Human Papillomavirus (HPV)
- Etiology of papillomavirus
- Risk factors causing HPV
- Ways of transmitting papillomavirus
- Stages of the infectious process
- Infections that causes papillomavirus
- Human papillomavirus: symptoms
- HPV and pregnancy
- Diagnosis of HPV
- HPV treatment
Papilloma, or papillary fibroepithelioma, is a benign skin neoplasm of viral nature, consisting of an epithelium-covered connective tissue stroma, riddled with many blood vessels. This formation is presented in the form of papillae, bulging outward, growing in different directions and resembling cauliflower blossoms in their appearance. A condition in which a person has many papillomas is detected, called papillomatosis.
By the nature of the epithelium, the papillary polyp is squamous (covered with a flat multi-layered non-squaring epithelium) and transitional-cellular (covered with a transitional epithelium). At the same time, the connective tissue stroma can be dense or loose, sometimes with characteristic signs of inflammation. The condition in which the stroma of the papillary polyp is highly developed and sclerosed is diagnosed as fibropapilloma.
For cutaneous papillomas, significant hyperkeratosis is characteristic (increased thickening of the epidermis), and for formations developing on mucous integuments, keratinization is less pronounced.
Etiology of papillomavirus
Human papillomavirus (HPV) belongs to the papovirus family, subgroup A. It is a small, thermostable pathogen that survives well in the external environment and carries heat treatment. It is devoid of supercapsid, and its capsid (membrane that protects the viral genome from external influences) consists of 72 capsomers. The virus slowly multiplies and is not detected in the blood.
Papillomavirus is an etiotropic pathogen, that is, it is capable of affecting a multi-layered flat keratinized and non-keratinized epithelium (skin and mucous membranes), as well as a cylindrical epithelium lining the lungs, cervical canal and prostate.
Penetrating into its host, the virus, spreading through the bloodstream, is fixed on the epithelium cells, is introduced into the DNA and forces them to work differently. A cell infected with a virus grows rapidly and divides, and as a result, after a while, a characteristic overgrowth appears on the affected area.
Currently, science has data on more than 120 serotypes of the virus, 35 of which affect the integumentary epithelium and mucous membranes. Some HPV serotypes can cause the development of cancer pathologies. Depending on their ability to provoke cancer, they are divided into 2 main groups: low-risk and high-risk oncogenic HPV.
Note: Oncogenicity is the ability of the papillomavirus to cause a degeneration of the infected layer of the basal epithelium into cancer.
6, 11, 42-44 and 73 types of HPV are considered low oncogenic risk viruses. And 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68 are types of HPV that are considered to be dangerous, that is, under certain conditions they can provoke the development of a malignant process . The most unfavorable, according to experts, are 16 and 18 types, causing squamous cell carcinoma and adenocarcinoma.
Risk factors triggering the development of PVI
In the first place, according to experts, are features of sexual behavior and sexual orientation of a person. These include early sex life, frequent change of sexual partners, disregard for personal protective equipment. However, many authors argue that almost always, PVI is associated with STDs (trichomoniasis, chlamydia, myco- and ureoplasmosis, as well as genital herpes).
Most often the disease is detected at a young age (in the period from 18 to 30 years). However, at the same time self-healing can occur (elimination phenomenon), reaching 70%. However, the malignancy of PVI most often occurs at the age of 45-50 years.
Ways of transmitting papillomavirus
HPV is an infectious agent that infects and transforms the basal cells of the epidermis. As a result, they begin to divide, forming a papillary polyp, or papilloma (Papilla in Latin means nipple, oma in Greek means a tumor).
Transmission occurs through contact with infected people or animals that have obvious signs of illness, as well as with virus carriers that have no clinical manifestations of the disease.
The entrance gates for the introduction of infection are various microtrauma of the skin. Infection most often occurs in areas of the largest crowds of people, especially where the air is rather humid (in gyms, baths and swimming pools).
It is also very often people who are engaged in cutting meat, poultry and fish (warts of butchers) suffer from human papillomavirus infection.
Genital warts, popularly known as genital warts, are transmitted by traditional sexual contact, as well as by oral or anal sex.
Infection of newborns can occur while passing through the birth canal of an infected mother. However, there is evidence of intrauterine infection with a virus, which is proven to give birth to infected children by caesarean section.
The airborne transmission of infection from the patient to the medical staff during surgical intervention (laser vaporization or radio wave coagulation) is also not excluded.
However, in clinical practice, there is another type of spread of HPV - self-infection (autoinoculation). So, after epilation or shaving, flat warts may appear on the chin, cheeks or on the shins, and people who gnaw nails very often have warts in the periungual region.
Stages of the infectious process
- Primary infection.
- Persistence (long-term survival) of the viral genome outside the chromosomes with the production of viral particles.
- Integration (interpenetration) of viral DNA into the genome of the host cell.
- Mutations in cellular DNA that cause genome instability.
- Embedding viral DNA into the host chromosome.
- The emergence of a clone of cells with mutated DNA and tumor formation.
Science has proven that human papillomavirus infection can exist in the body in two forms:
In the first case, the virus lives and multiplies, but its DNA is not inserted into the host’s cellular genome.
In the second case, following infection and penetration into the host cell, viral DNA is inserted into the cellular genome, and, as a result, starts the tumor process.
Infections that cause papillomavirus (from warts to cancer)
HPV can selectively affect the basal epithelium of the skin and mucous membranes, causing the occurrence of warts, genital warts and other characteristic benign and malignant formations. However, very often the infectious process can be asymptomatic.
Until recently, human papillomavirus infection was related to benign diseases. However, today it is considered one of the most serious pathologies transmitted through sexual contact.
Most often, the development of the pathological process is caused by non-oncogenic virus types, and the skin tumors that have arisen in this case are more likely perceived as a cosmetic defect. However, when a human is infected with the papillomavirus 16, 18, 31, 33, 35, 39, 45, 52, 55, 56 and 58 types, moderate or severe cervical dysplasia, non-invasive and invasive cancer of the female internal genital organs (vulva, vagina , cervix), rectum and penis.
Symptoms and forms of HPV
With the development of human papillomavirus infection, the incubation period most often lasts 2-3 months. However, in some cases it may shrink or grow. At the same time, HPV can be present in the human body from its very birth, but due to the high persistence of the immune system, many people are unaware of its existence, and only with a decrease in immunity can the virus manifest itself.
According to statistics, more than 85% of the world's population is infected with the papillomavirus, and therefore its presence in the body is more expected than its absence.
When a virus enters the body, it can behave differently, that is, manifest itself in the form of various types of benign formations on the skin and mucous membranes. That is why in clinical practice several forms of PVI are considered:
- Clinical or manifest form. It develops with transient cellular immunity disorders (for example, during pregnancy), in HIV-infected patients, and in individuals with genetically restricted specific HPV immunity.
- Subclinical form of papillomatosis is detected in immunocompetent individuals.
- Hidden, or latent form, occurring in the complete absence of symptoms, is observed when viral DNA enters the cellular genome.
What is a wart?
A wart is the most characteristic and frequent symptom of a papilomavirus infection. It is a dense convex formation of a rounded shape with clearly defined borders, reaching 1 cm in diameter. The wart is characterized by a rough, uneven surface, and its color can vary from beige to black. Most often, these formations are localized on the hands, fingers, elbows and knees. It should be noted that they are easily injured.
What is papilloma?
Papillomas are round-shaped soft warts that can appear on various areas of the skin (on the face, mouth, hands and feet, under the arms, in the decollete and neck, and also on the genitals). They are light brown, pearl, white or pink single rounded tuberous dense formations on the leg, and reaching a height of 1 cm. However, they can quickly grow and occupy a large area of skin. Papillomas respond well to treatment, and over time, in 20% of cases, they are able to disappear on their own. At the same time, the risk of developing a malignant tumor is low, and the tumor, most likely, remains a simple cosmetic defect.
What is a condyloma?
Condyloma is a benign neoplasm on a short pedicle, which causes HPV 6 and 11 types. According to many authors, it is condylomas that are able to degenerate into cancerous tumors. Most often they are localized in the urogenital area, near the mouth or near the anus. In this case, papillary polyps are presented in the form of a rash, which consists of many elements and has a characteristic property to merge. Very often on the mucous membrane of the genital organs, it becomes similar to the cockscomb. For this form of pathology provoked by HPV, rapid growth is characteristic. One of its consequences is the emergence of a Bushke-Levenshteyn tumor, characterized by its enormous size and capable of growing both outside and inside of tissues.
The color of the condylo varies from red to dirty brown, but at the same time, in the genital area, these formations can be lighter. To the touch they are softer and more tender than papillomas and outwardly resemble a multitude of villi accreted at the base.
In clinical practice, there are three types of warts: spiky, intraepithelial (with a characteristic endophytic growth inside) and flat. All of them, according to experts, should be promptly removed.
At occurrence of papillary growths, exudate begins to accumulate between them, their surface is moistened, becomes shiny and painful, and an unpleasant odor, maceration, infiltration and swelling may appear. As a rule, genital warts occur in places of greatest friction and traumatization occurring during sexual contact.
With deeper lesions of the urethra, patients develop symptoms of urethritis (burning, discomfort during urination, pain in the external genital organs and in the lower abdomen). In the case when patients with giant genital warts appear, they lead to the complete destruction of tissues, they very often ulcerate, which, in turn, leads to the development of a secondary infection.
Flat condyloma is a barely noticeable growth localized on the walls of the vagina or on the cervix of the uterus. Due to their invisibility, flat warts are very poorly diagnosed, but at the same time, they provoke the development of a number of unpleasant symptoms. This is the occurrence of abundant vaginal discharge, as well as bleeding after sexual contact and itching in the urogenital area.
In men, these formations can occur on the penis and in the urethra. Most often, they do not rise above the skin surface, and therefore are also almost imperceptible, however, they are capable of delivering a certain discomfort, burning and itching to their owner.
HPV and pregnancy
In pregnant women infected with papillomavirus, external condylomas can reach simply gigantic proportions, and in this situation the percentage of different clinical manifestations of the disease becomes much higher. However, after the birth of a child, self-healing can occur. This situation is explained by a change in the hormonal background of a woman, increased vascularization of tissues (the formation of new blood vessels), a violation of the vaginal microbiocenosis, and, most likely, an influence on the functional activity of cells of the immune system.
All women planning to become pregnant, experts recommend a comprehensive examination in order to detect HPV infection. If one of the degrees of cervical dysplasia or other clinical forms of the disease is present, anti-inflammatory and antiviral therapy is prescribed to a pregnant woman.
However, the latent form of human papillomavirus infection is not considered a contraindication for pregnancy.
Treatment of PVI should be carried out in the first trimester of pregnancy. In the same period, it is necessary to remove the existing exophytic condylomas, since in later periods their rapid growth may occur, leading to various complications of pregnancy and childbirth. At the same time, in the presence of genital warts, a child may be infected with laryngeal papillomatosis when passing through an infected birth canal.
Diagnostics of PVI
In recent years, medicine has made significant progress in the diagnosis of PVI. This became possible due to the systematization of data on HPV and diseases associated with it, the study of all existing ways of infection, many of the pathogenesis mechanisms of the infectious process and the state of the immune system, as well as possible morphological changes.
There are several ways to diagnose human papillomavirus infection, and in this case, experts adhere to generally accepted algorithms:
- Mandatory screening for HPV are subject to sexually active women and men.
- HIV-infected patients and individuals with symptoms of sexually transmitted diseases should also be examined.
- People who have proven risk factors for PVI.
- Patients with genital papillomas in the oral cavity and in the anogenital region.
- Patients suffering from various pathologies of the cervix.
- Couples planning a pregnancy.
The main diagnostic methods of PVI
- Visual inspection of lesions.
- Use a magnifier and colposcope.
- Cytological methods of research.
- Molecular biological techniques.
- Histological (pathological) study.
All patients who are examined for the presence of PVI are simultaneously being tested for syphilis , hepatitis and HIV, smears are taken for a bacterioscopic examination of the discharge of the urethra, vagina and cervix, and PCR and bacteriological tests are made for urogenital infections.
As a rule, detection of papillomavirus does not cause difficulties: the infection is detected during standard examinations by a gynecologist or a dermatologist. With appropriate symptoms, biopsy is performed. When flat condylomas localized in the anogenital area are detected in a patient to prevent the development of malignant diseases, human papillomavirus serotypes with an oncogenic marker are tested.
Необходимо подчеркнуть, что удаление папиллом не следует считать полным излечением от папилломавирусной инфекции, так как в данном случае человек не перестает быть вирусоносителем, то есть, в течение нескольких лет сосочковые полипы могут появиться снова. Именно поэтому в целях профилактики медики рекомендуют проводить оздоровление всего организма в целом.
В том случае, когда у человека обнаруживается папилломавирус, лечение назначается не всегда, а только при необходимости, то есть, при наличии характерной симптоматики. Успех в лечении ВПЧ достигается только тогда, когда пациенту будет назначена адекватная противовирусная и иммуномодулирующая терапия. В клинической практике применяется несколько методов удаления папиллом и кондилом:
1. Криодеструкция, или удаление новообразований жидким азотом.
2. Лазерное лечение.
3. Радиоволновой метод.
Сегодня большинство специалистов рекомендуют своим пациентам удалять сосочковые полипы при помощи лазера или радиоволнового ножа. Данные методики обеспечивают полную стерильность выполняемой процедуры, а также позволяют добиться максимального эстетического результата, то есть, после их применения на теле пациентов не остаются рубцов и шрамов.
Что касается процедуры лазерного удаления формирований, то помимо непревзойденной точности, лазерный луч прекрасно дезинфицирует рану, а также оказывает регенерирующее действие на кожу, то есть, стимулирует процессы заживления. Это идеальная методика, прекрасно себя зарекомендовавшая в гинекологии при лечении папилломатоза наружных половых органов, а также с её помощью удаляются кожные и слизистые новообразования, спровоцированные ВПЧ у мужчин.
Чаще всего после удаления сосочкового полипа иссеченный материал направляется в гистологическую лабораторию для проведения диагностического исследования.
4. Всем пациентам, подвергнутым ликвидации папиллом, показана иммуномоделирующая терапия, позволяющая закрепить полученный результат. С её помощью снижается активность вируса, а также осуществляется профилактика возникновения новых проявлений ВПЧ.
5. Очень часто при лечении палломавирусной инфекции назначаются препараты интерферона (средства белковой природы, усиливающего иммунную защиту организма от вирусных инфекций).
6. Неплохо себя зарекомендовала озонотерапия. Это инновационная методика, предусматривающая постановку озоновых капельниц, укрепляющих иммунитет и затормаживающих вирусную активность. При этом используется насыщенный газом обычный физиологический раствор, сохраняющий свои свойства в течение 20 минут после насыщения. Озоновые капельницы, обладающие противовирусным эффектом, насыщают ткани и органы кислородом, восстанавливают клеточный состав пораженных тканей, удаляют токсины и улучшают общее самочувствие пациента. После такого лечения все проявления ПВИ исчезают на 5, а то и на 10 лет.
В том случае, когда проводится лечение ВПЧ высокого онкогенного риска, пациент в обязательном порядке должен проконсультироваться у онколога и пройти цитологическое обследование.
7. Всем больным после лечения назначаются препараты, ускоряющие заживление кожных покровов.
Примечание: только после ровного заживления кожи проведенная терапия считается успешной.
Лечение ПВИ аногенитальной зоны
When flat condylomas are found in the anogenital zone, the following measures are taken during the treatment:
Destructive intervention aimed at the destruction of papillary polyps and the removal of the modified part of the epithelium;
Immunomodulatory and immunostimulating therapy;
The appointment of antiviral drugs that affect the replication, transcription and transformation of viral DNA;
Prescribing cytotoxic drugs that damage or destroy proliferating virus-infected cells;
Symptomatic treatment and treatment of related pathologies.
Note: currently, some specialists are conducting photodynamic therapy involving the use of photosensitizers (photosensitive substances). However, such treatment in wide practice has not yet found its application. There is also another technique that is at the stage of clinical trials. It is called prophylactic and therapeutic vaccination.
When exophytic warts are detected and in the presence of a typical clinical picture of papillomatosis, patients are prescribed a combination treatment with subsequent removal of the neoplasms. A few days before the operation, treatment with immunomodulators, interferons and antitumor agents is carried out. However, it should be noted that this method, according to most experts, does not give a pronounced therapeutic effect.
However, some patients are trying to get rid of papillary polyps with chemicals. I would like to emphasize that this technique is ineffective, and requires repeated exposure, and also leads to the formation of scar tissue.
Subclinical, that is, manifestations of PVI that are not visible with the naked eye are treated in the same way as exophytic forms, however, the physician must have a complete understanding of the volume of tissues affected by the virus. Otherwise, it would be wiser to conduct dynamic observation and use of local immunotherapy.
In the latent form of human papillomavirus infection, treatment is usually not carried out, since in this case, expensive medical therapy is ineffective, and very often, within 1-2 years, self-cure occurs in the virus carriers (more often in young women and men).
At the same time, sometimes the latent form of PVI (in 10–15% of cases) becomes subclinical. As a rule, some adverse factors contribute to this, as well as infectious-inflammatory processes developing in the anogenital region or in another affected area. With the weakening of the immune forces of the body and the development of chronic endocrine diseases of PVI can turn into a manifest form.
Most often, the prognosis for this disease is positive, however, in some cases, after removal of papillary polyps, relapses can occur, as well as relapses that turn into malignant forms. That is why all immunosuppressive individuals for two years were recommended dynamic observation, control of the immune status, as well as regular colposcopy with subsequent cytological studies. In each case, the treatment of PVI is prescribed individually, taking into account the patient's age, his immune status, localization of the pathological process, the nature of changes in the area of the cervical canal, as well as associated urogenital infections and somatic chronic pathologies.
According to experts, only prevention of HPV can reduce the risk of developing cervical cancer and cancer of the penis. Today, the following preventive methods are used:
- Primary prevention of human papillomavirus infection. It provides for the timely identification of risk factors and the prevention of the spread of infection, and also includes the development of preventive vaccines and other methods to prevent the development of papillomatosis.
- The secondary prevention section is a screening diagnosis, that is, a comprehensive medical examination of the human body, which allows to detect the disease at the earliest dates of its development.
- Tertiary prevention of PVI provides for a reduction in the frequency of recurrence of the disease in previously infected individuals.
At the same time, an important preventive aspect is san-clearance work with an explanation of the aspects of the disease among the population, in particular, among adolescents who are just starting to have sex.
A very simple, but at the same time, effective way to prevent infection with HPV is to use barrier methods of contraception and a preliminary survey of couples planning to have sex.
According to many experts, prophylactic vaccination against human papillomavirus is also an effective method of primary prevention (especially if the vaccine is administered before sexual activity begins).
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