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Chapter 142: Human Papillomavirus

Susuana Adjei; Austinn C. Miller; Stephen K. Tyring

HUMAN PAPILLOMAVIRUS

Therapeutic Approach

Human papillomavirus (HPV) is a common human infection spread by skin-to-skin contact, especially through sexual activity. HPV infections clinically manifest as warts referred to as verrucae and are further characterized based on location and morphology, namely verruca vulgaris, verruca plantaris, verruca plana, verruca filiformis, and condyloma acuminata. Although mainly benign, HPV-infected lesions can transform into malignant neoplasms after persistent infection or infection with the more oncogenic strains (ie, HPV 16, 18, 31, 33). There is no definitive treatment for HPV warts and therapy is aimed at clearance of lesions through various means. No single treatment is superior, but salicylic acid or cryotherapy are common initial choices; other treatments, such as topical/intralesional immunotherapy/chemotherapy, lasers, surgical excision, tend to be reserved for refractory cases. See Table 142-1.

Table 142-1HPV Treatment Table
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Table 142-1 HPV Treatment Table
MEDICATION NAME INDICATIONb MECHANISM OF ACTION DOSING ADVERSE EVENTS SUGGESTED MONITORING LEVEL OF EVIDENCE
Topical Therapy      
Salicylic acid VV; VPt; VPl Keratolytic; destroys epidermal HPV-infected cells Liquid or pad application; 17%-40% concentration; apply daily for up to 12 wk Irritation; exfoliation None IA1-3
Imiquimoda VV; CA Stimulates immune response 3.75%-5% cream; apply thin layer at bedtime until clearance Erythema, pruritus, pain None IB4-5
Trichloroacetic acid VV; CA Caustic; cell death 40%-90% solution; pare and apply; can be repeated weekly Pain, ulceration None IIA6-10
5-fluorouracil VV; CA Affects DNA synthesis; leads to cell death 1%-5% cream/gel applied to lesion BID Erythema; scarring; hyperpigmentation None IB11-14
Cidofovir CA; VPt; VV Inhibits viral replication; apoptosis 1%-3% gel applied 1-2 times daily Pain, ulceration, irritation; could worsen those with renal insufficiency None IB15-17
Podophyllotoxin VV; CA Causes wart necrosis Apply cream/gel BID for 3 d, then stop for 4 d to assess efficacy. Can repeat cycle if lesion not cleared Erosion, burning, pruritus; neurotoxicity None IB18-21
Cantharidin VV Blistering; destroys epidermis Apply 0.7% solution under occlusion Tingling of skin None IIA22
Potassium hydroxide CA; VPl keratolytic 5%-10% KOH solution; use daily Pain; mild erosion None IB23
Squaric acid dibutylester VV; VPl; VPt Contact allergen; sensitization, then repeated exposure Initial application of 1%-3% of SADBE in acetone, then weekly diluted application of 0.1%-0.3% till resolution Erythema, pruritus, blistering None IB24
Intralesional Therapy      
Intralesional immunotherapy (Candida, MMR vaccine, PPD, interferon) VV; CA T-cell-mediated immune response 0.3 mL intradermal injection every 2 wk after positive presensitization Injection site reaction; vitiligo at injection site; scarring; lymphangitis None IB25-27
Bleomycin VV Cytotoxic 1 mg/mL site injection; may repeat after 2 wk if not cleared Extensive tissue necrosis; pain; scarring None IB28-30
Cidofovir CA; VPt; VV Inhibits viral replication; apoptosis 15 mg/mL at 0.1 mL/wart injections monthly Injection site reaction; could worsen those with renal insufficiency None IB31
Acyclovir VV; VPt Inhibits viral replication 70 mg/mL biweekly Injection site ...

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