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Human Papillomavirus

One of the most common human infections in the world is that caused by Human Papillomavirus (HPV). HPV, which is commonly known as “wart virus”, is a microscopic virus particle that infects the skin. In the case of HPV, the infection is actually localized directly to the infected point in the skin, as opposed to herpes simplex, where the virus goes through the skin and into the nerve cells, traveling up the nerve cell connection to the nerve ganglia by the spinal cord, where the virus lives. With HPV, the infection is actually in the skin.

Most infections with HPV are invisible. This means that the virus has entered the skin at some point and altered the DNA structure of the human cell, usually causing no visible or apparent changes in the cellular structure. This happens, literally, in tens of millions of cases. The only way to detect these infections is by performing medical sampling of the skin, either with a swab or with a biopsy, and then the performing in a laboratory of testing for the appearance of HPV DNA in these samples.

Such sampling research has been very revealing. As far back as 1991, the Journal of the American Medical Association revealed that almost 50% of sexually active females seeking evaluation for unrelated conditions at a gynecological evaluation at a University Health Center environment demonstrated positive testing for HPV DNA in the vagina. Thus, a decade ago almost half of sexually active females revealed through testing that they had HPV DNA in their vaginas. These data were an astounding revelation regarding the prevalence of this infection that had never before been noticed.Interestingly in this study fewer than 10% of patients had actual visible, external signs of skin changes consistent with “genital warts”, the most common skin manifestation of HPV. The conclusion, therefore, was that about half of sexually active females in the 20-40 age range were infected with HPV, and fewer than one in ten patients were aware of it.

In the intervening years it has become apparent that the same sort of data applies to males as well. Penile skin can become infected and yet have no outward signs of infection. Only DNA testing for HPV, often on a random basis on the penis, might show such an infection. To accurately find any virus might require multiple samples, and even then the testing might miss the infection.

It is safe to say, therefore, that patients may be carrying HPV infections without any evidence of signs or symptoms and that only comprehensive testing of the genital skin may show it. Even then, the testing may miss it.

Testing for HPV is essentially limited to taking swabs or samples from potentially infected skin area. No truly, consistently effective blood test is available for the infection. Testing includes examination of the specimen of interest for the presence of viral DNA.

With an infection so prevalent in the population, the reader might wonder if the virus is actually very dangerous. After all, if possibly a hundred million people in America alone carry such a chronic infection and apparently have little if any symptoms, does the infection really present any real problem?

The most correct answer to this question is a careful “no”. HPV generally presents little problem. The occasional patients who develop warts on their extremities or elsewhere are usually treated with some sort of chemical or cautery device that destroys the outward sign of the virus. The visible wart is a condition where the DNA of the human skin has been changed by the virus, allowing the skin to develop a tumor-like growth in that area. The growth is generally felt to be “benign” – that is, not a cancer – since it apparently does not spread throughout the body, except possibly to other areas of the skin.

Evidence is beginning to accumulate, however, that HPV may be associated with various other cancers, including cancers of the head and neck. Spreading of these cancers may be due to actual particles of HPV spreading through the bloodstream.1

Evidence has also been shown that infants born to mothers with HPV may, in fact, have contamination of their mouth area with the virus. This study also showed, though, that virtually all of the infants cleared this virus spontaneously over a relatively brief period of time.

Once removed by chemicals or cautery, the wart usually goes away and remains gone. However, the skin surrounding the area from which the wart came usually remains infected with wart virus and may be contagious. The fact that the surrounding skin may still be contagious even though the wart has been destroyed applies to warts on the fingers as well as warts on the genitalia.

Recent published evidence, though, does suggest that many, possibly even most, patients will spontaneously clear up and eliminate HPV infections. This is encouraging, new information for many millions of HPV sufferers. Clinicians have noticed for years that infections with warts on the hands, for example, might spontaneously clear away. Apparently this same sort of clearance of the virus by the immune system happens to many genital HPV sufferers.

However, what is also clear is that many of the strains of HPV, especially some of the ones associated with cervical cancer, are much less likely to clear spontaneously. So, ALL patients who have experienced HPV and/or genital warts must be periodically re-examined to make sure that the affected area is cleared, especially females.

TAKE-HOME MESSAGE 1: Even though a genital wart has been removed, the patient may still be contagious in this area and may still harbor a virus that may be associated, in the setting of females, with cervical cancer.

HPV comes in different “strains”, or types. Certain types, most notably types 16 and 33, are associated with more serious changes in the skin that may lead to cancer. Studies now abound that have shown a close link between these types of HPV and cancer of the cervix. The presumption in these cases is that the patient acquired the HPV through sexual contact, allowing the cervix to become infected with that strain of HPV. Passing years, then, allow the HPV to begin to cause “mutation” in the DNA of the cells of the cervix, eventually resulting in cancer of the cervix.

This association between cancer of the cervix and HPV is well-established and very hard to discount. By now, as many as 90% of cases of cancer of the cervix can have detectable HPV in the cancerous cells. The correct conclusion to draw seems to be that HPV can “cause” cervical cancer. It is even proper to conclude that “unprotected intercourse can lead to cancer of the cervix”.

Fortunately the changes in the cells of the cervix are gradual. Cells may become “atypical”, sometimes being mistaken for the irritation seen in cells of the cervix associated with common vaginal and cervical infections, such as “vaginitis” or “cervicitis”. However, later changes become evident on the PAP smear through such features as “Cervical Intraepithelial Neoplasia” (CIN), which means that a tiny cancerous change has been found actually within the cells of the cervix. Such changes call for prompt action.

The first action, of course, is that any female who is of child-bearing years, especially if this female is sexually active, should have regular physical examinations by a knowledgeable gynecologist skilled in the area of evaluation and management of “cervical dysplasia”. This examination includes the regular visual examination of the cervix as well as the use of the PAP smear to examine for any evidence of abnormal cervical tissue. Only through these regular examinations can a patient at risk for contracting HPV be protected of these most serious consequences of the disease.

TAKE-HOME MESSAGE 2: Every sexually active person, especially females, should establish contact with a skilled physician who can examine the patient at regular intervals to rule out the possibility of HPV infection.

TAKE-HOME MESSAGE 3: Every female having sexual activity should have regular PAP smears, even if a hysterectomy has been performed.

Treatment of HPV Infections

Please make sure that you have read the discussion on the cause of HPV infections and the risks involved with these infections posted on this site.

Since it is nearly impossible to tell whether most people have HPV infections with a high degree of accuracy, then it is obvious that most people who carry HPV will not end up undergoing any treatment because the infection is not detected. For this reason, virtually all HPV transmission to sexual partners goes undetected and, thusly, untreated.

Simple warts are treated by killing both the skin of the wart itself and usually the skin directly beneath the wart. The theory is that the wart is extremely contagious with a high load of HPV virus, and the destruction of the wart is called for. The skin beneath the wart must be destroyed because this is actually the area from which the wart grew. If the skin beneath the wart is not destroyed, then the wart may return.

Often this treatment is curative with no further warts resulting. Also, the destruction of the wart and its underlying skin creates an inflammatory response in the body which seems to assist the body in preventing further wart formation, especially in the area of the wart itself.

Herbal treatments are available, if unproved in the scientific literature. Certain topical essential oils have been shown to have antiviral properties for HPV in the scientific literature. A preparation called “Warts No More” is available without prescription at www.fonoils.com. Speak to Peter Klapper, the original researcher and discoverer of the preparation with any questions that you may have.

Some encouraging results have been shown using the electrophoresis technique with a silver electrode available at www.dermaseptic.com. Scientific data is sparing on this technique, at this writing.

Other medical treatments are very useful. Salicylic acid preparations are very effective in directly dissolving the wart and have been time-tested for years. Often this acid creates a local inflammation in the area of the wart, creating the immune response mentioned above. Many such wart remedies are available in the marketplace. Other acid preparations are available for use by physicians which are much quicker and stronger, sometimes requiring analgesia for pain relief.

A recent preparation, Aldara, from 3M, contains a chemical called “imiquimod”. This chemical is said to stimulate the immune system of the body apparently through the production of “cytokines” that can cause the body to destroy cells infected with the virus. On the average, after about four months of treatment, about sixty per cent of patients overall clear their wart-type lesions. This chemical is not made for internal lesions. It is not indicated for herpes at this time, though a related chemical is being tested for genital herpes.

Electrocautery and laser are very effective in directly destroying both the wart as well as the skin beneath it. Such treatment usually leaves a small hole in the skin, perhaps 2 millimeters or more, in the area where the wart was destroyed. This hole is actually a third-degree burn, and the skin heals “circumferentially”, closing in slowly from the area around the burned hole. This therapy is very specific, very quick, and much more expensive than the acid therapy. These treatments often require local, or sometimes even general, anesthesia so that the patient can tolerate the treatment.

Treatment of abnormal cervical tissue, including CIN (mentioned above), is usually carried out by either direct acid treatment of the affected areas, by laser, or by similar instruments which can actually destroy the infected part of the cervix. Such treatment is highly successful and time tested. However, even after such treatments, the patients with CIN must be carefully monitored to make sure that the patient remains free of disease. Else, a cervical cancer may develop even in a patient previously treated for CIN.

Vaccines to treat warts are, at this time, still far into the research future. Hopefully some sort of inoculation will be available which will stimulate the body to eradicate HPV from infected cells. Research is ongoing throughout the world to determine if it is even possible for the immune system of the body to in fact be able to remove HPV DNA from infected cells. Only time will tell. We will continue to actively monitor research to determine when such therapies can be recommended.

Prevention of HPV Infections

This discussion will make a distinction between non-genital and genital infections for the purpose of covering the aspects of prevention.

HPV is transmitted to another area of the body or to another person through the contact by an infected piece of skin with a non-infected piece of skin. The presumption is that the non-infected area has to have a small, perhaps microscopic, break in the skin that allows a tiny amount of tissue from the infected area to get into the non-infected area, allowing an infection to set up.

It is easy to imagine that someone with a wart on a finger might scratch an itch elsewhere on the body and transmit the virus to that area. This is a common way in which warts are spread around on different areas of the same person.

Warts are also contagious, excreting large loads of HPV viral particles. If a person with a wart on a finger were to touch a genital area in a manner vigorous enough to slightly break the skin, this might transmit the virus to that area.

The same thing applies to intimate contact between partners. If a person with a wart anywhere on that person’s body were to place that area in contact with the genitalia of the other person, this could cause the wart virus to be transmitted to the genital area of the partner. This applies to warts on fingers as well as warts on the genitals of the infected partner.

Sadly, most areas of skin that possess HPV infection have no outward signs. Thus, the infection may be transmitted to the uninfected area of a partner without any knowledge of this fact by either partner. This is the manner in which almost all HPV infections are apparently transmitted. So, practically, if partners choose to have direct skin-to-skin contact between genitalia, then it may be impossible to know if HPV virus is being transmitted or not.

Latex condoms are effective in preventing transmission of HPV to partners. The condom must cover potentially infected areas completely. If a partner has no outward signs of infection on an area high on the penis near the scrotum, for example, the partner may in fact spread HPV to a partner even while wearing a condom. Thus, it is reasonable to use latex condoms, but no complete assurance can ever be given that the condom will be completely protective.

Various plastic membranes are available for females now which may be very effective at preventing transmission of most STD’s, not just HPV. Such devices must be of an appropriate size for the female, even perhaps requiring proper fitting by a medical provider such as a gynecologist for maximum protection and comfort. As mentioned above vaccines are not yet available that can provide protection for people who do not yet carry the virus.

Exciting new research is ongoing suggesting that perhaps “chemical condoms” for females, and/or “Intravaginal Release” medications may be very effective in preventing transmission of a broad range of STD’s, including HPV. While no final information is yet available at the time of the posting of this article regarding the potential release date for this material, we have found through our research that exciting trials are beginning in Europe this year. We will continue the regular monitoring of ongoing research to determine when or if such materials or devices will become available.

Conclusion

Infections with Human Papillomavirus are extremely common in society, perhaps infecting most people. While most infections are benign and rarely cause any symptoms, the risk factors for cancerous changes in females in the cervix area is a serious threat to women and to the public health. Regular examination by qualified medical professionals, regular self-inspection by patients of their genital areas, use of latex condoms, use of other barrier devices, and possibly the use of “alternatives in intimacy” (see elsewhere on www.herpes.org) may allow for a dramatic decrease in the transmission of HPV and it resulting consequences.

Summary of Take-Home Messages

TAKE-HOME MESSAGE 1: Even though a genital wart has been removed, the patient may still be contagious in that area.
TAKE-HOME MESSAGE 2: Every sexually active person, especially females, should establish contact with a skilled physician who can examine the patient at regular intervals to rule out the possibility of HPV infection.
TAKE-HOME MESSAGE 3: Every female having sexual activity should have regular PAP smears, even if a hysterectomy has been performed.

Reference
1 Capone RB, Pai SI, Koch WM, Gillison ML, Danish HN, Westra WH, Daniel R, Shah KV, Sidransky D, Detection and quantitation of human papillomavirus (HPV) DNA in the sera of patients with HPV-associated head and neck squamous cell carcinoma. Clin Cancer Res 2000 Nov;6(11):4171-5

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