What is the management for a patient positive for Human Papillomavirus (HPV) who has already received the HPV vaccine and continues to develop warts?

From the Guidelines

Management for a patient who is HPV positive, already vaccinated, but continues to develop warts should focus on treating the existing warts while monitoring for new lesions, with first-line treatment options including topical therapies such as imiquimod 5% cream or podophyllotoxin 0.5% solution, as recommended by the Centers for Disease Control and Prevention 1. The goal of treatment is to remove visible warts, as the vaccine does not treat existing infections or provide complete protection against all HPV strains that cause warts.

• Treatment options include:
  • Topical therapies: imiquimod 5% cream (applied 3 times weekly for up to 16 weeks) or podophyllotoxin 0.5% solution (applied twice daily for 3 days, followed by 4 days off, for up to 4 cycles) 1
  • Office-based procedures: cryotherapy with liquid nitrogen (applied every 1-2 weeks until resolution), electrocautery, laser therapy, or surgical excision It's essential to understand that while HPV vaccination prevents infection with certain high-risk HPV types, it doesn't treat existing infections or provide complete protection against all HPV strains that cause warts, as noted in the recommendations for quadrivalent human papillomavirus vaccine 1. The immune system typically clears HPV infections over time, but this process can take months to years, and some patients may experience recurrent warts despite vaccination, highlighting the importance of regular follow-up appointments to monitor for recurrence and assess treatment response 1.
• Patients should be advised that treatment focuses on removing visible warts rather than eliminating the virus completely, and multiple treatment sessions may be required. Regular follow-up appointments are recommended to monitor for recurrence and assess treatment response, as the risk for HPV infection might continue as long as persons are sexually active 1.

From the FDA Drug Label

The treatment area should include a 1 cm margin of skin around the tumor. Sufficient cream should be applied to cover the treatment area, including 1 centimeter of skin surrounding the tumor. Imiquimod Cream should be rubbed into the treatment area until the cream is no longer visible. If there is clinical evidence of persistent tumor at the post-treatment assessment for clinical clearance, a biopsy or other alternative intervention should be considered. Lesions that do not respond to therapy should be carefully re-evaluated and management reconsidered; the safety and efficacy of a repeat course of Imiquimod Cream treatment have not been established Apply twice daily morning and evening (every 12 hours), for 3 consecutive days, then withhold use for 4 consecutive days This one week cycle of treatment may be repeated up to four times until there is no visible wart tissue. If there is incomplete response after four treatment weeks, alternative treatment should be considered.

For a patient positive for Human Papillomavirus (HPV) who has already received the HPV vaccine and continues to develop warts, management options include:

• Using Imiquimod Cream as described, with careful monitoring for local skin reactions and consideration of alternative interventions if the tumor persists 2
• Using Podofilox Topical Solution 0.5% as described, with treatment limited to less than 10 cm2 of wart tissue and no more than 0.5 mL of the solution per day, and consideration of alternative treatment if there is incomplete response after four treatment weeks 3 Key considerations:
• Careful evaluation and monitoring of the patient's response to treatment
• Consideration of alternative interventions if the tumor persists or if there is incomplete response to treatment
• Patient education on proper application technique and management of local skin reactions

From the Research

Management of HPV-Related Warts

The management of a patient positive for Human Papillomavirus (HPV) who has already received the HPV vaccine and continues to develop warts involves various treatment options.

• Topical treatments such as podophyllotoxin and imiquimod are commonly used and have shown efficacy in treating genital warts 4, 5.
• Cryotherapy, which involves the use of liquid nitrogen to freeze off the warts, is also a recommended treatment option 4, 5.
• Other treatment options include surgical excision, loop electrosurgical excision procedure, and laser therapy 4, 5.
• The choice of therapy depends on the number, size, and location of lesions, as well as patient preferences, cost, convenience, adverse effects, and clinician experience 4, 5.

Treatment of Recalcitrant Warts

For recalcitrant periungual and subungual warts, photodynamic therapy combined with liquid nitrogen cryotherapy and curettage has been shown to be effective 6.

• This treatment approach may be considered for patients who have not responded to other treatments.
• The use of quadrivalent HPV vaccination in combination with topical treatments such as imiquimod or podophyllotoxin is also being investigated as a potential therapeutic approach 7.

Prevention and Screening

While the HPV vaccine can prevent infection with certain types of HPV, it is not a treatment for existing infections.

• Regular cervical cytology screening is recommended for women to detect any abnormal cell changes that may be related to HPV infection 8.
• Patients with high-grade squamous intraepithelial lesions should be referred for colposcopy and biopsy, and confirmed cases should be treated with cryotherapy, laser therapy, or loop electrosurgical excisional procedure 8.