Is it justified for a patient with vitiligo and genital warts to request Gardasil 9 (9-valent human papillomavirus vaccine)?

HPV Vaccination for Patient with Vitiligo and Genital Warts

Yes, it is justified for a patient with vitiligo on the penis and genital warts to request Gardasil 9 vaccination, as it can prevent infection with additional HPV types that cause genital warts and HPV-related cancers.

Rationale for HPV Vaccination in This Patient

Protection Against Multiple HPV Types

• Gardasil 9 protects against 9 HPV types:
  • Types 6 and 11 (responsible for 90% of genital warts) 1
  • Types 16,18,31,33,45,52, and 58 (responsible for approximately 90% of HPV-related cancers) 1, 2
• Even if the patient already has genital warts from one HPV type, vaccination can still protect against other HPV types included in the vaccine 3

Age-Based Recommendations

• For males aged 9-26 years, HPV vaccination with Gardasil 9 is routinely recommended 3
• For males aged 22-26 years, Gardasil 9 "may be administered" 3
• For men who have sex with men (MSM) and immunocompromised persons, vaccination is recommended through age 26 years 3
• The FDA has approved Gardasil 9 for individuals through age 45, with shared clinical decision making recommended for those 27-45 years 4

Special Considerations for This Patient

Existing Genital Warts

• Having current genital warts does not contraindicate vaccination 3
• Vaccination is still beneficial as it can protect against:
  • Other HPV types not causing the current infection 1
  • Reinfection with the same HPV type after clearance of the current infection 5
• Important note: The vaccine is not a treatment for existing genital warts or HPV infection 1

Vitiligo Considerations

• There are no specific contraindications for HPV vaccination in patients with vitiligo
• The only contraindications are severe allergic reaction to a previous dose, severe allergy to yeast, or moderate/severe acute illness 6

Vaccination Schedule

Dosing Schedule Based on Age

• For individuals 9-14 years: 2-dose schedule (0,6-12 months) 3, 6
• For individuals 15-26 years: 3-dose schedule (0,2,6 months) 3, 6
• For immunocompromised individuals: 3-dose schedule regardless of age 6

Important Limitations and Expectations

What the Vaccine Cannot Do

• Gardasil 9 will not treat existing genital warts or HPV infection 1
• It does not eliminate the need for appropriate cancer screening 1
• It does not protect against HPV types to which a person has previously been exposed through sexual activity 1
• It does not protect against diseases due to HPV types other than those covered by the vaccine (6,11,16,18,31,33,45,52, and 58) 1

Effectiveness Considerations

• The vaccine is most effective when given before exposure to HPV through sexual activity 3, 4
• However, even sexually active individuals can benefit from vaccination as they may not have been exposed to all HPV types in the vaccine 4
• Limited evidence suggests that HPV vaccination may not prevent recurrence of genital warts in those already affected 7

Clinical Approach

1. Confirm patient's age to determine appropriate dosing schedule
2. Assess for any contraindications to vaccination
3. Provide education about what the vaccine can and cannot do
4. Administer according to recommended schedule
5. Ensure appropriate treatment for existing genital warts is also provided
6. Continue appropriate cancer screening as recommended

Human papillomavirus vaccination offers significant protection against HPV-related diseases and is justified in this patient regardless of current genital warts or vitiligo status.