What are the management and treatment options for Human Papillomavirus (HPV) in adults?

Management and Treatment Options for Human Papillomavirus (HPV) in Adults

HPV management in adults primarily involves vaccination for prevention through age 26 years, with shared clinical decision-making for ages 27-45 years, while active infections are mostly self-limiting with no specific antiviral treatment except for topical sinecatechins for external genital warts. 1, 2

Prevention Through Vaccination

Vaccination Recommendations by Age Group

• Ages 9-26 years:

  • Catch-up HPV vaccination is recommended for all persons through age 26 years who are not adequately vaccinated 1, 2
  • Dosing schedule:
    • For persons initiating vaccination before their 15th birthday: 2 doses (0,6-12 month schedule) 1, 2
    • For persons initiating vaccination on or after their 15th birthday or for immunocompromised individuals: 3 doses (0,1-2,6 month schedule) 1, 2

• Ages 27-45 years:

  • Not routinely recommended for all adults in this age group 1
  • Shared clinical decision-making is recommended for some adults who are not adequately vaccinated 1
  • Consider vaccination for those at risk for new HPV infection:
    • Individuals with new sexual partners
    • Those not in long-term, mutually monogamous relationships 1
  • Note: Vaccine effectiveness is lower in this age group due to likely prior HPV exposure 1

• Ages >45 years:

  • HPV vaccines are not licensed for use in adults over 45 years 1, 2

Special Populations

• Immunocompromised individuals:

  • Should receive vaccination through age 26 years 2
  • Require 3-dose schedule regardless of age at initiation 1, 2

• Men who have sex with men:

  • Should receive vaccination through age 26 years 2

• Pregnant individuals:

  • Vaccination should be delayed until after pregnancy
  • No pregnancy testing needed before vaccination
  • Breastfeeding individuals can receive HPV vaccine 1

Management of Active HPV Infections

External Genital and Perianal Warts

• Topical treatment with sinecatechins (Veregen):
  • FDA-approved for external genital and perianal warts in immunocompetent patients 18 years and older 3
  • Application: Apply three times per day to all warts
  • Apply approximately 0.5 cm strand to each wart, ensuring complete coverage 3
  • Continue until complete clearance of warts, up to 16 weeks maximum 3
  • Limitations:
    • Not for urethral, intravaginal, cervical, rectal, or intra-anal warts 3
    • Avoid use on open wounds 3
    • Not established for immunosuppressed patients 3

Cervical HPV Infection

• Screening:
  • Continue cervical cancer screening according to guidelines regardless of vaccination status 1
  • No specific treatment for asymptomatic HPV infection
  • Management focuses on treating precancerous lesions if detected through screening

General Management Principles

• Most HPV infections (approximately 90%) are transient and clear within 1-2 years without intervention 4, 5
• No specific antiviral treatment exists for the virus itself
• Management focuses on:
  1. Treating visible lesions (warts)
  2. Monitoring and treating precancerous lesions
  3. Prevention through vaccination and safer sex practices

Prevention Strategies Beyond Vaccination

• Barrier methods:

  • Consistent use of condoms and dental dams may decrease spread of the virus, though not completely effective as HPV can infect areas not covered by barriers 6

• Risk reduction:

  • Limiting number of sexual partners
  • Delaying sexual debut
  • Avoiding alcohol and tobacco use, which are associated with persistent HPV infection 6, 5

Important Considerations and Pitfalls

• HPV vaccines are prophylactic only:

  • They prevent new HPV infections but do not treat existing infections or HPV-related disease 1
  • They do not accelerate clearance of existing infections 1

• No pre-vaccination testing:

  • No HPV or antibody testing is recommended before vaccination 1, 2
  • Even sexually active individuals may benefit from vaccination if not exposed to all vaccine HPV types 2

• Continued screening importance:

  • Vaccination does not replace the need for cervical cancer screening 1
  • Vaccinated individuals should follow standard screening guidelines 1

• Herd immunity:

  • Widespread vaccination provides indirect protection to unvaccinated individuals through reduced community transmission 4, 7