Adherence to recommended schedules for human papillomavirus (HPV) quadrivalent vaccine is relatively low, and even lower among blacks, raising concerns about disease disparity, according to research published online Dec. 13 in Pediatrics.

To determine the level of adherence to the recommended schedule for vaccination and to identify factors associated with completing the three-dose series, Lea E. Widdice, M.D., of the Cincinnati Children’s Hospital Medical Center, and colleagues reviewed data on 3,297 females aged 9 to 26 who initiated HPV vaccination.

Sixty-seven percent of the females self-identified as black and 29 percent as white. The researchers found that more than 50 percent of the doses were received late and fewer than 3 percent were received earlier than recommended. Completion rates by seven and 12 months were 14 and 28 percent, respectively. Completion by seven months was more likely to be achieved in whites, females whose contraception use necessitated intramuscular injections at three-month intervals, and those with private rather than public insurance.

“Adherence to recommended intervals and completion of the vaccine series were low. Lower rates of completion in black patients compared with white patients raises concern that disparities in vaccine completion could exacerbate existing disparities in cervical cancer,” the authors write.

Gardasil (human papillomavirus vaccine), the vaccine that can prevent most cases of cervical cancer in girls, has won the FDA’s blessing as a vaccine to prevent anal cancer, a huge victory for men!

The FDA’s  approval for Gardasil as an anal cancer vaccine opens the way for the medication’s maker, Merck and Co. Inc., to market the vaccine to boys and young men between the ages of nine and 26 – an option that will be most meaningful for men who have sex with men, but valuable to all.  Nobody likes getting HPV on their penis.  It really can devastate many boys and men.  When the HPV ends up on their anal area – the risk of anal cancer is high.  Although this is most commonly seen in homosexual men, it is not infrequent for heterosexual men to be at risk.  It is easy to imagine how HPV can start on the shaft, and with a scratch here, and an itch there – end up on the back side.

This is a great win for men – and we hope that the approval by the FDA will quickly translate to coverage amongst insurance companies to make the vaccine accessible quickly to this new population.

What are anal warts?

Anal warts (also called “condyloma acuminata”) are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow larger than the size of a pea. Usually, they do not cause pain or discomfort to afflicted individuals. As a result, patients may be unaware that the warts are present. Some patients will experience symptoms such as itching, bleeding, mucus discharge and/or a feeling of a lump or mass in the anal area.

Anal warts, thought to be caused by the human papilloma virus, can grow larger and spread if not removed.

It is important to know that Anal warts can be found both heterosexuals and in men who have sex with men.  Either way, it is nothing to be ashamed of – and it is something that you SHOULD SEEK TREATMENT FOR.

What causes these warts?

They are thought to be caused by the human papilloma virus (HPV) which is transmitted from person to person by direct contact. HPV is considered a sexually transmitted disease. You do not have to have anal intercourse to develop anal condyloma.

Do these warts always need to be removed?

Yes. If they are not removed, the warts usually grow larger and multiply. If left untreated, the warts may lead to an increased risk of cancer in the affected area.  This is similar to the risks of cervical cancer in women.

What treatments are available?

If warts are very small and are located only on the skin around the anus, they may be treated with a topical medication. They may also be treated by a physician by freezing the warts with liquid nitrogen. Warts may also be removed surgically. Surgery provides immediate results but must be performed using either a local anesthetic – such as novocaine – or a general or spinal anesthetic, depending on the number and exact location of warts being treated. Warts inside the anal canal usually are not suitable for treatment by medications, and in most cases need to be treated surgically.

Must I be hospitalized for surgical treatment?

No. Surgical treatment of anal warts is usually performed as outpatient surgery.

How much time will I lose from work after surgical treatment?

Most people are moderately uncomfortable for a few days after treatment, and pain medication may be prescribed. Depending on the extent of the disease, most people return to work the next day.

How long is treatment usually continued?

Follow-up visits are necessary at frequent intervals for several months after the last wart is observed to be certain that no new warts occur.

What can be done to avoid getting these warts again?

In some cases, warts may recur repeatedly after successful removal, since the virus that causes the warts often persists in a dormant state in body tissues. Discuss with you physician how often you should be evaluated for recurrent warts. Abstain from sexual contact with individuals who have anal (or genital) warts. Since many individuals may be unaware that they suffer from this condition, sexual abstinence, condom protection or limiting sexual contact to single partner will reduce your potential exposure to the contagious virus that causes these warts. As a precaution, sexual partners ought to be checked, even if they have no symptoms.

June 14-20^th is National Men’s Health Week and June 20^th is Father’s Day.

Lets celebrate both by sharing the gift of knowledge.  Here are some key facts about STD/STI’s that every man should know.

STD/STIs are certainly a critical piece of the sexual health puzzle but being sexually healthy is about much more.

Our most basic advice is:

• Abstinence is good and can happen at different times in life
• Talk to your parents, they were your age once
• Talk to your partner (before you have sex)
• Make sure you and your partner know how to use a condom correctly
• Find a good healthcare provider and talk to them
• Get help if you don’t think you’re in a healthy relationship
• Get yourself tested and make sure your partner gets tested (before you have sex)
• Take advantage of the vaccines that will help protect you
• Learn what you need to know–and keep learning
• Your sexual health is important–-you have a right and a responsibility to protect it!

Genital infection with low-risk types of HPV is associated with genital warts in men. Infection with high-risk types of HPV is associated with a proportion of preinvasive squamous lesions of the penis (penile intraepithelial neoplasia or PIN) and with penile cancer, as well as with preinvasive squamous lesions of the anus (anal intraepithelial neoplasia or AIN) and with anal cancer.

Invasive penile cancer is quite uncommon, especially in circumcised men.

In 2002, the age-adjusted incidence rate for penile cancer in the U.S. was 0.8 per 100,000 men (985 new cases). The age-adjusted incidence rate for anal cancer was 1.2 per 100,000 men (1,453 new cases). However, the risk of anal cancer for MSM is significantly higher.

Because of the increased incidence of anal cancer in MSM, especially HIV-infected MSM, some specialists recommend screening for AIN by cytology in this population. However, there are limited data on the natural history of AIN, the reliability of screening methods, the safety and response to treatments, and the programmatic considerations that would support this screening approach.

Until more data are generated on screening for AIN, this screening approach is not recommended.

There is currently no FDA-approved HPV DNA test for males, nor is HPV testing of males recommended. There is no clinical utility in testing men for HPV; infection does not indicate increased risk of disease for the man or his partner. While HPV is common in men, HPV-associated cancers are rare.

There are no routine methods for culturing HPV. Serology tests are available for HPV, but these tests are used only in research settings. Many persons with detectable HPV DNA do not have antibodies, so these tests are not a good method to indicate infection with HPV.

While it is possible that vaccination of males with the HPV vaccine may offer direct health benefits to males and indirect health benefits to females, there are currently no efficacy data available to support use of HPV vaccine in males. Efficacy studies in males are ongoing.

Additional information is available on the CDC website at:

http://www.cdc.gov/STD/hpv/hpv-clinicians-brochure.htm

To access treatment guidelines for HPV and genital warts, please review CDC s 2006 STD Treatment Guidelines available online at:

- HPV Infection

http://www.cdc.gov/std/treatment/2006/hpv.htm

- Genital Warts

http://www.cdc.gov/std/treatment/2006/genital-warts.htm

Penile warts are diagnosis that a trained doctor can make without a biopsy.  If patients have many warts or ones that look suspicious for other lesions like cancer I often biopsy a representative sample and freeze (with liquid nitrogen) or burn (electrocautery) or laser (C02 or YAG) the rest.  If a patient has warts on the foreskin and wants a circumcision I sent the tissue for biopsy. 

If your doctor didn’t send a biopsy and it didn’t come back that’s fine.  If it keeps coming back and there was never a biopsy ask your doctor to sent a piece to the lab or make sure they are convinced its not cancer.

I hope this post is helpful.  Go to our find a physician tab if you need an evaluation

Thanks,

Dr. A.

Jessica writes:

“I got married 8 months ago, and 2 months ago, for the first time ever i was diagnosed with HPV. According to the Dr, it didnt necessairly come from my hubsand, but i cant help feel like it did. Thankfully, i have no genital warts or currently any cancer causing lesions, but i Do have a brand new, first time ever skin wart on my knee. Ive just started liquid nitrogen treatment for the removal of that.
Im increadably disspaointed, and borderline terrified. This is a first for me, and while some people say “its no big deal”- to me it is a big deal. this is something ive never had to deal with before and to make it worse, i know next to nothing about the Virus. Ther are so many different websites on it that have s many different opinions, i hardly know which one to believe!!

I think the next best step for me is education myself on this virus, how to treat it, and how to NOt spread it!”

Thanks for writing!  First off… you have found a good place to discuss your concerns.  Please do not be terrified.  Warts are quite common.  Instead… lets get educated!

Your Doctor’s advice is correct.  The wart did not necessarily come from your husband.  You may be able to blame him for lots of things… but you can’t point a finger at him for this one.  Further, the type of wart that grows on the skin is typically a different strain of virus than that found in the genital areas.

There are many treatment options for common warts, and Liquid Nitrogen is often a good place to start.
Best of luck, and keep us updated!

by: Michelle Lipke

Liquid nitrogen is a popular destructive treatment for warts.  It is readily available in both dermatology and primary care offices.   Verucca-Freeze and many similar brands available over the counter are a liquid applied from a spray can, but only freeze to -70C.  Warts may not resolve with the over the counter freezing due to the fact that they do not freeze as fast as the liquid nitrogen available in the clinic setting; as well as the proper application technique may not always be used. The wart virus, known as human papilloma virus (HPV), is not destroyed by the freezing procedure.   Liquid nitrogen freezes at -196C and works by destroying the skin cells which in turn release the wart virus.  They body responds to this process by causing an immune response to resolve the wart.

The cryo-spray gun and cotton wool bud are the two main methods for treating common warts with liquid nitrogen.  Different providers often have a personal preference of which method they choose to perform this treatment.   There was no difference in cure rate between cryo-spray gun and cotton wool bud for warts treated every two weeks for three months.

Warts need to be frozen until 1-2 mm of surrounding skin turns white.  Repeat freezing after thawing may cause more effective tissue damage for some wart locations to help them resolve.  Paring the wart down with a scalpel or razor blade may reduce callous which can act as an insulator reducing the effect of the freeze.  Warts are usually treated on average of every two weeks, but sometimes the interval of treatment can depend on how a patient responds to the freezing in regard to side effects.

The common side effects from liquid nitrogen include redness, swelling, blistering and pain.  Plantar wart treatment may temporarily reduce the ability to walk due to pain and blistering.  Excessive blistering may create a ring recurrence around the treated wart which is thought to be caused by bordering dormant wart virus.  The freezing may cause lightening or darkening of the skin after the wart has resolved, especially in dark skinned individuals.  Deeper structures such as tendons, nerves and veins can be damaged with treatment that is too aggressive.

A new product called Veregen (sinecatechins) 15% ointment is now available for the treatment of warts. Sinecatechins are an extract from Green Tea, that cleared almost 90% of anogenital warts in clinical studies.

The medication is only approved for treatment of external genital and perianal warts, and is not without side effects.  One out of five patients experience erythema, pruritus, burning, pain/discomfort, erosion/ulceration, edema, induration or a vesicular rash.  The medication is also going to be expensive, and likely not covered by many insurance plans.

Anal warts are caused by the human papilloma virus, which is usually transmitted through sexual contact but not necessarily through anal intercourse. The same type of warts may occur on the penis, scrotum, vagina or labia. It is important to recognize and treat anal warts if you have them, as the risk of developing cancer is high.  The time from exposure to the virus and growth of the warts is commonly from one to six months, but it can be longer. During that time the virus remains in the tissues but is inactive. There are many types of human papilloma virus; some cause warts on the hands and feet and others cause genital and anal warts.