Vulvar manifestations of human papillomavirus infection.

As technology continues to improve, we are increasingly able to detect the presence of HPV in both clinically diseased and histologically and clinically normal vulvar tissue. Unfortunately, the technology for effective treatment of these conditions has not advanced as rapidly. Still, fundamental information about the interaction of HPV with the host cell continues to be collected and will provide us with an increased understanding of the importance of latent infection and its progression to clinical vulvar disease. There are a host of therapeutic modalities available for the treatment of HPV-associated conditions of the vulva, ranging from simple topical medication like podophyllin to sophisticated combination therapies involving carbon dioxide laser destruction in conjunction with interferon. Regrettably, there is no "magic bullet" that is totally effective for any of the HPV-associated vulvar diseases. This makes it more important to weigh the benefits and morbidity of treatment regimens before they are used. Until the success rate of available therapies improves, it is important to have definitive goals for therapy, because it is currently impossible to completely eradicate HPV from tissues. Examples of therapeutic goals might range from removal of visible lesions or treatment of symptomatic areas to treatment of premalignant or malignant lesions. At present, perhaps the most important service we can provide for patients is close follow-up of HPV-associated vulvar diseases in an attempt to prevent the development of invasive malignancy. Regardless of the choice of treatment, the primary objective of the clinician should be to help the patient but to do no harm.

Office therapy for human papillomavirus infection in nongenital sites.

The many different treatment possibilities for the eradication of warts provide evidence that no single method that is completely effective has been found. Although the various methods described herein are usually successful therapies for warts, they are all associated with treatment failures and side effects. Until the perfect cure for warts is discovered, the physician must evaluate every wart carefully before deciding on a course of action.

Ancillary diagnostic tests for detection of human papillomavirus infection.

A variety of ancillary tests useful in the diagnosis of HPV infection are currently at the clinician's disposal. Use of 5% acetic acid for detection of inapparent HPV infection is a simple procedure that can be performed in any office setting. Colposcopy is useful alone or in combination with the use of acetic acid but may not be as readily available. Use of laboratory-based tests is gaining popularity as an adjunctive measure, particularly in combination with Papanicolaou smears, for the detection of cervical carcinoma or intraepithelial neoplasia. Although the most readily available ancillary laboratory tests are the immunologically based tests, they suffer from lack of sensitivity. The more sensitive and specific DNA hybridization tests, such as the dot blot and the Southern blot, are being adapted for general clinical use. These hybridization tests will allow routine screening of patients for infection with potentially oncogenic HPV types. The PCR is perhaps the most exciting new development in hybridization technology. This technique is the most sensitive technique available, allowing amplification of amounts of HPV DNA as small as a single copy. With further development and automation of this technique, the clinician will soon have an almost unlimited ability to diagnose occult HPV infection.

Epidermodysplasia verruciformis-associated papillomavirus infection complicating human immunodeficiency virus disease.

Three males infected with the human immunodeficiency virus (HIV) were noted to have extensive flat warts of the face and/or body. In two there were also pityriasis versicolor-like lesions. Biopsies showed foamy, basophilic, distended cytoplasm in granular layer keratinocytes, characteristic of the human papillomavirus types seen in epidermodysplasia verruciformis. DNA hybridization techniques demonstrated the presence of HPV-type 8 in one patient and HPV 5 and 8 in another. Patients with immune suppression due to HIV infection may demonstrate the clinical features of epidermodysplasia verruciformis with the same potentially oncogenic HPV types.

Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection.

Papillomavirus DNA has been reported recently in the vapor (smoke plume) derived from warts treated with carbon dioxide laser; this raises concerns for operator safety. We therefore have studied a group of human and bovine warts to define further the potential risk of wart therapy and to test whether a surgical mask could reduce exposure. Half of each wart was treated with carbon dioxide laser and the other half with electrocoagulation. The vapor produced by each form of therapy was collected with a dry filter vacuum apparatus and analyzed for the presence of papillomavirus. Vapor from human plantar warts was analyzed for the presence of human papillomavirus DNA, because there is no infectivity assay for human papillomavirus. Of plantar warts treated, five of eight laser-derived vapors and four of seven electrocoagulation-derived vapors were positive for human papillomavirus DNA. Greater amounts of papillomavirus DNA were usually recovered in the laser vapor than in the electrocoagulation vapor from the same wart. Bioassay readily detected infectious bovine papillomavirus in the vapor from bovine warts treated with either modality; more virus was present in laser-derived material. A surgical mask was found capable of removing virtually all laser- or electrocoagulation-derived virus, strongly suggesting that such masks can protect operators from potential inhalation exposure to papillomavirus.

Delayed healing in full-thickness wounds treated with aluminum chloride solution. A histologic study with evaporimetry correlation.

Optimizing wound healing parameters seems to be the utmost importance in the present age of sophisticated wound care and dressings. We studied the effect of two hemostatics: 30% aluminum chloride and ferric subsulfate (Monsel's solution) on the rate of wound healing in Yucatan miniature hairless pigs. Wound healing was examined in occluded and nonoccluded full-thickness 3-mm punch biopsy wounds. Wounds were treated either with 30% aluminum chloride solution or ferric subsulfate solution or were allowed to clot with minimal pressure from a gauze pad. The course of wound healing was followed utilizing evaporimetry readings from the wound sites in addition to periodic histologic examination in an attempt to correlate the evaporimetry readings with corresponding histology. Delay in reepithelialization was noted histologically both in wounds treated with aluminum chloride and in those treated with ferric subsulfate compared to controls. Presumably this delay was the result of tissue necrosis caused by these hemostatic agents, resulting in slightly larger and less cosmetically acceptable scars. Plots of evaporimetry data revealed a biphasic pattern of water loss during healing, with an initial rapid decline in water loss followed by a much slower decline. Histologic reepithelialization seemed to correlate best with the point on the evaporimery curve where the slope changed from the phase of rapid water loss to a slower rate.

Blastomycosis-like pyoderma--report of a case responsive to combination therapy utilizing minocycline and carbon dioxide laser debridement.

Blastomycosis-like pyoderma is an uncommon reaction pattern to a superficial bacterial infection in persons with a variety of predisposing conditions such as chronic ethanol use and poor nutrition. We are reporting a case that initially responded poorly to previously described treatment regimens but responded well to combination treatment with carbon dioxide laser debridement and long-term minocycline.

Premature sebaceous gland hyperplasia: successful treatment with isotretinoin.

Hyperplasia of sebaceous glands is a common cause of papulonodular facial lesions that occur in middle-aged and older patients. Recently, several cases of premature sebaceous gland hyperplasia have been reported. In these patients the lesions had persisted despite vigorous attempts at therapy. We present a case of premature sebaceous gland hyperplasia that was successfully treated with isotretinoin.

CO2 laser treatment of trichoepithelioma with focused and defocused beam.

A patient with multiple trichoepithelioma was treated with the carbon dioxide (CO2) laser. The beam was utilized in a defocused mode for debulking and exposing the tumors. The focused mode was used for destruction of the dermal remnants of the tumors and in the sculpting of lesions to match the contour of the external ear. Examination of lesional tissue for the presence of estrogen or progesterone receptors revealed the absence of these receptors.