[Question #1586] HPV in context of possible immunosuppression

44 months ago
Dear Doctors,

I have been on intranasal steroids (Nasocort) for a duration of around 3 months for allergic rhinitis. I have been using the recommended dosage of 2 sprays per nostril, once daily. This adds up to around 220 mcg daily. I realize that often, after spraying the intranasal steroids, some of it drips down the back of my throat. My question is, whether the intranasal steroids usage would have caused some degree of local or systemic immunosuppression that would impair the ability of my body to clear HPV infections? I have recently engaged in oral sex with my partner, who has had multiple sexual partners in the past. I suspect that she might have HPV, and is thus concerned if I have been exposed, and if so, my chances of clearing the infection. 

I have read that HPV infections are associated with oropharyngeal and penile cancers, and is quite distressed by the news. I am afraid that the HPV may stay in my oral cavity and eventually result in cancer.

In addition, could I seek your advise as well, as to what preventive measures I should take moving forward in this relationship? Should I go for HPV testing of the oral cavity/ penis?

Lastly, I read a paper that stated HPV DNA could be found on the fingers of persons diagnosed with genital HPV. As such, would it mean that my fingers can carry the virus (after fingering) and I could potentially auto-innoculate the virus into my mouth, etc? 

I have been feeling rather distressed, and is hoping I could get an expert's opinion regarding my situation. I hope to hear from you soon.

Best Regards,
Daniel
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Welcome to the forum. Thanks for your question.

You needn't be concerned, for several reasons. The kind of immune suppression caused by corticosteroids is not known to increase the risk of either acquiring HPV or having it progress or to be less well controlled by the immune system. People on very high dose steroid therapy for various reasons do not have a signficantly increased risk of HPV problems. Further, Nasocort is not systemically absorbed; its effect is strictly limited to the nose cavity. Swallowing a little bit also makes no difference; it is not absorbed from the GI tract. As for oral HPV and oral sex, it is true that throat cancer due to HPV 16 is on the rise. (Many sources refer broadly to oral cancer. In fact, only one kind -- squamous cell cancer of the pharynx -- is caused by HPV, and only by a single HPV type, HPV16.) However, it remains a rare cancer, far less common, for example, than lung, prostate, breast, and other cancers; and is not necessarily more frequent in people who regularly perform oral sex. Even among people who acquire HPV16 orally, the vast majority don't get cancer as a result. Nobody should avoid oral sex because of fear of oral cancer.

As for your relations with your current partner, of course she has (or has had) HPV. We all get it. You have it or have had it. At least 90% of all sexually active people get HPV, and HPV16 is among the most common types. Getting HPV, including the high risk (potentially cancer-causing) types is a normal, expected, unavoidable consequence of being sexually active. If you're under the usual age cut-off of 26 years, you can be vaccinated to prevent future infections with the 9 HPV types that cause most health problems, including HPV16 and six others that cause 90% of HPV-related cancers.

HPV DNA can be detected under the fingernails of people who have genital HPV infections. However, the virus is not believed to actively infect the fingers; they're just carrying virus because of contact of hands with genitals. There is no evidence that finger contact transmits HPV. Testing for HPV is routinely done in women along with pap smears, but there are no recommended, approved tests for HPV in men, either genital or oral cavity.

The bottom line is that there is no basis for feeling as distressed as you have been. You are no more at risk for HPV, genital or oral, than anyone else with an average dating life. If you're under age 26, get vaccinated. Otherwise, don't worry about it.

I hope this has helped, but let me know if anything isn't clear. Best wishes and happy new year--  HHH, MD


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44 months ago
Dear Professor Handsfield,

Your reply brought me great relief. 

I was very concerned because I thought that local immunosuppression would have impaired the ability of my body to clear the HPV infection of the throat. 

With regard to immunization, the vaccine offered in my country of residence is Gardasil for types 6, 11, 16, 18. Post exposure, I have went for my first course of vaccination, and would continue with the 2 remaining dosages over the next few months. In your opinion, would I have to add on the newer nonavalent vaccination on top of the quadrivalent vaccine that I am on?

Thank you again Professor. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
There indeed is no evidence that local steroids -- either oral inhalation, or if someone were using a steroid cream in the genital area -- increases risk of either catching HPV or activating a previous HPV infection, or of the immune system to clear HPV infection.

Good move to be vaccinated. I'm glad to hear it. Over time, most countries probably will switch over to Gardasil 9. In any case, coverage for types 16 and 18 confers protection against 70% of cervical cancers (and probably penile and other genital cancers) -- but because HPV16 accounts for almost all oral cancers due to HPV, it should give nearly 100% protection against HPV-related phrayngeal cancer. You're also covered against the two types (6, 11) that cause 90% of genital warts. If you want protection against the other 5 types covered by Gardasil 9, you'll need all three doses of that version when it becomes available. However, this iis a higher priority for females than males. (To clarify one more point:  you are protected only against HPV strains with which you have not yet been infected. You'lre still at risk for recurrence of infection with any of the four types with which you were infected before vaccination.)

Anyway, I'm glad to hear the information has been helpful. Thanks for the thanks.

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44 months ago
Thank you for your reply Professor Handsfield.

May I clarify what does recurrence of infection of types exposed before vaccination mean? Assuming that my body clears up the HPV infection (I hope), would I be immune to the type exposed? If there are risks of recurrences, would that be a call for concern? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
The immune system suppresses HPV, but HPV DNA may persist for prolonged periods in previously infected tissues. Usually this doesn't mean anything -- the immune system continues to prevent reactivation. However, sometimes the infection does reactivate. That's why women can develop abnormal pap smears many years after the original HPV infection; and why sometimes genital warts reappear years after clearing up. As a sexually active person, you can assume you have been infected with HPV (it happens to at least 90% of all people, including half of all persons after only three lifetime sex partners). If you already have (or have had) say HPV 18, the vaccine will not prevent reactivation of that infection. However, the chance of reactivation is low, especially in men.

It sounds like you could use a basic tutorial about HPV infections. There are several excellent sources. You could start with the US Centers for Disease Control and Prevention (www.cdc.gov/std) and the sponsor of this forum, the American Sexual Health Association (http://www.ashasexualhealth.org/stdsstis/hpv/) (which includes a couple of educational videos I did for ASHA).

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
That completes the two follow-up comments and replies included with each question, and so concludes this thread. I hope the discussion has been helfpul. Happy new year.

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