HPV - Human papilloma virus

Content

Introduction

Introduction

The human papillomavirus (HPV) is a DNA virus of which about 120 types have been identified capable of infecting humans.

Some can cause common skin diseases (warts) while others (especially types 6 and 11) can cause the appearance of condylomas, small elongated pink growths, single or multiple, at the level of the external genital organs (penis in men, large and labia minora in women), of the region around the anus, mouth and throat (oro-pharynx) (Video).

Condylomas, which are the most commonly encountered sexually transmitted disease in Italy, especially in the age group between 15 and 40 years, do not cause disturbances (symptoms), but tend to increase in number and recur (relapse) over time.

Other types of HPV (especially 16 and 18) can cause, after years, the appearance of pre-tumor (pre-neoplastic) lesions and carcinoma, a malignant tumor that occurs more frequently in the cervix (cervix uterine).

This cancer is one of the most common cancers among women, especially in developing countries, while in Italy it is decreasing as a result of the prevention campaigns carried out.

HPV-related carcinoma can affect the penis and anus, albeit more rarely, while carcinoma of the mouth and throat is increasing, especially in young people.

Contagion occurs mainly by direct contact, through the skin and genitals, but some forms of warts can also be transmitted indirectly (public baths, swimming pools, home environment).

The types of HPV that cause warts are generally transmitted sexually and the use of condoms (male or female) protects only the covered areas (read the Hoax).

Infection can be prevented by means of specific vaccines (bivalent, tetravalent or nonavalent) to be administered, preferably, before the start of sexual activity.

Prevention of cervical cancer (Video) requires women from 25 years of age to carry out the HPV test, which looks for viral DNA in the lining of the uterine cervix, and the Papanicolau cytology test, also called a pap test ( sampling through a spatula and subsequent analysis of the cells that line the cervix).

Men, in the presence of lesions or suspicious formations on the external genitalia or on the anal region, should be directed to a histological and virological assessment.

Symptoms

Symptoms

The human papilloma virus (HPV) usually reproduces (replicates) in the infected skin or mucous membranes and does not spread throughout the body.

Common warts manifest as small ulcers or bumps on the skin of the hands, feet, face and, more rarely, the chest. If not eliminated, they tend to persist without causing disturbances (symptoms) for a long time.

Condylomas are small elongated rosaceous growths, single or multiple, which occur at the level of the external genital organs: penis and skin that lines the testicles (scrotum) in men, large and small labia in women; moreover, they can develop in the region around the anus and, rarely, in the mouth.

Condylomas appear weeks or even months after the viral infection and generally do not cause disturbances (symptoms) but, if not treated, they can persist for a long time and increase in number (read the Bufala).

Furthermore, warts can recur (relapse) months or years after their removal.

Cancer of the cervix may not show its presence for a long time or cause local disturbances (symptoms) (bleeding and discharge, menstrual pain, pain in sexual intercourse).

In the more advanced stages, it can cause disorders (symptoms) related to the compression of the surrounding organs (urinary disorders, constipation, pain in the rectum).

Carcinomas of the external genitalia or around the anus can cause visible changes (thickening, redness, ulceration) on the skin or mucous membranes.

Carcinoma of the mouth-throat (oro-pharynx) can manifest itself with alterations or disorders locally or do not cause discomfort for a long period.

In the more advanced stages there is the involvement of nearby lymph nodes which are enlarged.

Causes

Causes

The HPV virus is acquired mainly by direct contact with the skin (skin) or mucous membranes.

Skin warts can also be transmitted indirectly in environments such as swimming pools, gyms, saunas and in the home.

Condylomas can develop following unprotected vaginal, anal, oral-genital and oral-anal sex.

The appearance of warts usually takes a few weeks and, in some cases, even a few months after the infection.

The virus tends to remain nested in the inactive (latent) phase in the contagion site and to reactivate subsequently even after months / years from the removal of the warts.

The types of HPV responsible for pre-cancerous changes and cancers (cervico-vaginal, penile or anus) are transmitted through unprotected sexual intercourse, particularly if there are active lesions associated with the reproduction (replication) of the virus ( read the Bufala).

The virus can remain in a dormant phase for many years, without causing any disturbance. In this phase the virus is however potentially capable of causing, over time, the transformation of epithelial cells into tumor cells, characterized by uncontrolled growth and spread to surrounding organs and lymph nodes.

A pregnant woman can, theoretically, pass the virus to her baby by passing through the birth canal or by Caesarean section. Diffusion through the placenta (via placenta) has not been demonstrated and it is believed that the absolute probability of transmission of HPV is low.

Diagnosis

Diagnosis

The alterations caused by HPV are very varied (heterogeneous) and, consequently, the procedures for ascertaining them (diagnosing them) depend on their type.

Due to their characteristics, skin warts are easily detected by a general practitioner, a dermatologist or an infectious disease specialist.

The ascertainment of the presence of warts (diagnosis) generally takes place through direct observation in the context of a specialist medical examination and histological or instrumental examinations are not usually required, unless the warts are present in areas that are not external and not easily observable (cervico-vaginal canal, pharynx).

Verification of the presence of precancerous alterations (lesions) or carcinoma of the cervix (cervical cancer), penis, anus or oropharynx requires the execution of a histological examination. This examination requires the removal of cells from the cervix with a spatula (pap test), or a biopsy and can show morphological-structural changes in the tissue. With regard to the pap smear, various degrees of cellular alteration can be distinguished, from dysplasia (abnormalities in the shape and structure of the cells of a milder degree) up to carcinoma.

The HPV test also allows the identification of the type of HPV possibly present in the analyzed tissue (cervical smear, swab or biopsy) by means of a so-called genetic amplification. The detection of a type of virus associated with a high risk of carcinoma (types 16 or 18) requires further investigation and possible early treatment of the lesions.

Therapy

Therapy

The treatment must be differentiated according to the type of lesion, the size and the place where it is present.

The treatment of skin warts consists in the local application of chemicals with keratolytic action, or interferon, and, in the most manifest forms, in cryotherapy, laser therapy or surgical removal. For some years an antiviral drug (cidofovir) has been available. it can be applied locally with a moderate effectiveness, however, no cure is able to prevent the reappearance (relapse) of the virus because it can persist for a long time in the deep layers of the skin (epidermis).

The treatment of warts varies in relation to the number and the affected area.

The external forms can be removed by cryotherapy (burn with cold liquid nitrogen), laser therapy, diathermocoagulation (burn with heat), surgical removal or by local application of drugs with immunomodulating (imiquimod, interferon) or cytotoxic (podophylline) function .

Condylomas in non-external areas (vagina, oropharynx) may require removal by local surgery under instrumental guidance.

To be decisive, the treatment must completely eliminate the virus in order to avoid the reappearance of the warts in the following months. In any case, even if the lesions are completely eliminated, the virus can persist in an inactive (latent) form in the tissue and lead over time (months, years) to the reappearance of the warts.

Cervical cancer, including pre-cancerous changes, generally requires partial (conization), or complete (hysterectomy) surgical removal of affected areas (including regional lymph nodes) along with courses of chemotherapy or radiotherapy.

Even the forms of carcinoma of the penis, anus and gold-pharynx require surgical removal of the affected area and anticancer treatments.

Prevention

Prevention

As for the prevention of skin warts, it is good to avoid going to environments such as swimming pools and gyms with bare feet.

It is also essential to carefully clean the aforementioned environments, particularly those that are very busy.

The rapid elimination of warts can significantly reduce the risk of contagion at home or in places frequented by other people such as, for example, schools, gyms, swimming pools.

Infection with the types of HPV associated with the appearance of warts or carcinoma can be avoided by using a condom, male or female, or the dental dam (latex membrane, a sort of oral condom) in sexual intercourse (read the hoax) However, protection concerns only the skin areas or mucous membranes covered by these barriers since the skin above the testicles (scrotum), the labia majora and the region around the anus can be the site of contagion.

Several vaccines against HPV are available, starting from bivalent (serotypes 16 and 18) up to tetravalent (serotypes 6, 11, 16 and 18) and the latest generation nonavalent (serotypes 6, 11, 16, 18, 31, 33, 45, 52 and 58), able to prevent infection by the types of HPV most associated with the onset of warts or carcinoma. Since 2010, the Ministry of Health has recommended preventive vaccination for girls at the age of 12, mainly in relation to the risk of cervical cancer (Video). Lately, it was considered appropriate to extend this recommendation also to the male sex in relation to the prevention of warts and carcinomas of the penis, anus and oropharynx.

The prevention of cervical cancer requires that all women, starting from 25 years of age, carry out the HPV test and / or pap test to ascertain the possible presence of HPV and alteration of cellular tissue in the cervical mucosa. .

Similarly, in men the presence of suspicious changes in the external genitalia or in the anal region should lead to a histological and virological assessment.

Complications

Complications

Without treatment, skin warts can enlarge and extend to the surrounding skin (skin).

Genital warts that are not adequately removed or treated can persist for a long time or increase in number and size, creating a significant disturbance to sexual, urinary and defecation function. The presence of warts is also associated with an increased susceptibility to contracting other sexually transmitted infections.

Cancer of the uterine cervix, penis, anus and oropharynx can progress rapidly and expand to surrounding tissues with severe morphological and functional impairment of the affected organs (bladder, rectum). In addition, the cancer can spread to regional lymph nodes and give rise to widespread metastases in the body.

Living with

Living with

The alterations associated with human papillomavirus (HPV) infection are extremely varied (heterogeneous) both according to the area in which they occur and the consequences they cause.

The appearance of a wart on the skin is an extremely common situation that can be resolved quite easily with the help of a specialist doctor.

Condylomas at the genital or anal level do not cause particular disorders but can persist for a long time, increase in number or return (relapse) after months / years, causing psychological discomfort and the risk of contagion for the person. sexual partner.

For this reason, in the event of the appearance of warts, it is essential to refer to a specialist doctor (dermatologist, gynecologist, infectious disease specialist) for their effective treatment and safe removal.

Any sexual partners must also undergo a "thorough specialist medical examination.

In consideration of the possibility of recurrence of condylomas after months or years, it is necessary to use a protection in sexual intercourse (male or female condom, dental dam) in the period following their removal and carry out regular checks to ascertain whether it reappears before possible (early).

Bibliography

Bibliography

United Against AIDS (ISS). HIV and other sexually transmitted infections

Ministry of Health. Human papillomavirus (infections from)

WHO Media center. Human papillomavirus (HPV) and cervical cancer (English)

World Health Organization (WHO). Human papillomavirus vaccines: WHO positione paper, October 2014. Weekly epidemiological record. 2014; 89: 465

EpiCentro (ISS). Hpv infections and cervicocarcinoma

Salfa MC et al. Sexually Transmitted Infections: update of the data of the two sentinel surveillance systems active in Italy at 31 December 2014. Newsletter of the Higher Health Institute. 2016; 29: 3

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