Application by patient:

Imiquimod (cream 5%): topical use. It is not indicated for internal use (vaginal/anal). Application must be in each lesion, three per week, for a period of 4–16 weeks. Side effect as local irritation/burning is not uncommon. It can be used alone or associated with physical removal method through surgical exeresis or electrocoagulation. The ideal practice is to make the application shortly before bedtime and wash the area with common soap and water 8 h after application. As a routine, client is informed to wash the area where imiquimod was applied 7 h later rather than 9 h later, which minimises the collateral effects.

Podophyllotoxin 0.5%: topical use. Used in cycles as follows: twice a day, for 3 days, with an interval of 4 days without application. More than four cycles should not be used. Local irritations are frequent, and patient should be oriented to suspend the use in such case. Not indicated for pregnant women.

Sinecatechins Oitment (Veregen^®) 10% w/w in 15 g tubes (Canada). In the USA, this product is commercialized with a concentration of 15%. Used only on skin, three times a day (morning, afternoon and evening). The treatment must be done until lesions disappear. But treatment should not exceed 16 weeks. The side effects are similar to those of imiquimod’s. The application of sinecatechins oitment should be suspended in case of intense side effects.

Application by physician:

Podophyllin 10–25% (we prefer in tincture of benzoin. But it can be oily or alcoholic): topical use. The teratogenic origin is not indicated for the mucous membranes. The region must be washed 4 h after application. Care must be taken with excesses—application should be repeated every week.

Trichloroacetic acid—TCA (30–90%): topical use. Weekly serial applications until involution of lesions.

Surgical removal: perhaps the simplest and most effective method. There are many ways to carry out the lesion excision: with delicate surgical scissors and later soft cauterization of the bases through laser or electric scalpel (electrocoagulation).

Cryotherapy with liquid nitrogen: weekly serial applications until the lesions’ regression.

Cryocauterization

Cryotherapy destroys warts by thermal-induced cytolysis. Healthcare professionals must be trained on the proper use of this therapy because over and undertreatment can result in complications or low efficacy. Pain after application of the liquid nitrogen, followed by necrosis and sometimes blistering, is common. Local anesthesia (topical or injected) might facilitate therapy if warts are present in many areas or if the area of warts is large.

Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2 weeks.

Fluorouracil (5-FU)

Fluorouracil (5-FU) is an antineoplastic agent, cytostatic, analogue of Uracil and therefore a pyrimidine antagonist, which inhibits the synthesis of viral DNA/RNA, and with immunostimulating action. The medication comes as a cream 5%. It is indicated for use in both skin and mucous membranes. It can produce side effects such as erythema, swelling, burning, itchiness, pain, ulceration and dysuria. Two treatment schemes are recommended: daily use for 5 days or weekly application for 10 weeks. Wash lesions 4 h after external applications. Vaginal and cervical lesions should use 3–5 mL of cream with applicator deeply at bedtime. Insert a vaginal tampon and protect the vulva with Vaseline or zinc oxide. The use in vulva produces vestibulitis, and in the vagina can cause chronic ulcerations and adenosis, reason why we do not recommend its routine use.

Prophylactic vaccine against HPV: immunogenic materials used are virus-like particles (VLP) HPV-specific types 6, 11, 16 and 18. These particles represent only the viral capsomers without any genetic content. This causes the immunogenetics to be maintained without the slightest possibility of causing infections. Such methodology is widely and safely used in other vaccines, such the hepatitis B. The first vaccine was approved in 2006 and has four VLPs (6, 11, 16 and 18). Thus, it protects against Condyloma acuminata (anogenital warts) and concomitantly intraepithelial neoplasias and cancer of the vulva, vagina, cervix and anus. The posology is three doses IM: 0 day, 60 days and 180 days. The second vaccine was approved for use in women and girls over 10 years of age and has proven effectiveness for the intraepithelial neoplasias and cervical cancer. This vaccine contains two VLPs (16 and 18). Must also be applied in three IM doses: 0, 30 and 180 days. In September 2009, the U.S. agency that regulates food and drugs administration (FDA) approved quadrivalent vaccine against HPV 6, 11, 16 and 18 in men from 9 to 26 years of age. In Europe, the similar committee, EMEA, also approved a very important decision: the extension of the use of the same vaccine for women over 45 years of age. Earlier, the World Health Organization awarded its seal to this product. The HPV 16 and 18 bivalent vaccine has also been approved by FDA. Nowadays, it is proved that the protecting effect of these prophilatic vaccines surpasses 9 years. In 2010, during the international event Eurogin Monte-Carlo, Joura EA et al. (Impact of Gardasil^® in women who have undergone definite therapy, SS 4–3) have shown that there are benefits in using quadrivalent vaccine against HPV in women who have had cervix or vulvar diseases and were properly treated, once they have reported significantly lower rates of new diseases caused by HPV in the genital area. More recently, international study has shown good results with the quadrivalent vaccine in preventing penile and anal lesions in research involving only men. All this proves that these vaccines bring great benefits for the human species, with low side effects. Some countries have already managed to vaccinate large portion of their teens. More recently, FDA has approved the nine valent HPV vaccine against types 6, 11, 16, 18, 31, 33, 45, 52 and 58. The nine valent vaccine was 97% effective in the prevention of cervical cancer in vulva and vagina caused by additional types 31, 33, 45, 52 and 58, as well as of diseases caused by the previous four types of HPV vaccine in clinical studies.

Treatment of systemic and local secondary infections promotes the remission of lesions. The same happens in the post-delivery women with HPV lesions, especially genital warts.

Numerous therapies are a sign that none of them is sufficient for an ideal control. All, without exception, have high rates of HPV recurrence (> 50%).

With the current knowledge, it is not true to say “once with HPV always with HPV”.

Moast intraepithelial lesions, especially those of low-grade, also tend to evolve. However, the clinical, laboratory and emotional monitoring should not be neglected.

The cesarean delivery should be considered when there are lesions obstructing the birth canal, disabling any type of episiotomy, and also high-grade or vegetant cervical lesions, due to high risk of lacerations and bleeding.

Re-examining the patient 3 months after the disappearance of the lesions is a good behavior.

As we believe in sexual transmission and in the association with STD, we are favourable to classical medical examination of sexual partners. This is different from “peniscopy” only.

Emotional verbal untrue or exceeded concepts assaults may be worse than clinical lesions. In this particular topic we indicate the short-movie Lara’s Show (https://​www.​youtube.​com/​watch?​v=​GgwlpwLyT-k).

Read the book “HPV, Que. Bicho É Esse?” (http://​virushpv.​wordpress.​com)—Larah’s program (in English) based on the novel “HPV, Que. Bicho É Esse?”

In 2010, an international study about histological samples from several countries was published, and showed the participation of isolated HPV 6 HPV (mainly) and HPV 11 in several penis cancer cases, although the most prevalent type is HPV 16. So far HPV has been detected in about 60% of cases of penile cancer. It has also been found, as the only present type, HPV 6 in pieces of histological cervical cancer.

The physician must not exaggerate the severity of the diagnosis or prognosis, nor complicate the treatment, exceeds the number of visits, examinations or any other medical procedures.

Primary screening for HPV-DNA to prevent cervical cancer.

In the recent years there are some concern about the effectiveness of Pap smear as primary screening for cervical câncer, meanly in the development countries, where the incidence of cervical câncer is stable. An alternative defended by researchers is the use of DNA-HPV test, due to its high sensitivity to detect high-grade lesions and the possibility of auto-collect. Although rare, benign or malignant clinical manifestations are observed in very different areas from the usual ones, such as esophagus [4].