Human Papillomavirus and Genital Warts

BackgroundWe aimed to determine (i) if other sexually transmitted infections (STIs) increase the risk of incident human papillomavirus (HPV) infection and (ii) if HPV infection predicts the incidence of other STIs.MethodsWomen aged 20–38 years were followed semi-annually for 18 months in Thailand (n=1200). Assessment was made on cervical HPV genotypes, cervical cytology, sexual behaviour, demographic factors and diagnoses of other STIs including chlamydia, gonorrhoea, syphilis, genital herpes and trichomoniasis. Incident detection was defined as any type-specific HPV or other STI which was detected at current visit but not at previous visit. Associations were measured by ORs with 95% CIs estimated in generalised estimating equation models.ResultsDuring follow-up, 241 new cases of HPV, 110 incident cases of high risk (HR)-HPV and 46 new cases of other STIs were observed. Diagnosis of other STIs at previous visit was statistically significantly associated with twofold increased odds of any new HPV detection after controlling for sexual behaviour, age, pap smear status and contraceptive use [adjusted OR (aOR): any HPV: 2.16 (95% CI: 1.08% to 4.34%)] (Abstract O1-S02.02 table 1). No significant association was found between diagnosis of other STIs and subsequent incident detection of HR-HPV [aOR: 2.01 (95% CI: 0.74% to 5.48%)] (Abstract O1-S02.02 table 1). Positive detection of any HPV or HR-HPV predicted nearly twofold increased odds of other STIs with the estimates bordering on statistical significance [aORs: any HPV: 1.81 (95% CI: 0.94% to 3.49%); HR-HPV: 2.00 (95% CI: 0.82% to 4.83%)] (Abstract O1-S02.02 table 2).Abstract O1-S02.02 Table 1Unadjusted and adjusted estimates of detection of other STIs on HPV incidence (total number of visit pairs=3221)Number of visit pairs N=3221Incident detection at current visitUnadjusted OR† (95% CI)Adjusted OR† (95% CI)Diagnosis of the following at previous visitN (col %)New cases of any HPV, n= 241(7.5%) n (row%)New detection of any HPV type across consecutive visitsSTIs other than HPV infection* No3158 (98.0)230 (7.3)1.01.0 Yes63 (2.0)11 (17.5)2.46 (1.31 to 4.62)2.16 (1.08 to 4.34)New cases of any HR-HPV, n=110 (3.4%) n (row%)New detection of any HR- HPV type across consecutive visitsSTIs other than HPV infection* No3158 (98.0)105 (3.3)1.01.0 Yes63 (2.0)5 (7.9)2.42 (0.93 to 6.27)2.01 (0.74 to 5.48)* STIs other than HPV infection included the following: laboratory diagnoses of genital chlamydia, gonorrhoea, syphilis, as well as clinical diagnoses of genital herpes or trichomoniasis.† Estimates adjusted for age and study site at enrolment, as well as the following covariates assessed at each follow-up visit: pap smear diagnosis at previous visit, contraceptive use in last 6 months, number of lifetime partners, partners having sex with others in last 6 months, having new partner in last 12 months, male partner using condom in last 6 months, number of partners in last 6 months.HPV, human papillomavirus; HR-HPV, High-risk HPV, defined as HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 (IARC 2007); STIs, sexually transmitted infections.Abstract O1-S02.02 Table 2Unadjusted and adjusted estimates of HPV detection on incidence of other STIs (total number of visit pairs=3221)Detected with the following at previous visitNew cases of other STIs, n=46 (1.4%) n (row%)New detection of other STIs across consecutive visitsAny HPV No2590 (80.4)31 (1.2)1.01.0 Yes631 (19.6)15 (2.4)1.94 (1.05 to 3.58)1.81 (0.94 to 3.49)New cases of other STIs, n=46 (1.4%) n (row%)New detection of other STIs across consecutive visitsAny HR-HPV No2930 (91.0)38 (1.3)1.01.0 Yes291 (9.0)8 (2.7)2.14 (1.00 to 4.61)2.00 (0.82 to 4.83)Estimates adjusted for age and study site at enrolment, as well as the following covariates assessed at each follow-up visit: pap smear diagnosis at previous visit, contraceptive use in last 6 months, number of lifetime partners, partners having sex with others in last 6 months, having new partner in last 12 months, male partner using condom in last 6 months.Covariates that were found to be statistically significantly associated with the outcomes (p<0.05) and/or significantly influence the effect size of the primary association of interest (≥10%) were included in the final models for confounding control. Parity, smoking status, and other factors measured, such as age of sexual debut and frequency of sex in last 6 months,did notsatisfy these criteria in the data analyses and hence werenotincluded in the final models.HPV, human papillomavirus; HR-HPV, High-risk HPV, defined as HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 (IARC 2007); STIs, sexually transmitted infections.ConclusionsWe show that other STIs increase the risk of HPV incidence after controlling for sexual behaviour. The data qualitatively suggest mutual associations of HPV with other STIs. Further studies are warranted to evaluate if these reflect true biologic interactions between HPV and other sexually transmitted microbial agents, or mere confounding from unmeasured sexual risks.

Objective To determine the genotypes of human papillomavirus (HPV) and to estimate their correlations with recurrence of perianal and anal condyloma acuminatum (CA) among men who have sex with men (MSM) in Shanghai.Methods Tissue specimens were obtained from the lesions of perianal or anal CA in 57 MSM.Flow-through hybridization and gene chip were used to determine the genotypes of HPV in these specimens.Follow-up was carried out to observe the recurrence of CA in these patients after CO2 laser treatment.Results Of the 57 specimens,56 (98.2％) were positive for HPV,and a total of 11 HPV subtypes were identified.The predominant genotypes were HPV 11 (42 cases,75％ ) and HPV 6 (30 cases,53.6％),sequentially followed by HPV 16 (8 cases,14.3％),HPV 18 (4 cases,7.1％),HPV 33 (2 cases,3.6％),HPV 59(2 cases,3.6％),HPV cp8304 (2 cases,3.6％),HPV 31 (1 case,1.8％) and HPV 35 (1 case,1.8％).Of the HPV-positive specimens,64.3％ (36/56) harbored low risk HPV types (11 and/or 6),and 35.7 ％ (20/56) harbored high risk HPV types.Among the 20 specimens positive for high risk HPV,17 (85％) harbored both low risk- and high risk-HPV genotypes.During the 6-month follow-up after CO2 laser treatment,recurrence was observed in 95％ of patients with high risk HPV and 66.7％ of patients with low risk HPV (P ＜ 0.05).Conclusions Among MSM with perianal and anal CA in Shanghai,the predominant genotypes of HPV are low risk types 11 and 6; high risk HPV infection is usually complicated by low risk HPV infection; the recurrence of CA is higher in patients with high risk HPV than in those with low risk HPV. Key words: Condylomata acuminata; Human papillomavirus; Homosexuality; Male

The Human Papilloma Virus is the most common sexually transmitted infection worldwide. More than 200 different genotypes have been identified so far, and they are classified in five genera (Alpha, Beta, Gamma, Mu and Nu) [1]. Most of the infections caused by these types are transient and asymptomatic, since they are rapidly cleared by an intact immune system. However, HPV may cause clinical manifestations of variable severity. About 40 mucosal genotypes have been associated with the development of anogenital lesions [2]. These span from benign warts (condylomata), mainly caused by the low-risk HPV 6 and 11, to cancerous lesions, caused by high- risk (HR) types (e.g., HPV 16 and 18). Indeed, HR-HPV are implicated in the development of most cervical (close to 90% of the cases), anal (>80%), vulvar (around 40%), vaginal (around 70%), penile (around 50%) and oropharyngeal (13–56%) cancers. Because of the ascertained link between anal HPV infection and anal cancer development, and, in particularly, the increasing incidence of this neoplasia over the last years, the interest on the burden of anal HPV infection has been growing. Indeed, about 88% of anal cancer cases worldwide are associated with HPV infection 2. HPV 16 (75–80%) and HPV18 (about 3.5%) represent the most prevalent types in this neoplasia [3]. Most sexually active persons will have detectable HPV at least once in their lifetime [4]. The estimated incidence of HPV infection is high, with 14 million persons infected annually and 79 million persons with prevalent infection [5]. In the last years it emerged that in Italy the anogenital warts were more frequent (40,871 cases, 39.7% of the total) among other sexually transmitted diseases as latent syphilis (9190 cases, 8.9% of the total), bacterial cervicovaginitis (8798 cases, 8.5% of the total) and genital herpes (7860 cases, 7.6% of the total). In particular the anogenital warts were the most frequent pathologies among men (30,092 cases, 41.5% of total men) (http://www.iss.it/ccoa/index.php?lang=1&id=55&tipo=4). HPV-associated diseases include anogenital and other mucocutaneous warts as well as cervical, anal, vaginal, vulvar, penile and oropharyngeal cancer [1]. Anogenital warts (AGWs) (also known as genital warts, condylomata acuminata, condylomas) are benign proliferative lesions caused by human papillomavirus (HPV) types 6 and 11, which are found in >95% of lesions [1, 6]. AGWs are often co-infected with “‘high-risk” HPVs such as HPV 16–18. Genital warts are sexually transmitted, with transmission rates of about 60% between partners [7].

Human papillomavirus (HPV) infection is a leading cause of cervical cancer. Although this relies on infection and persistence of HPV in epithelial cells, often occurring in the context of other sexually transmitted infections (STIs) and bacterial vaginosis (BV), data on the relationships between these and their relative effects on epithelial barrier integrity in women remain sparse. This study describes the epidemiology of HPV combined with STI and/or BV prevalence and the relative impact on matrix metalloproteinases (MMPs) among South African women. Roche Linear Array was used for HPV genotyping in menstrual cup pellets of 243 HIV-negative women participating in the CAPRISA 083 cohort study. Vulvovaginal swabs were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis using Xpert® CT/NG assay and lateral flow assay, and Gram staining was performed to diagnose BV using Nugent scoring criteria. Concentrations of 5 MMPs were measured in menstrual cup supernatants by multiplexed ELISA. Fisher's exact tests, Mann-Whitney U tests, and multivariable regression models determined associations between HPV infection, STI and/or BV, and MMP concentrations. HPV was prevalent in 34% of women (83/243; median 23 years, interquartile range (IQR) 21-27 years). Low-risk (lr) (71%, 59/83) and high-risk (hr)-HPV infections (54.2%, 45/83) were common. Hr-HPV was frequently detected in STI and/or BV-positive women compared to women without STIs or BV (p = 0.029). In multivariable analysis, BV was associated with increased odds of hr-HPV detection (OR: 2.64, 95%CI: 1.02-6.87, p = 0.046). Furthermore, Gardasil®9 vaccine-type strains were more frequently detected in women diagnosed with STI and/or BV (55.2%, 32/58 vs 24%, 6/25; p = 0.009). Among STI and/or BV-positive women, HPV detection was significantly associated with increased MMP-10 concentrations (b = 0.55, 95% CI 0.79-1.01; p = 0.022). Most women with hr-HPV had another STI and/or BV, emphasizing an urgent need for STI and BV screening and intensive scale-up of cervical cancer screening and HPV vaccination programmes. Furthermore, the study highlights the need for more extensive research to confirm and understand the relationship between HPV infection and barrier integrity.

Human Papillomavirus Genotypes and Anal-Related Lesions Among HIV-1-Infected Men in Milan, Italy

Objective To compare the prevalence and genotype distribution of human papillomavirus（HPV）between human immunodeficiency virus（HIV）-positive and-negative populations. Methods Patients with condyloma acuminatum or persons who recently had sexual contact with patients with condyloma acuminatum were enrolled into this study, and classified into HIV-positive group（n = 62）and HIV-negative group（n = 2 716）. GeneChip analysis was performed to detect HPV and determine HPV genotypes in mucocutaneous samples collected from the external genitalia of these subjects. Statistical analysis was carried out by chi-square test using the SPSS software version 19.0. Results The prevalence rates of HPV infection, high-risk HPV types and low-risk HPV types were significantly higher in HIV-positive persons than in HIV-negative persons（74.19%（46/62）vs. 42.30%（1 149/2 716）, 67.74%（42/62）vs. 29.57%（803/2 716）, 58.06%（36/62）vs. 24.71%（671/2 716）, respectively, all P < 0.01）. The detection rate of HPV was also increased in HIV-positive men compared with HIV-negative men（92.11%（35/38）vs. 37.38%（382/1 022）, χ2= 45.98, P< 0.01）. Although the top three genotypes of low-risk HPV were types 6, 43 and 11 in both HIV-positive and-negative groups, the prevalence rate of HPV 6 was 37.10%（23/62）in HIV-positive group, but only 11.12%（302/2 716）in HIV-negative group. The top five genotypes of high-risk HPV were types 16（22.58%, 14/62）, 52, 66, 58 and 18 in HIV-positive group, and types 16（7.77%, 211/2716）, 58, 56, 66 and 52 in HIV-negative group. Coinfections with multiple HPV subtypes were common in both groups, and the number of concurrent HPV genotypes was as high as 8 in HIV-positive group, and 9 in HIV-negative group. The prevalence rate of coinfections with three or more HPV genotypes in HIV-positive group was significantly higher than that in HIV-negative group（65.21%（30/46）vs. 16.71%（192/1 149））. Conclusions Compared with HIV-negative populations, HIV-positive populations show elevated prevalence of HPV infection, high-risk HPV genotypes and low-risk HPV genotypes. Moreover, the prevalence of HPV is higher in HIV-positive men than in HIV-negative men. These findings are worthy of further attention in clinic. Key words: HIV infections; Papillomavirus infections; Alphapapillomavirus; Superinfection

HPV vaccines in Brazil and the world

Objective To explore the distribution of human papillomavirus ( HPV ) types in patients with condyloma acuminatum ( CA ) and to investigate the association of viral types with recurrence of the disorder.Methods Electrocautery was performed in 130 patient to remove lesions with CA.The HybriMax was used to detect human HPV types in the skin lesion.After electrocautery,all the patients received intramuscular injections of BCG-PSN for two cycles.The incidence of recurrence and the HPV types of patients with recurrent CA were recorded within 6 months after treatment.Results The positive rate of HPV-DNA was 94.62％.13 types of HPV were detectable,of which low-risk HPV6 was 47.69％and HPV11 was 27.69％,accounting for a higher incidence rate.The muhiple infection rate was 24.62％.The recurrence rate of multiple infection with different HPV types was obviously higher than that of single infection ( 43.75％ vs.26.31％,P ＜ 0.05 ).Conclusions HPV-6 and HPV-11 were the main types of condyloma acuminatum infection in patients.Multiple HPV infection has a higher incidence rate and has a certain correlation with the recurrence of the disorder. Key words: Condyloma acuminatum; HPV-DNA; Prognosis; Recurrence

Introduction: Sexually Transmitted Infections (STIs) are generally acquired through sexual contact, and the risk is very high for Female Sex Workers (FSWs). The most common STI in FSWs is Human Papillomavirus (HPV) infection. Majority of the HPV infection is asymptomatic, while a minority of the infection is responsible for causing cervical cancer. High-Risk HPV (HR-HPV) serotypes, HPV 16 and HPV 18, are known to cause cervical cancer. Aim: To determine the seroprevalence of HPV infection among FSWs attending STD clinic at a tertiary care hospital in Southern India. Materials and Methods: This cross-sectional study was done during the period between September 2015 and August 2016 in a total of 65 FSWs in Govt. Stanley Medical College, a tertiary care hospital in Chennai, Southern India. The serum was separated after 5 mL of blood was drawn to test for the presence of HPV 16 and 18, Human Immunodeficiency Virus (HIV), and syphilis. Endocervical and vaginal swab specimens were taken to look for the presence of other STIs. Necessary socio-demographic and clinical information such as mode of sex, any sexual exposure, extramarital or premarital, protected sex or not, history of associated STIs, and any history of blood transfusion, i.v. drug abuse, or surgery was also obtained. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) 20.0 software. Probability value (p-value) &lt;0.05 was considered statistically significant. Results: Analysis of the blood samples showed that four samples were found positive for HPV infection, while two samples each were positive for HIV and syphilis. Analysis of the swab specimens showed the presence of other associated STIs in 20 samples. Among the four HPV positive samples, three were found positive for HPV 16, and one was positive for HPV 18. Risk factors such as age, marital status, HIV, and syphilis had a very strong association with HPV infection (p-value&lt;0.01). Conclusion: The prevalence of HR-HPV serotype HPV 16 was higher than HPV 18. Hence, education about STIs, safer sexual practices, and HPV vaccination are essential in this population in order to prevent the transmission of infection to the general population.

Introduction: Human papillomavirus (HPV) and human immunodeficiency virus (HIV) are the most common sexually transmitted infections (STI) globally. According to the World Health Organisation (WHO) there are around 17.4 million women living with HIV and over 290 million HPV infected women worldwide.Purpose: This review is to summarize available data concerning the relationship between HIV and HPV infection among women. The analysis comprises molecular mechanisms of HPV infection among HIV(+) women as well as HIV infection among HPV(+) women, prevalence of HPV and cervical lesions among women living with HIV and screening of HPV and cervical cancer (CC) among HIV infected women.Material and methods: The review includes publications from 2011 to 2020. The data has been collected by the use of the PubMed, Ovid, Up-To-Date and WHO website. Key words used to search for references include: HPV, HIV, prevalence, molecular mechanism, screening.Results: HIV infection is a risk factor for HPV acquisition. On the one hand, prevalence of HPV, multiple HPV, high risk HPV (hrHPV) infections and cervical intraepithelial neoplasia (CIN) is higher among HIV(+) women. On the other hand, HPV infection can also predispose to HIV acquisition. Evidence on how these viruses influence each other can be a breakthrough in the range of prevention, detection and treatment of both HIV and HPV infection.Conclusions: Relationship between HPV and HIV is an interest of nowadays medicine. Possibly, these viruses may cooperate and enable infection of each other. It has been showed that the prevalence of HPV, multiple HPV, hrHPV infections and cervical lesions is higher among HIV(+) in comparison to HIV(-) women. Further studies should be performed providing an insight into a molecular mechanism responsible for this cooperation.

Human papillomavirus (HPV) infection and HPV-associated anogenital diseases, such as warts, cancers precursors, as well as anogenital invasive cancers, are significant health care problems (Fig. 11.1). Current estimates of the worldwide prevalence of HPV indicate that approximately 10% of women in the general population will harbor cervical HPV infection at a given time (de Sanjose et al., 2007). Furthermore, estimates of human cancer incidence linked to infectious agents suggest that HPV infections in female individuals presently contribute to more than 51% of cancer cases, whereas infection in male individuals accounts for slightly more than 4% of HPV-associated neoplasias (Hausen, 2008). Cervical cancer causes considerable morbidity and mortality in the young female population and con­stitutes a significant economic burden to developing countries. According to 2002 data from the International Agency for Research on Cancer (Parkin et al., 2005), approximately half a million women worldwide develop cervical cancer every year (Fig. 11.1), and over two-thirds of these cases are associated with HPV infection of either oncogenic type 16 (51.0%) or HPV type 18 (16.2%). Consequently, successful strategies that can protect against HPV infection are expected to decrease the rates of HPV-related diseases. Sexual abstinence is the most effective preventive measure against HPV infection and other sexually transmitted diseases (STDs). Although Winer et al. (2006) reported that the regular use of condoms may reduce the risk of genital HPV infection, transmission to the unprotected perigenital skin can still occur.

To assess attitude and knowledge among parents or guardians of 12-year-old girls about human papillomavirus (HPV), cervical cancer, and HPV vaccination. Material andMethods: A mail survey was sent to a randomized sample of 1,000 parents or guardians of 12-year-old girls from a cohort of total 2,092 girls born in 1995 and registered in the Icelandic National Register by the end of December 2007. Of the 994 eligible parents, 583 (59%) returned the questionnaire. Majority of the respondents were mothers who had two or three children. More than one-third of respondents had university education and 84% were married or living with a partner. Over two-thirds did not know that HPV causes cervical cancer and genital warts. Almost all (> 90%) would vaccinate theirs daughters with a HPV vaccine, 73% said they would vaccinate their sons, or themselves if the vaccine was effective for them. Only 11% believed HPV vaccination would increase promiscuity or decrease cervical screening attendance. In Iceland, willingness to vaccinate young girls with HPV vaccine is high, however, knowledge about HPV infections is limited.

Objective: Low-risk (LR) human papillomavirus (HPV) infection is a recognized cause of anogenital warts (AGW). LR-HPV 6 and 11 are the HPV types that were reported to be associated with AGW. However, data specific to the HPV types that associate with AGW in Thailand are scarce. Accordingly, this study aimed to determine the prevalence of HPV in patients with AGW, and to investigate for association between HPV types and AGW among Thai males attending the sexually transmitted disease clinic of Siriraj Hospital – Thailand’s largest national tertiary referral center. Materials and Methods: This prospective study was conducted at the Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during April 2017 to December 2019. Thai males with at least one AGW were included. AGW specimens were obtained, and HPV genotyping was performed at both the genital and perianal areas. Results: A total of 43 Thai male participants (mean age: 37.3±13.8 years; range: 19-72) with AGW were enrolled. The rate of HPV positive detection at the genital area and the perianal area was 86.0% and 72.1%, respectively. The most common HPV types at the genital area were HPV 6, followed by HPV 11. Alternatively, the most common HPV types at the perianal area were HPV 11, followed by HPV 6. Conclusion: The findings of this study suggest LR-HPV types 6 and 11 as the culprit pathogenic causes of AGW among males in Thailand. These findings further support and emphasize the importance of HPV vaccination for prophylaxis against both HPV and AGW.

BackgroundReports of human papillomavirus (HPV) infection and genotype distribution in Chinese men are limited, and HPV vaccination has not yet been recommended for men in China.Material/MethodsWe retrospectively reviewed the prevalence and genotyping of male genital HPV. A total of 1227 male patients (aged 17 to 81 years) attending the dermatology and sexually transmitted disease clinics at Putuo District Center Hospital in Shanghai from 2015 to 2019 were included. Genital exfoliated specimens were obtained for detection and genotyping of 27 HPV types by Luminex-based multiplex assay.ResultsThe prevalence of any HPV was 65.5% (804/1227). The rate of multiple infection was 25.8% (317/1227). The 5 main HPV types were 6 (32.0%), 11 (23.2%), 16 (5.6%), 43 (4.3%), and 59 (4.0%). Among all detected HPV genotypes, 65.5% (875/1336) were 9-valent HPV genotypes. No significant differences were observed in the detection rate of HPV infection over 5 years (P>0.05). Age groups ≤24 years (70.7%) and ≥55 years (72.9%) showed higher infection rates, and significant differences were detected in rates of low-risk HPV infection in different age-stratified groups (P<0.05). Prevalence of HPV infection among patients with warts (74.4%) was significantly higher than that of patients with other clinical characteristics (40.4%) and physical examination (63.6%).ConclusionsOur study suggested that more than half of Chinese male patients have detectable HPV infections, and penis-genital and anogenital warts were the most common clinical manifestations. Moreover, the available 9-valent HPV vaccine covers the most frequently observed HPV types among men.

The Department of Health has chosen the bivalent vaccine Cervarix™ for its national vaccination programme in England. Although this will protect against human papilloma virus (HPV) 16 and 18, which cause 70% of cervical cancers, it will offer no protection against genital warts. In 2006, there were 83 745 new diagnoses of genital warts (first episode) and 44 655 recurrent episodes in patients attending departments of genitourinary medicine in England, Wales, and Scotland.1 In addition to the financial implications of treating patients with anogenital warts, estimated at £22.4 million in 2003, the psychological impact of the disease should not be underestimated. HPV is the commonest sexually transmitted viral infection in the developed world and of the almost 200 types of HPV; about 40 infect the ano-genital tract.2 ‘Low risk’ types, such as HPV 6 and 11, cause genital warts and minor cervical cellular abnormalities (for example, borderline changes or mild dyskaryosis on cytology) whereas ‘high-risk’ types, such as HPV 16 and 18, may cause high-grade dysplasia (intraepithelial neoplasia) and cancer of the cervix, vulva, vagina, penis, and anus. Approximately 80% of sexually active individuals will at some time become infected with HPV. Most HPV infection is subclinical, producing no signs or symptoms and studies of cervical infection show that about 80% of women clear the virus within 2 years of infection.3 Approximately two-thirds of people exposed to HPV 6 or 11 will develop genital warts, most commonly within a few months of exposure, although occasionally the incubation period can be much longer. The treatment of genital warts should be determined by taking into consideration wart type (keratinised/non-keratinised), site, number and patient preference. For example, multiple non-keratinised warts may be suitable for self-applied podophyllotoxin or imiquimod (the latter is more expensive — British National Formulary prices: approximately £15 & £51 respectively), whereas larger keratinised lesions are best approached by cryotherapy or excision/diathermy (requires local anaesthetic, preferably post-application of EMLA® cream). Perianal warts are not necessarily acquired by anal intercourse and are not infrequently misdiagnosed as hemorrhoids (usually in cases where an examination has not been performed). Women with genital warts do not require more frequent cervical cytology and colposcopy is only recommended in women with abnormal cytology (as per NHS Cervical Screening Programme) or with cervical lesions of diagnostic uncertainty or clinical concern. Top Tips in 2 minutes: human papilloma virus (HPV) vaccines.