Human Papilloma Virus (HPV) and Molloscum Contagiosum
The following page outlines commonly asked questions about HPV, HPV vaccination, genital warts and treatment options.
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About HPV
What is HPV?
Human Papillomavirus (HPV) infections are the most common sexually transmitted infections. Most infections occur without symptoms and resolve without treatment. Most Canadians will have an asymptomatic HPV infection at some time. There are more than 200 strains of the HPV virus. Most HPV infections, including those that cause cancer, typically resolve within 12 months. HPV can cause anogenital warts. HPV infection is related to 80-90% of anal cancers, 40% of vaginal and vulvar cancer, 40-50% of penile cancers, and 25-35% of mouth and throat cancers. Most of these cancers are related to high-Risk HPV types 16 and 18.
How is HPV transmitted?
HPV infections occur through sexual contact (skin to skin, or mucosa to skin). Exposure can also occur to offspring through maternal genital contact at the time of a vaginal delivery.
Can I get HPV if I use a condom?
Yes. HPV is transmitted from genital skin/skin contact, so the use of a condom can reduce the likelihood of transmission but does not protect against all contact and therefore does not fully prevent HPV transmission.
What are risk factors for getting HPV?
Risk factors include:
Having a previous STI
Having intercourse at an earlier age
Having a higher number of lifetime sex partners
Using tobacco or marijuana
Being on an immunosuppressant or having an immune-suppressing medical condition
HIV infection
Can I get HPV from oral sex?
Unprotected oral sex is a risk factor for acquiring HPV. Many people will be exposed to oral HPV, with 10% of men and 3.6% of women having oral HPV. Most people clear HPV within a couple of years, but others can have a persistent infection. HPV can affect the oropharynx (back of throat including tongue and tonsils). Approximately 70% of oropharyngeal cancers are caused by HPV.
What are ways to lower my risk of getting HPV?
Condom usage and dental dams can lower the chance that HPV is passed from one person to another.
What is my likelihood of having an HPV infection in my lifetime?
Studies estimate a 75% risk of having an HPV infection once in your lifetime.
How is sexual behaviour related to HPV infection?
Sexual behavior is the main determinant of HPV infection. The risk increases with the acquisition of a new sexual partner, a higher number of recent or lifetime sexual partners, and commencing sexual activity itself.
What are High Risk (HR) and Low Risk (LR) subtypes?
High-risk subtypes of HPV are the types that are most commonly associated with the development of pre-cancerous or cancerous changes. Examples of HR types include type 16 and type 18, which are protected for by the Gardasil 9 Vaccine.
By contrast, Low Risk (LR) subtypes such as type 6 and 11 can have low or no cancer risk, but can lead to precancerous cervical changes in women.
How long do HPV infections last?
The overall time to clearance of both high-risk (HR) and low-risk (LR) types of HPV may be similar for women and men, with an average of 8 months for women and 7.5 months for men. Some strains, particularly HR types like HPV 16, may persist longer, especially in women.
Genital Warts
What are genital warts, and what causes them?
Genital warts are small, skin-coloured growths that appear in the genital or anal area. They're caused by certain types of human papillomavirus (HPV). The virus infects the top layer of the skin, causing warts to develop. Not everyone infected with HPV will develop genital warts, as the body's immune system often clears the virus on its own. However, in some cases, the virus can persist and cause warts to form.
How are genital warts transmitted? Can I get them even if my partner doesn't show any symptoms?
Genital warts are transmitted through sexual contact, including vaginal, anal, and oral sex. Even if a partner doesn't have visible warts, they can still carry and transmit the HPV virus responsible for causing genital warts. Using protection like condoms can reduce the risk of transmission, but they don’t eliminate the risk entirely, as HPV can infect areas not covered by a condom.
How do I know if I have genital warts? What are the typical signs and symptoms?
Genital warts can appear as small bumps or clusters that may be smooth or rough, flat or raised. They often don't cause any discomfort, but some people might experience itching, burning, or tenderness. The warts can develop anywhere in the genital area, including the vulva, vagina, cervix, penis, scrotum, anus, or thighs. A healthcare provider can usually diagnose genital warts through a physical examination. If necessary, additional tests may be performed to confirm the diagnosis.
Are genital warts dangerous or cancerous? What are the long-term implications of having them?
Genital warts themselves are generally not cancerous, but they are caused by HPV, some types of which are linked to cancers such as cervical cancer. The types of HPV that cause genital warts are typically not the same as those that can lead to cancer. Having genital warts does not necessarily mean that you will develop cancer. However, regular screenings and preventive measures, such as HPV vaccinations, are essential to reduce risks associated with HPV.
How are genital warts diagnosed? Will I need any specific tests?
Genital warts are usually diagnosed through a visual examination by a healthcare provider. Women might be offered a Pap smear if due (done every 3 years in Ontario), which can detect changes in the cervix that might be related to HPV infection, including the types that may lead to cancer. Unfortunately, there is no HPV test performed on visible warts to determine the serotype at this time.
What are the treatment options for genital warts? Can they be permanently removed?
Treatment options for genital warts include topical treatments like creams or gels, cryotherapy (freezing the warts), laser therapy, and surgical removal. The choice of treatment depends on the size, location, and number of warts. While these treatments can remove the visible warts, they may not eliminate the HPV virus from the body, so warts can recur. There is no cure for HPV, but the body's immune system often clears the infection over time, and the HPV vaccines can protect against the most common strains that cause warts.
Is it possible to prevent genital warts? What precautions can I take?
Genital warts can be prevented by practicing safe sex, such as using condoms, though condoms may not cover all affected areas. Getting vaccinated against HPV is an effective way to prevent the types of HPV most commonly associated with genital warts. Regular screenings and open communication with sexual partners about sexual health can also reduce the risk.
Can genital warts recur after treatment? What are the recurrence rates, and how can I minimize the risk of recurrence?
Yes, genital warts can recur after treatment. Recurrence rates vary, ranging from 20% to 30% within the first three months after treatment. This recurrence is often due to the HPV virus remaining in the body.
How common is clearance and recurrence of anogenital warts?
Anogenital warts may spontaneously clear in 10%-30% of cases over three months, with a median time to clearance of six months. However, recurrence is common. It can be due to re-activation of latent or undetectable virus, or re-infection.
Is it required (by law) to notify a partner about an HPV infection?
Infection with HPV is not classified as a notifiable condition, so there is no legal requirement to notify a partner. However, partner notification can be beneficial in encouraging risk-reduction practices. For individuals with AGWs, it may be helpful to discuss preventive measures with new partners. These measures can include immunization against HPV, consistent use of male condoms, regular screening for HPV and other sexually transmitted infections, and self-examination. The goal of these discussions is to promote understanding and encourage behaviours that reduce the risk of transmission and complications.
HPV Vaccination
What is Gardasil 9, and what is it used for?
Gardasil 9 is a vaccine designed to protect against nine types of human papillomavirus (HPV), which is responsible for certain cancers and other diseases. HPV can cause cervical, vulvar, vaginal, and anal cancers, as well as genital warts. Gardasil 9 works by stimulating the body's immune system to fight the virus, reducing the risk of developing these conditions. It's commonly administered to both males and females and is especially recommended for preteens and teenagers.
How is Gardasil 9 different from previous versions of the Gardasil vaccine?
Gardasil 9 is the latest version of the Gardasil vaccine, providing protection against nine strains of HPV. Earlier versions protected against fewer strains. The original Gardasil protected against four HPV types, while Gardasil 9 covers five additional types. This expansion makes Gardasil 9 more comprehensive in preventing HPV-related conditions.
Who should receive the Gardasil 9 vaccine?
Gardasil 9 is typically recommended for boys and girls aged 9 to 26. It's especially encouraged for preteens to receive the vaccine before potential exposure to HPV. People within this age range, including those who are sexually active, can benefit from the protection the vaccine offers against HPV-related cancers and diseases.
Are there any age restrictions for receiving Gardasil 9?
Yes, Gardasil 9 is primarily recommended for individuals between the ages of 9 and 45. The vaccine is most effective when given to preteens and teenagers, ideally before they become sexually active. For those in the age group of 9 to 26, the vaccine provides protection against various HPV-related conditions, including certain cancers. Adults between the ages of 27 and 45 may also receive the vaccine after discussing their individual risks and benefits with a healthcare provider. The effectiveness of the vaccine might vary based on the individual's age and potential prior exposure to HPV.
Is Gardasil 9 recommended for individuals over the age of 45?
For individuals over the age of 45, the use of Gardasil 9 is considered "off-label." This means that while the vaccine is not formally approved for this age group, we can provide a prescription based on your risk factors and medical history. The effectiveness of the vaccine in this age group may be less certain as it hasn't been directly studied.
Someone over 45 who hasn't had significant sexual exposure or would like it based on future exposures can obtain a prescription, understanding there is limited understanding of the effectiveness or incidence of side effects, and it is a costly vaccine (~$200/vaccine). It's also possible that an individual may have already been exposed to some of the strains protected for in the vaccine, and will not derive benefit for those specific strains.
How many doses of Gardasil 9 are required for complete vaccination?
The number of doses required depends on the age at which the vaccine series is started. For those who start the series before the age of 15, two doses are typically given. For those who start at age 15 or older, three doses are usually required. The doses are spread out over several months to provide optimal protection.
Can Gardasil 9 be administered to both males and females?
Yes, Gardasil 9 is recommended for both males and females. While it's well-known for preventing cervical cancer in females, it also protects against other cancers and genital warts in both sexes. Males can benefit from protection against anal and penile cancers, as well as prevention of the spread of HPV to sexual partners.
What types of HPV does Gardasil 9 protect against?
Gardasil 9 protects against nine types of HPV. Specifically, it targets HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. These strains are responsible for the majority of HPV-related cancers and genital warts. Types 16 and 18 cause most HPV-related cancers, while types 6 and 11 are commonly linked to genital warts. By covering these nine types, Gardasil 9 provides broad protection against the most dangerous strains of HPV.
How much does the vaccine cost?
The Gardasil 9 vaccine costs approximately $200 per vaccine (three are needed). Many insurance plans cover the cost of vaccination, so please check in with your insurance provider. You will need 3 vaccinations given initially, 2 months later, then 4 months later (0, 2, and 6 months). This means your total vaccine series will cost approximately $600.
Once I have a prescription, how can I get vaccinated?
After a brief conversation with a doctor to determine if the vaccine is appropriate for you, we will fax a prescription to your local pharmacy for the complete series. Your local pharmacist, walk-in clinic, or primary care provider (nurse practitioner or family physician) can give you the injection.
Can I get the vaccine for free in Ontario?
In Ontario, the vaccine is covered (free) for students in grades 7 to 12, as well as males up to 26 years of age who self-identify as having sex with men (self-identify as gay, bisexual, or trans). If you are in this age group, you can visit a health unit and must consult with a health care provider before receiving the vaccine.
I've had abnormal PAPs. Can I still get Gardasil 9?
Although women who have had an abnormal pap, or have had cervical cancer or genital warts may have had a prior infection with one or more HPV types, they will still benefit from receiving HPV vaccine for the types to which they haven't been exposed. Vaccination doesn't have a beneficial effect on pre-existing cervical disease, but we strongly encourage HPV vaccination if you will have new sexual partners as you have the potential to be exposed to the virus.
I started my HPV vaccine, but I missed the booster shots. Can I still get re-vaccinated?
Our current recommendations are that vaccination can be restarted where you left off, and the entire series does not need to be restarted.
What are common vaccine side effects?
The most common adverse effects were mild or moderate injection site reactions (pain, redness, and swelling). Since its introduction, hundreds of millions of doses of HPV vaccine have been administered, with the most common reported adverse events being vaccination site reactions and muscle pain.
Who cannot get the HPV vaccine?
The HPV vaccine is not given to patients who have had an anaphylactic reaction to a prior dose, or who are currently pregnant because data is limited about its safety in pregnancy. HPV vaccines may be administered to breastfeeding women.
HPV Testing
Can I get tested for HPV?
Public health laboratories do not check for the HPV virus at present time. This test can specifically be requested for women at the time of completing your pap test but is presently an uninsured test with an approximate cost of $80. It is not recommended to get tested for HPV, because there is little we can currently do about HPV once you have acquired it. Because most infections spontaneously resolve, there is little value added from doing HPV at the time of your pap test. The most important testing related to HPV is routine pap testing for women.
There is no routine HPV testing specifically for men.
Molloscum Contagiosium
What is molluscum contagiosum, and what causes it?
Molluscum contagiosum, also known as water warts, is a common skin condition caused by a type of virus called molluscum contagiosum virus (MCV). It produces round, dome-shaped lesions on the skin that are often pinkish-purple in color.
How does molluscum contagiosum spread?
The condition spreads through direct skin-to-skin contact or indirectly through objects like towels, clothes, toys, or razors. It is theoretically possible to also spread in swimming pools and wet environments. Sometimes, it can spread from mother to child during childbirth.
What do molluscum contagiosum spots look like?
The lesions, called mollusca, are firm, white to flesh-colored, and dome-shaped. They might have a central dimple from which a cheesy material can be expressed. They are typically one millimeter to one centimeter in diameter.
Who is at risk of developing molluscum contagiosum?
While it can affect anyone, it's mostly diagnosed in children aged two to five years, sexually active teenagers, adults, and people with weakened immune systems.
How is molluscum contagiosum diagnosed?
Doctors usually diagnose it through a clinical examination of the spots.
What are the treatment options for molluscum contagiosum?
Treatment may include physical removal of mollusca through cryotherapy, curettage, or laser treatment. Topical medications may also be used. However, the condition often resolves on its own in six to 12 months, so waiting for spontaneous resolution is a valid option.
Are there any complications associated with molluscum contagiosum?
Complications are rare but may include inflammation, infection, irritation, or conjunctivitis if the spots are on the eyelids. Scarring is unusual unless the lesions are scratched or scraped.
Treatment of Genital Warts
What are the common treatment options for genital warts?
The most common treatments are self-applied Podophyllotoxin solution or liquid nitrogen treatment at home or in a doctor's office.
Podophyllotoxin 0.05% Solution, Gel, and 0.15% Cream (most common self-applied)
Self-administered treatment at home
Imiquimod 5% cream
Self-administered treatment at home
Imiquimod 3.75% cream
Self-administered treatment at home
Sinecatechins 15% ointment
Self-administered treatment at home
Trichloroacetic acid (TCA) 80–90% solution
Physician administered (uncommon)
Liquid Nitrogen (most common physician-applied treatment)
Physician administered (common)
Electrosurgery
Physician administered (uncommon)
Laser Treatment
Physician administered (uncommon)
Does TeleTest offer treatment for genital warts/molloscum contagiosum?
TeleTest physicians currently prescribe Podophyllotoxin and Sinecatechins for the treatment of genital warts and molloscum contagiosum.
You may select 'Anogenital Wart Treatment' through the STD category.
Does TeleTest offer treatment for molloscum contagiosum?
Molloscum contagiosum can be treated with Podophyllotoxin. While the drug has not officially been approved for the treatment of Molloscum, it is routinely used to treat Molloscum and has been demonstrated to be an effective treatment option based on a number of studies.
One double blind study found that 0.5% podophyllotoxin cream was effective with a 92% clearance rate with no recurrence after 9 months.
Off-label usage of Podophyllotoxin for Molloscum carries specific risks, specifically that it has not been studied for this purpose. It carries the same application risks in treating Molloscum as it does for treating genital warts (i.e. local skin reactions, etc).
Do genital warts go away on their own?
Between 30-40% of warts will self-resolve without treatment within 4 months.
Does treatment of warts prevent transmission to a sexual partner?
Unfortunately, no. HPV can remain living in the skin surrounding where a wart was treated previously, or where no wart previously existed. The presence of HPV without symptoms is often how most HPV transmission occurs. There is no known end-point after which a person is no longer infectious. However, a large majority of HPV infections resolve within 12 months.
Sinecatechins 15% Ointment
What is Sinecatechins 15% ointment, and what is it used for?
Sinecatechins 15% ointment is a medicine made from green tea extract. It's primarily used to treat genital warts, a common skin condition caused by the human papillomavirus (HPV).
How is Sinecatechins 15% ointment applied?
This ointment is typically applied to the affected area three times a day. A healthcare provider will give you specific instructions on how to use it. It's important to follow the directions closely and avoid washing the treated area for at least 3 hours after applying the ointment.
What are the potential side effects of Sinecatechins 15% ointment?
Some common side effects may include redness, itching, or soreness at the application site. Serious side effects are rare but could include severe irritation or allergic reactions.
Can anyone use Sinecatechins 15% ointment?
Sinecatechins ointment is not suitable for everyone. It should not be used by pregnant women, people with certain medical conditions, or on children under 12 without a healthcare provider's guidance.
How long does it take to see improvement with Sinecatechins 15% ointment?
Treatment with Sinecatechins 15% ointment can last up to four months, and improvements might be seen within a few weeks.
How effective is Sinecatechins 15% ointment for treating genital warts?
Studies have found that Sinecatechins ointment can result in the complete disappearance of warts by as high as 58 percent. Recurrence rates (warts coming back) are also low, ranging between 6 to 9 percent at 12 weeks after treatment.
What are the more common side effects of Sinecatechins 15% ointment?
Approximately 1 in 5 of users might experience mild side effects like redness, burning, itching, or pain where the ointment is applied. These are generally manageable.
Are there any rare or severe side effects associated with Sinecatechins 15% ointment?
Although rare, some severe reactions have been reported, including lymphadenitis (swollen lymph nodes), vulvovaginitis (inflammation of the vulva and vagina), balanitis (inflammation of the head of the penis), and ulceration (open sores). If you experience any of these, seek medical attention immediately.
If Sinecatechins 15% ointment doesn't work for me, what are my other options?
Sinecatechins 15% ointment is one of several treatments for genital warts. If it doesn't work for you, your healthcare provider will likely discuss other options, such as other topical treatments, cryotherapy (freezing the warts), or surgical removal.
Podofilox 0.5% Gel
What is Podophyllotoxin, and how does it help with genital warts?
Podophyllotoxin is a medication made from certain plants that are specifically used to get rid of genital warts. It attacks the wart cells, preventing them from growing. This makes the warts shrink and eventually disappear, helping the affected area heal.
How is Podophyllotoxin used, and what options are there?
Podophyllotoxin comes as a 0.05% solution or gel and a 0.15% cream. It's applied directly to the warts twice a day for three days a week, up to four weeks. The solution is often used on penile warts, while the cream or gel is more comfortable for anal or vaginal warts.
What are the success and recurrence rates for Podophyllotoxin?
Clinical trials have shown clearance rates of 45% to 77% with Podophyllotoxin. Recurrence rates can be as low as 38%. If warts persist after four courses, other treatments may be needed.
What side effects might I notice with Podophyllotoxin?
Side effects are common, especially with the first course of treatment, and might include pain, redness, erosion (shallow sores), burning, or itching at the application site. Often, these side effects occur if too much is applied.
Is Podophyllotoxin safe for everyone, including pregnant individuals?
Podophyllotoxin is generally considered safe, but its effects on unborn children have not been thoroughly studied. Therefore, it's not recommended during pregnancy.
Imiquimod 3.75%-5% Cream
What is Imiquimod cream, and what is it used for?
Imiquimod cream is a skin treatment used for external genital warts (CA) and other skin conditions like basal cell carcinomas. There are two concentrations available: 5% and 3.75%. The exact way it works isn't fully understood, but it seems to boost the immune response to help clear warts.
How do I apply Imiquimod cream?
For 5% concentration, you apply it at bedtime three times a week for up to 16 weeks. The 3.75% version requires daily application for a maximum of eight weeks.
What are the success rates for Imiquimod treatment?
Success rates vary. For the 5% cream, one study found that wart clearance was achieved in 56% of patients while the 3.75% formulation had a 33% clearance rate in one study and 28% in another.
What side effects might I experience with Imiquimod?
Side effects for the 5% cream include itching, redness, burning, irritation, tenderness, ulcers, and pain at the application site. Some might feel headaches, muscle aches, fatigue, or general malaise. The 3.75% cream's main side effects are itching, burning, or pain, and it appears to have a milder side-effect profile.
What are the recurrence rates for Imiquimod treatment?
Recurrence rates are relatively low. For the 5% cream, one study found the recurrence rate was 13%. Using the 3.75% cream, another study found an 85% complete clearance rate after 12 weeks.
Are there differences between the 5% and 3.75% concentrations of Imiquimod?
Yes, the 5% concentration generally has higher clearance rates but might have more side effects and a longer treatment duration. The 3.75% cream has a shorter treatment time and may have milder side effects, but its clearance rates might not be as high.
Can Imiquimod cream be used during pregnancy?
We do not recommend the use of Imiquimod during pregnancy.
References
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