GENITAL INFESTATIONS Flashcards by Alex Kinsky

What is the most common viral sexually acquired infection?

Genital warts as a result of HPV

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What does HPV stand for?

Human papilloma virus

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How many HPV types have been discovered and how many infect the genital epithelium?

Over 100 types

40 of which infect genital epithelium

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What are the two most common types of HPV virus to infect the genital epithelium and cause benign genital warts?

HPV 6

HPV 11

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How are genital warts spread? What does this mean for sexual contact?

Direct skin to skin contact

This means that wearing a condom will not necessarily protect as condoms do not cover all the genital skin. It also means penetrative sex is not required for transmission.

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What is the median incubation period for warts?

3 months (range of 2 weeks to 9 months or even longer)

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What percentage of people with HPV genital infection will develop warts? Are they still infectious?

Many people (one estimate suggests 99%). However, they are still infectious, although those with genital warts are more likely to transmit HPV.

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What are the clinical features of genital warts?

Lumps in the genital area (may be singular or multiple)

Usually asymptomatic

Can be itchy

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Where do genital warts tend to occur?

In locations which undergo small trauma during sexual intercourse, but may be seen anywhere on genital skin:

Penile

Intrameatal

Peri-anal

Intra-anal

Vulva

Intra-vaginal

Cervical

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What are the different types of genital wart based on appearance?

Condylomata acuminata

Smooth papules

Flat papules

Keratotic warts

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What do condylomata acuminata genital warts look like?

Cauliflower-like appearance

Skin coloured, pink or sometimes hyperpigmented

If on mucosal surfaces then generally non-keratinised

If on skin then may be keratinised

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What do smooth papular genital warts look like?

Smooth

Dome-shaped

Skin-coloured

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What do flat papular genital warts look like?

Macular to slightly raised

Flesh coloured with smooth surface

More commonly found on internal structures (eg cervix), but do also occur on external genitalia

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What do keratotic genital warts look like?

Thick horny layer

Resemble common warts or seborrheic keratosis

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How is diagnosis of genital warts usually made?

Clinical diagnosis based on examination under bright light

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What should prompt biopsy of a genital growth?

Unclear diagnosis

Pigmented lesions

Indurated lesions

Fixed lesions

Do not respond or worsen with treatment

Persistent ulceration or bleeding

Immunocompromised patients (where more vigilance is required to recognise pre-malignant lesions)

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What is the differential diagnosis for genital growths?

Infections:
Molluscum contagiosum
Condylomata lata of syphilis

Acquired dermatological conditions:
Seborrheic keratosis
Lichen planus
Fibro-epithelial polyp, adenoma
Melanocytic naevus
Neoplastic lesion

Normal variants:
Pearly penile papules/coronal papillae
Fordyce spots
Vestibular papillae (micropapillomatosis labialis)
Skin tags

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What investigations should be done in someone with genital warts?

STI screen to exclude concurrent STIs

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In someone diagnosed with genital warts, how do we go about contact tracing?

We don’t. However, current partners may benefit from assessment to exclude undetected STI.

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How does a diagnosis of genital warts affect a woman’s cervical smear screening schedule?

It doesn’t

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What percentage of genital warts will disappear without treatment by 3 months?

5-30%

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What percentage of genital warts will stay the same by 3 months?

20%

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What percentage of genital warts will get bigger by 3 months?

50%

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Which group of patients are more likely to see spontaneous resolution of genital warts?

Children

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What are the first line treatment options for non-keratinised larger vulval, perineal, penile or perianal warts?

Podophyllotoxin 0.5% OR Imiquimod

What are the first line treatment options for keratinised, small number or low volume vulval, perineal penile or penile warts

Cryotherapy OR Imiquimod

What class of medication is imiquimod?

Alpha-interferon stimulant

What are the second line treatments for more persistent warts?

Excision Electrosurgery Laser treatment

Within what time period are warts likely to respond to topical treatment?

2-3 months

How do we treat intra-vaginal warts?

Treatment often not necessary. Cryotherapy Electrosurgery Trichloroacetic acid (TCA)

How do we treat cervical warts?

Treatment often not necessary Cryotherapy Electrosurgery Laser ablation Excision Trichloroacetic acid (TCA) Consider colposcopy if uncertain about diagnosis

How do we treat urethral meatal warts?

If base of lesion is seen: Cryotherapy Electrosurgery Laser ablation Podophyllotoxin 0.5% or imiquimod If lesion is deeper is urethra: Often no requirement needed Surgical ablation under direct vision

How do we treat intra-anal warts?

Treatment often not necessary Cryotherapy Electrosurgery Laser ablation Trichloroacetic acid (TCA) - with care Podophyllotoxin Imiquimod

What percentage of patients will experience a recurrence of genital warts within 3 months of treatment?

30-60%

Within what time frame will most HPV infections clear in immunocompetent patients?

2 years

What percentage of patients are left with subclinical HPV?

10%

What are the main complications of genital warts?

Detriment to quality of life Low self-esteem Clinical depression Increased stress Negative impact on relationships

What is the organisms that causes molluscum contagiosum?

Pox virus

How is the pox virus transmitted to cause molluscum contagiosum?

Skin to skin contact - and therefore can be sexually transmitted but this is not the only way

What groups of patients is molluscum contagiosum most commonly found in? What sites are most commonly affected?

Children - hands, face, arms and trunk

What is the incubation period for molluscum contagiosum?

3-12 weeks (but can be up to 6 months)

What are the clinical features of genital molluscum contagiosum?

Papular lesions 1-3 mm in size Smooth Pearly coloured - resemble vesicles but in fact solid Central umbilication Affects skin around pubic hair, thighs, buttocks and lower abdomen Normally spares mucous membranes

How do we diagnose molluscum contagiosum?

Normally clinically through inspection If doubt, central punctum can be extracted and poxvirus-like particles viewed under electron microscope. Histology will also reveal enlarged epithelial cells with intracytoplasmic molluscum bodies.

What investigations should be done in someone who presents with genital molluscum contagiosum?

Full STI screen

When do we treat molluscum contagiosum?

It is only treated for cosmetic reason. It usually resolves spontaneously in 3 months

How do we treat genital molluscum contagiosum?

Cryotherapy Extraction of central core Piercing with stick that has been dipped in tincture of iodine or phenol

What percentage of patients will experience a recurrence of molluscum contagiosum within 8-24 months?

35%

What is the microorganism responsible for scabies?

Parasitic mite Sarcoptes scabiei

How is scabies transmitted?

Direct prolonged skin to skin contact

How long does skin to skin contact need to be maintained for in order to transmit scabies?

20 mins

What causes the symptoms of scabies?

Hypersensitivity reaction to absorbed mite excrement into skin capillaries

How long after first infection do symptoms of scabies usually take to come to fruition?

May take up to 4-6 weeks

How long after re-infection do symptoms of scabies take to come to fruition?

24-48 hours because of previous sensitisation.

What are the main symptoms of scabies?

Intense itching Especially at night Polymorphic and symmetrical rash Burrowed appearance to rash - small raised greyish wavy channel on skin surface extending from an erythematous papule Reddish-brown pruritic nodules - found especially on scrotum, penis and groin Excoriations

What are the main sites affected by scabies?

Interdigital spaces of hands Flexor surfaces of wrists Extensor surfaces of elbows Anterior axillary folds Buttocks Genitalia in males Periumbilical region

How is scabies usually diagnosed?

Clinical diagnosis based on classic appearance Confirmation by microscopic presence of mite, eggs or faecal excrement can be performed from skin scrapings, curettage or shave biopsy

What investigations would you do for someone with scabies?

Full STI screen

How do we treat scabies?

Avoid close contact until patient and partner have completed treatment Topical permethrin 5% aqueous lotion Topical malthion 5% aqueous lotion Applied to whole body from neck downwards and then washed off 12 hours later (best to apply overnight) Anti-histamines for itch Bed linen and clothes should be washed at 50˚

What are the complications of scabies?

Itch may persist for several weeks following treatment

What is the form of scabies that occurs specifically in immunocompromised patients and the elderly?

Norwegian scabies

What are the clinical features of Norwegian scabies?

Widespread Crusted lesions with thick scales Only a mild itch

How do we treat Norwegian scabies?

Ivermectin

What are the more commonly used names for pediculosis pubis?

Crabs Pubic lice

Which areas are affected by pubic lice?

Hairs of the: Pubic and perianal areas Thighs Abdomen Axillae Eyebrows Eyelashes

How are pubic lice transmitted?

Direct skin to skin contact

What is the incubation period of pubic lice?

Between 5 days and several weeks

What are the clinical features of crabs (or pubic lice)?

Itch Rust coloured spots on underwear - represents louse faecal matter

How do we manage pubic lice?

Avoid close body contact and treat partner Topical treatments: Malthion 0.5% aqueous lotion - apply and leave for 12 hours Permethin 1% cream - apply and leave for 10 minutes, can be used on eyelashes Phenothrin 0.2% - apply and leave for 2 hours Carbaryl 0.5% and 1% - apply and leave for 12 hours Second application after 3-7 days required. Fine tooth comb should be used to clear out dead eggs