Human papillomavirus( HPV) - Causes, symptoms and treatment. MF.

Dermatovenerologists, urologists, oncologists, cosmetologists, pathomorphologists, immunologists, virologists face the problem of diagnosis and treatment of human papillomavirus( HPV).This issue has always been and is acute because of the high infectiousness of the virus and the ability of HPV to induce tumor processes.

HPV are tropic to epithelial cells, so they are found in the skin, conjunctiva, mucous membranes of the mouth, esophagus, bronchi and rectum. As a result, cells begin to proliferate, but complete replication of the virus occurs in highly specialized cells. HPV is the only virus that can produce a tumor in vivo.

Types of human papillomavirus

The division of HPV by the oncogeneity of

Currently, about 100 HPV species are known and in addition to the fact that almost every one of them causes tumor processes of definite localization, they are divided into 2 groups with high and low oncogenic risk. HPV with high oncogenic risk is: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 68. HPV with low oncogenic risk: 6, 11, 42, 43, 44.

Symptomshuman papillomavirus

Formations on the skin caused by HPV:

• Ordinary warts on the skin are caused by the following types of HPV: 1-4( plantar warts or foliar spines), 26-29, 38, 41, 49, 57, 63,65, 75-77.Ordinary warts are the most common benign epidermal proliferative formations. At first they are formed in the form of domed papules, the size of a pinhead, and as they grow they darken and acquire a rough shape. They can be located singly or in groups, but in any case, first a mother wart is formed around which the daughter is formed. In the place of origin of warts, pain, a slight burning sensation can be felt, but there may also be no pathological sensitivity. The most frequent localizations are on the dorsal surfaces of the upper and lower extremities, on the eyelids in the form of filiform warts, in the beard, in the scalp, in the interdigital spaces, on the palmar and inner surfaces of the fingers, on the red border of the lips, on the plantar surface( this localizationhas a tendency to grow into the depth of the skin).
Plantar warts are localized at compression sites( the metadorsal region of the sole and heel), they are represented by coarse keratotic papules with a tendency to grow into the tissue and spread rapidly. This kind of warts is quite resistant to treatment. They look like corns and when they walk, they hurt.

Plantar warts

• Butcher warts: 2, 7. This type of wart resembles the skin horn, it is a long filiform papule, often located on the upper limbs, and may also occur after cuts on the finger.

• Flat warts are caused by 10, 49, 28 type of HPV, they slightly rise above the surface of the skin, with a tendency to group. They are bodily or pale brown, more often located on the forehead and shoulders in the form of keratomas or nevi, and this type of wart is found on the penis, cervix, external genitalia and rectum.

Flat warts

• Verruxiform epidermodysplasia: 2, 3, 5, 8-10, 12, 14, 15, 17, 19, 20-25, 37, 47, 50. This is a rare life-long dermatosis characterized by prolonged persistence and refractoriness of the virus,manifests itself in the form of disseminated flat wart rashes or hypo / hyperpigmented spots resembling pityriasis. The spots are covered with small scales, tend to merge. It is inherited by recessive type, and therefore under threat people are in close-walled marriage. Eruptions are localized in open areas: face, neck, upper limbs. This type of HPV never regresses and is resistant to treatment, and the risk of malignancy is also high.

Verdictiform epidermodysplasia

• Okolonogevye warts are caused by 16 types of HPV, located on the sides of the nail bed, with a tendency to ingrowth into the skin and further dystrophy of the nail.

• Bowen's disease: 16, 34, 35, 55. Otherwise, this disease is called Bowenal pappus, it is detected in the form of multiple small papules located in the anogenital zones, and more often in young people. Benignity is questionable, because it is induced by the 16th type of HPV.

Bowen's disease

• Squamous cell carcinoma: 5.8, 14, 17, 20, 41, 47.

• Keratocantham: 37

• Melanoma: 38

Genital formations( anogenital warts):

• Genital warts: 6, 11, 42, 44, 51, 54, 55, 69. These formations are smoothed as cauliflower or cockscomb. The most frequent areas of damage: foreskin, glans penis, endoral region, peranal area, small labia, vagina, cervix, mouth of urethra, corners of mouth. And the presence of spiky kandil always indicates the sexual act through which the infection occurred. The most vivid representative of the diseases of this group of HPV is the giant condyloma of Buschke-Levenshtenna, which is located either on the trunk of the penis, or in the region of the coronary furrow, or in the perianal region. First, small papillomas appear, which then grow rapidly, merge and form a lesion with a wide base. The main difference from all other warts is progressive growth with destructive changes of underlying tissues, as well as a recurrent course. Another representative - papillomatosis of the vulva, is represented by granular elements in the vulva. The greatest danger is represented by HPV with associated diseases of the urogenital tract( chlamydia, mycoplasmosis, CMV).Cervical cannillas are difficult to diagnose and are most dangerous for pregnant women, because during this period they undergo disintegration, as a result of which bleeding is opened to which a secondary infection often joins. But after birth, this kind of condyloma can spontaneously regress, but only if, during pregnancy, they were preserved.

Genital warts

• Anal intraepithelial neoplasia: 16, 18, 30, 31,33, 35, 39, 45, 51, 52, 56, 58, 66, 69.

• Cancer: 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 54. 56, 66, 69.

Formations in the oropharynx:

• Papillomas: 6, 7, 11, 32, 57, 72, 73. One representative of this species isblossoming papillomatosis, in the oral cavity it looks like a cauliflower - white vegetative plaques on the oral mucosa. It often occurs in the elderly. About this form of papillomavirus infection is little known, so it is impossible to unequivocally answer the question about her malignancy. Papillomatosis of the larynx can spread to the trachea, bronchi and lung tissue. This disease is mainly caused by 6 and 1 type, it is more likely to affect children and adults. As a result of the defeat of the larynx, the first symptoms are dysphonia and aphonia, hoarseness of voice, difficulty breathing.

• Focal epithelial hyperplasia: 13-32

• Cancer: 2, 6, 11, 16, 18, 30.

Clinical manifestations can be cutaneous and extracutaneous( on the mucous membranes, in the perihotic region, on the cervix, etc.).

Diagnosis of human papillomavirus

• Objective examination of
• Histological examination that helps to see atypy of cells, the presence of koylocytes, helps to differentiate HPV with high and low oncogenic risk( with low oncogenic risk, diploid or polydiploid DNA is detected, and at high - aneuploid DNA), also allows you not to miss malignancies.
• The PCR method is highly specific and highly sensitive, this method helps to predict the course of the disease.

Treatment of HPV

Despite a variety of treatments, it is believed that HPV can not be completely eliminated, so all treatment is reduced to the elimination of clinical and subclinical manifestations. The approach to treatment should be strictly individual. For successful treatment, several principles must be observed:

• Periodic examination for the timely detection and treatment of anogenital warts, because the main pathway of transmission of infection is sexual( but perhaps household - very rare).
• If HPV foci are detected, they should be monitored continuously to prevent malignancy and development of metastases.
• Patients should be advised to use condoms or to avoid accidental sexual intercourse.

The basic methods of treatment:

1. Destructive methods: surgical excision, curettage, electrosurgery, cryodestruction, laser surgery.

• Surgical treatment is performed if there is a suspicion of malignancy. It is not used so often, because when you remove the wart, you may experience severe bleeding. During this manipulation, the excised wart is sent to a biopsy, and the wound is sutured.
• Curettage - wart removal with the help of curette, i.e. by curettage. After this, electrocoagulation is performed, and a dry bandage is applied to the wound.
• Electrosurgery is used in the separation of small warts. But even in this case, relapses are possible. This method can also be used for large warts, but before starting them it is necessary to soak or insert the electrode into the thickness of the wart, so the separation between the cells becomes less stable.
• Cryodestruction is performed by liquid nitrogen.
• Laser surgery is currently the leading position in surgical treatment, ie, in addition to destruction, hemostasis is carried out in parallel. In addition to the laser evaporation of the wart, it also has a direct toxic effect on HPV, so this method of treatment is the first choice for the treatment of cervical intraepithelial neoplasia, and it is also dominant in the treatment of genital warts in pregnant women( even in the latter stages of development).

2. Chemicals with cauterizing effect: solicilic acid, trichloroacetic acid, solcoderm. The main advantage of this method is relative safety.

• Salicylic acid has a pronounced keratolytic effect, but for better penetration of salicylic acid into the depth of the wart, they should be soaked in warm water, and at the end of the procedure, remove these abnormal formations with the help of a penza, and then tape with adhesive tape.
• Trichloroacetic acid at a working concentration of 50-90% provides chemical destruction of the tissue, but after its use, soreness or ulcers develop on the spot.
• Contaridine does not have a direct antiviral effect, but it inhibits mitochondria of infected epithelial cells, this leads to their death, acanthosis and the formation of a bladder. The application is left for 24 hours, and the bladder formations are waiting for 2 days. After that, the healing takes place not later than 1 week, without leaving a scar.
• Solcoderm, unlike other drugs, has only a strictly limited effect, without damaging the surrounding tissues. This method is one of the leading chemical.

3. Cytostatic drugs: podophilin, podophylotoxin, 5-fluorouracil, cleomycin.

• Podofillin is a cytostatic drug, is a substance from the plant and is used to treat anogenital warts in the form of 10-25% alcohol solution. The death of cells occurs by inhibiting the synthesis of DNA by an indirect pathway.
• 5-fluorouracil is toxic for viral DNA.This drug is used for the resistance of anogenital, flat and vulgar warts to other methods of treatment.
• Bleomycin is a sulfur-containing glycopeptide cytostatic, with antitumor, antibacterial and antiviral activity! This drug is injected directly into the wart tissue, where it binds to the viral DNA and blocks its synthesis. The injection is painful, so before the procedure, you need to anesthetize the place with EMLA cream, and dilute the drug with an anesthetic. The procedure is carried out every 2-3 weeks.

4. Immunotherapy: interferon, imiquilod, isoprinosine. This method of treatment is used only in combination with other methods, because it has no specific effect, but activates only the components of the immune system.

5. Combined therapies include a combination of the above methods.

Therapist doctor Shabanova I.Е.