On the later end of the bell curve

[winnebago]

Hi Dr. H,

Congratulations on such a prestigious award earlier this year!

Background:
--Diagnosed with low-risk genital warts on my perineum 18 months ago. Certainly at right of bell curve.
--32 year-old-female.
--A few small outbreaks within the first few mos.
--Had no gws for a period of 6 mos. Then got an outbreak that was about 4 small warts, the most I've ever had to my knowledge.
--Cleared. 6-7 mo with no symptoms. Then, Less than a week ago I got another outbreak.
--Have not been sexually active since diagnosis.
--New fellow in my life. Mid-30's, few sex partners likely > 3 (thinking of your exposure stats)
--Had planned on having sex based on your experience w/ patients who have been symptom-free for 6 months or more not spreading it to partner.

1. Due to the location of warts, can rubbing/friction cause them  to pop up? I.e  Can jogging, and thus friction in the area promote an outbreak? Sex?

In other posts you've mentioned that w/i 3-4 mo period after wart clears, would make sense to tell any potential partners. Clearly, I have entered two separate symptom-free periods at or longer than 6 mos. I don't feel comfortable making a decision based on the assumption that he may have been exposed. Instead working from no exposure to gw strain(s) I have:

2. Your recommendation on how long we should wait after this outbreak settles to ensure (as much as possible) that I will not spread it to him?

3. Does it make sense for me to get the strain tested from biopsy I'll have done in my doctor's visit this week? And, if it is 6 or 11, does it make sense for him to get the vaccine? (Cost of vaccine aside.)

4. Is it reasonable for me to still have hope that I might fall within that 2 year period of clearing the virus and no longer having symptoms?

Thanks in advance for your assistance and for dedicating your professional pursuits to educating and supporting so many of us! Your impact is immeasurable!

[Edward W Hook, MD]

Thanks for the clarification. Working through your questions:

1.  I am not aware that jogging or other minor trauma casues HPV to re-activate.

2.  As I said, still 3-4 months.

3.  I favor the vaccine for men and would not bother with the expense of getting the HPV typed.  Even if your wart was due to another type of HPV, there appears to be some limited amount of cross-protection for the types of HPV not contained in the vaccine.

4.  Yes although without a doubt your situation is, as you say, on the far end of the bell curve.

Finally, I understand your concern for your BF.  I would add however that should he acquire HPV from you, his course of disease may not be the same as yours.  I realize that this is not all that reassuring but it is the case.  EWH

[Edward W Hook, MD]

Glad to hear of your biospy results.  Long story short, the terms you mention are in no way related to HPV infection or warts. Time to put that concern aside.  

Regarding your final question, there are over 100 different types of HPV. There are no data to suggest that having had low risk genital HPV infection places you at risk for other sorts of HPV.  I would try not to worry.

This will end this thread. Take care.  EWH

[winnebago]

I spoke with my doctor today regarding the biopsy and she reiterated that it was not condyloma nor was it anything cancerous. I interpreted her saying that it was not condyloma as meaning it was not hpv, perhaps erroneously? She mentioned a few things such as "polipoid mucosa" and basically said that it could have been a skin tag.  I find it hard to believe that I would suddenly get a skin tag in the same exact spot where my wart(s) have been, especially because I am careful to avoid friction and I don't have any other skin tags in the area.

Akin to your reply, when I directly asked about the potential that the homeopathic topical application (thuja, lomatium & vitamin A in a cocoa butter base) suppressed the virus to an undetectable state, she didn't refute that it was possible. My immune system marches to the beat of it's own drum so I am used to unusual things happening.

Nonetheless, in the long run it is a moot point, as my boyfriend is getting vaccinated and we are waiting for 6 months anyway. I just like to track my experience with the virus to detect anything that might be triggers.  

If I have not surpassed the number of questions allotted to me: Does having low-risk genital strain(s) of hpv make me more susceptible to catch facial flat warts? My boyfriend was recently diagnosed with warts on his face that he's had for years, but didn't realize.  Clearly my immune system is struggling a bit with the genital strains. I must have definitely come in contact with them with my face, hands, etc.and am wondering whether or not I should be on the look-out.

Thanks for all of your assistance.

[Edward W Hook, MD]

The cream you used might have modified the nature of the lesion you had to make it unrecognizable as anything specific however that would be rather unusual.  I would press whomever did the biopsy for a cleared description of whether or not it was HPV.  There are many other sorts of skin lesions which can be mistaken for HPV.  EWH

[winnebago]

An update:
The most recent biopsy taken was not a condyloma. I have no idea what it was, as it felt exactly like the warts I've had in the past and was in the same spot as the others. I was using a homeopathic cream that had made them go away the last time, so I'm wondering if it could have interfered with the biopsy this time, or if it was some other weird skin condition. Perhaps there's no way to know for sure.

My boyfriend went ahead and started the vaccine, so to be on the safe side, we"ll probably still stick with the plan of waiting until he is finished with it, whether or not this episode was a wart or not.

[winnebago]

Thanks a bunch for your insight!

As a side note, I'm actually grateful that, overall, I am responsive to surgical and homeopathic routes of treatment and my outbreaks aren't ever bad. Typically one wart, never more than four or so. It's more of a concern that he'd get a less responsive case. Anyhow, thanks again!

[winnebago]

Thanks for your reply. I forgot that the two of you moderate this forum. Sorry about that. I actually had lots of the information you're asking in the initial post but it exceeded the character limit and I had to trim it down.

They have indeed been biopsied 5 times and always came back as low-risk condyloma. Additionally, I recently had something on my groin area that was suspect and that was, indeed, just a skin tag.

So, now that it has been established that they've been biopsied and confirmed as gws, I'd be grateful if you can re-address the questions 2-4.

Also points of clarification:
Re Question1: I actually was referring not about transmission to someone else, but could the friction from jogging and sex cause me to get additional outbreaks. The two times over the past year and a half that I attempted to start jogging again, I got outbreaks. I'm trying to gauge if it is coincidence or not. Also, could sex possibly reactivate my current strain(s) and cause warts?

Re: Question 3: I did, indeed get the vaccine. I was referring to whether or not it made sense for my boyfriend to get the vaccine, working on the premise that there is a good chance he has not been exposed to the strains that cause genital warts. I was wondering if it makes sense for me to send my biopsy for genotyping so that if it came back as something other than 6 or 11 I would know that the vaccine would not provide protection for him against the strain(s) I have. (I know there are no definites and that he may have already been exposed, as I noted in the first post.)

Unfortunately, while condoms offer some protection they are not going to be as effective because, as I mentioned the warts are on my perineum, making his scrotum among other areas not covered by the condom, prime candidates for friction with the area. With all due respect, while most sexually active people have HPV, it is not a situation where most have a strain that can cause genital warts. It is the symptoms and the anxiety, recurrences, doctors visits, and multiple treatments that may or may not work that I would like to protect him from. While there are worse things out there, people's individual experiences with genital warts varies and recent qualitative studies are showing how psychosocially harmful it often is. I feel that those effects are so often overlooked.  

Thanks again for your earlier reply, and thanks in advance for your additional input.

[Edward W Hook, MD]

Welcome to the Forum.  Dr. Handsfield and I share the forum.  You got me.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.   Thanks for the comments regarding Dr. Handsfield’s award.  he certainly does deserve it.  Now, on to your questions.

Before I work through your questions, let me ask a few additional questions which may help me to help you.  First, are you sure that these are warts?  How were they diagnosed?  The reason I ask is that there are other dermatological conditions that can mimic warts. Furthermore, since the treatment of warts is essentially destructive in nature, many such wart-like, appear to "respond" to therapy for warts.  One of the things which mimics warts quite often and can occur in the areas you describe are what are called "skin tags" which do occur in areas of friction.  Now, on to your questions:

1.  Friction creates microscopic abrasions which absolutely do increase the risk of HPV transmission.  While there are, unfortunately, exceptions to every "rule", I stand by our repeated statements that after 3-4 wart-free months, transmission is not an issue.  The course you describe is part of what makes me wonder if these are really warts?

2.  See above, 3-4 months.  In the meantime, condoms reduce the risk of HPV transmission by about 60% in carefully conducted studies.  

3.  I think having a biopsy is a reasonable approach because of the reasons I have mentioned above.  As for HPV vaccine, emphatically YES.   Studies prove that even in persons who have had warts before, the vaccine is helpful due to its effect on other HPV types.

4.  The first step is to be sure that this is HPV.  I have my doubts.

Finally, a comment about HPV and warts.  I appreciate and admire your concern about the possibility of spreading infection to your partner.  On the other hand, please remember that is these are warts and if he were to get them, it would not be the "end of the world, particularly if you had discuss the issues with him.  For better or worse, at present HPV is a "fact of life" and most people have it or will have it at some point in the future.  Despite this fact, only a tiny minority of persons with HPV get the consequences of infection (primarily women and primarily cancer and pre-cancerous lesions).  HPV is the most commonly acquired STD.  Over 85% of sexually active women will have HPV infection at some time in their lives.  The figure for men is less well studied but similar.   In some HPV will cause genital warts, in others it will not cause warts but may lead to changes in PAP smears.  In a very small minority of women, HPV infection can persist and lead to the pre-cancerous lesions that PAP smears detect and which can then be treated.  For men there is far less risk of any sort.

I hope my comments are helpful to you. EWH