloma acuminata, and no single treatment regimen is superior.
The treatment strategy is to eliminate as many of the visible lesions as possible until the host immune system can control viral replication.
Because most HPV infections spontaneously regress when the immune system controls viral replication, the need to treat subclinical or mild disease is controversial.
Treatment is usually reserved for patients with visible vulvar condyloma.
The type of treatment is influenced by previous therapies, sexual behavior, immune status, and the patient's willingness to comply with therapy.
Development of a therapeutic vaccine against HPV is currently being investigated. Two published trials demonstrated either a clinical complete response or a clinical partial response in women with vulvar or vaginal dysplasia (Davidson, 2003; Baldwin, 2003).
Patients who are HIV positive or immunosuppressed due to immunosuppressive drugs usually require more than one treatment method. Often, the condyloma in these patients is refractory to therapy.
Regardless of the mode of therapy chosen, recurrence rates are high for any patient with condyloma acuminata. This can result in a high level of frustration for the patient and the physician.
For most patients, medical therapy should be the first option. These different medical treatment modalities can by performed in the physician's office or at home. Morbidity is low. Surgery should be reserved to treat condyloma resistant to medical therapy. Most patients should not need surgical therapy unless the condylomatous lesions are too large to treat medically or if the lesions would interfere with an abdominal delivery.
Surgical Care: Surgical treatment of condyloma acuminata is usually reserved for patients in whom local therapy has failed. Several options are available, including local excision, laser therapy, cryotherapy, and electrosurgical excision.
Simple excision
Simple excision is usually performed in an outpatient surgical suite.
After general or regional anesthesia is administered, the individual lesions are removed with a knife.
This procedure is reserved for refractory cases or extensive disease.
Reports in the literature indicate that within one year of surgery, complete wart clearance occurs in 35-72% of individuals treated with surgical excision. One report found surgical excision as effective as laser surgery (Duus, 1985).
Patients with a few small lesions can have vulvar condyloma removed in the office. The underlying skin should be anesthetized with 1% Xylocaine and the condyloma removed with a #15 knife blade. One or 2 sutures may be needed to reapproximate the healthy skin.
Carbon-dioxide laser therapy (Duus, 1985; Reid, 1992)
Laser treatment of vulvar condyloma acuminata effectively destroys the condyloma while sparing adjacent healthy tissue.
This procedure is performed in outpatient surgery with general or regional anesthesia.
The amount of energy needed to remove a condylomatous lesion with the laser depends on parameters controlled by the surgeon. These parameters include the setting of the machine in watts, the length of time the beam is fired, and the spot size on the tissue. Some researchers calculate the power density, which equals the power (watts)/area (cm2). No exact power density is needed to remove vulvar or vaginal condyloma. The surgeon needs to be flexible in the application of the laser for each patient. If the laser is calibrated to 20 watts, continuous mode, the spot size can be adjusted easily to provide the proper power density (Lipow, 1986).
Most patients experience significant discomfort beginning 24 hours after surgery and require narcotic analgesia.
Laser therapy should be reserved for recalcitrant cases of condyloma or extensive disease.
Complete wart clearance after laser surgery has been reported to occur in 23-52% of patients within 3 years of surgery.
The recurrence rates are similar to surgical excision.
Electrosurgery (Simmons, 1981)
For isolated lesions unresponsive to topical therapy, electrosurgical techniques can be performed in the office with local anesthesia.
The most popular method is to use a loop electrode that removes the lesion or lesions.
Pain after surgery is common and can be treated with narcotic analgesics. Topical analgesics, such as lidocaine jelly, can be beneficial to some patients.
A recurrence rate in one trial was 22% compared with 44% for podophyllin resin.
Cryotherapy (Godley, 1987)
Cryotherapy should be limited to small lesions that can be treated with small cryoprobes.
Data from several clinical trials report a 63-88% clearance 3 months after therapy.
The recurrence rate of 22% is similar to electrosurgery.
This therapy is safe to use in pregnancy.
The primary drawbacks are discomfort, ulceration, or scabbing at the treatment site.
Activity:
The patient should refrain from sexual contact after any surgical procedure for condyloma acuminata.
Soaking the genital area in warm water or sitz baths usually offers excellent pain relief.
The genital area should be dried gently with a towel or a hair dryer.
Loose fitting cotton underwear is helpful to avoid chafing.
No other activity restrictions exist, although patients often have trouble sitting for long periods of time in the first week after surgery.
Patients who have condyloma removed from the periurethral area may experience dysuria. Sitz baths and topical analgesics are beneficial.
DRUG TREATMENT : No one curative treatment exists for condyloma acuminata (Auborn, 2000). Simple topical therapies are the initial treatments of choice for most patients. They are cost effective and result in minimal toxicities. Most result in a 30-90% success rate in eliminating visible condyloma. Many clinical studies using topical therapies are not well designed, making comparisons between therapies difficult.
1.ANTIMITOTICS : Arrests dividing cells in mitosis, resulting in death of proliferating cells.
- PODOPHYLLIN
- PODOFILOX
2. ANTINEOPLASTIC AGENTS : Topical preparation containing the fluorinated pyrimidine, 5-fluorouracil. Antineoplastic and antimetabolite agent
- FLUOROURACIL
3. DESICCANTS :These are acids that are most effective when applied to moist warts. They are nontoxic and can be used in pregnancy.
- TRICHLOROACETIC ACID
4. IMMUNE RESPONSE MODIFIERS: Stimulates production of cytokines and has demonstrated strong antiviral activity.
- IMIQUIMOD
- INTERFERON ALPHA 2B
5. MISCELLANEOUS TOPICAL OINTMENTS :
- KUNECATECHINS
6. VACCINES : A human papillomavirus (HPV) vaccine is now available for prevention of HPV-associated dysplasias and neoplasias, including cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions. The immunization series should be completed in girls and young women aged 9-26 years.
- PAPILLOMAVIRUS VACCINE ( GARDASIL )