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ANAL WARTS

Anal warts (also called Condyloma Acuminata) result from previous infection with the Human Papilloma Virus (HPV). They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow larger than the size of a pea. They range from small pinkish-white small lesions to much larger lesions that are cauliflower in appearance.








CAUSE
Over 90% of anal warts are due to infection with HPV subtypes 6 & 11. These are rarely associated with anal cancer. Less than 10% of anal warts are due to infection with HPV Serotypes 16 & 18. However, serotypes 16 & 18 are both strongly associated with risk of developing anal cancer. Immunosuppressed patients (e.g. HIV) are at higher risk of infection. The highest risk populations are the HIV male population, particularly those men who have sex with men.

SYMPTOMS
Perianal warts frequently itch, bleed and result in perianal wetness. There may be an associated lump. They are often confused for a hemorrhoid.

COURSE
Most non-immunocompromised patients clear their warts over time, although repeated treatments may be needed to obtain full clearance. There is a long-term risk of Anal Intra-epithelial Neoplasia (AIN) with warts, particularly those due to HPV serotypes 16 & 18. High Grade Anal Intraepithelial Neoplasia (AIN) has a 10% chance progressing to Anal Cancer over a 5 year period. Anal PAP smear is done annually for HIV positive MSM and every 3 years for HIV negative MSM to look for AIN.

MEDICAL MANAGEMENT
- Trichloracetic acid/Bichoracetic acid is applied topically and isuseful for treating small lesions in the anal canal
- Podofilox (NOT IN ANAL CANAL) is more effective being the purified anti-wart compound, and is available in 0.5% gel or solution. This can be administered twice a day for 3 days, followed by 4 days of no treatment, and this cycle is repeated for four cycles. It is successful in less than 70% of cases and causes ulceration in 10-20% of cases.
- Imiquimod (NOT IN ANAL CANAL) is an immune response modifier that increases local production of interferon. A complete response can be expected in 50% of patients. It is applied at bedtime three times a week, left in place for 6–8 h and then removed by washing; treatment may take up to 16 weeks.

SURGICAL MANAGEMENT
Surgical management mainly consists of electro-cautery (diathermy) to remove large lesions, whilst minimizing disfigurement. It is rarely possible to remove every wart, and recurrence of warts is typical. Occasionally large excision with skin grafting is required.

High Resolution Anoscopy with acetic acid staining is for excluding Anal Intra-epithelial Neoplasia (AIN) in high risk individuals such as HIV positive men who have sex with men (HIV-MSM).

PREVENTION
Anal warts are sexually transmitted and spread by direct skin contact and are avoided by having protected intercourse. Barrier methods (condoms) help prevent against, but do not eliminate the risk of wart virus transmission.

VACCINATION
The HPV vaccine (Gardasil®) prevents infection against HPV serotypes 6, 11, 16 & 18 known to cause warts.


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