[Question #1654] Hpv and skin regeneration

45 months ago
Hello doctors,

Basically I had genital warts 11 years ago, at the age of 17. Treated with Aldara, disappeared quickly and never came back. A couple years later I started having abnormal paps/positive high risk HPV. Because the warts went away so quickly and the paps went back and forth between normal and only low grade abnormal, hpv in general was just not something I let bother me much, per the advice of many doctors. When my most recent pap/colpo was normal again, I really put it all in the back of my mind. 

However due to recent events, fresh anxieties have arisen for me re: relationships and disclosure. As a lady with male partners, I'm mostly concerned about transmitting warts. Until now, I've followed your counsel about no obligation to disclose after 3-6 months no warts, now I am at 11 years. Alas lately I've spent too much time in online forums where you regularly read things like, "because there is even the smallest chance your infection can recur when your immune system is down, you must tell everyone forever, or you're a horrible dishonest person." I think back over the past decade during which I've suffered from many immune-distressing things from dengue to chikungunya, malaria, multiple severe cases of food poisoning, ongoing general stress, the death of a parent, and invasive surgery under general anaesthesia. Through all of this, no wart has ever surfaced again. I've also had two 2-year long relationships, neither of whom developed warts, and several short term flings, none of whom reported any problems. My logical mind tells me I am practically, if not biologically cured (still holding out hope for the latter), but the voices of internet strangers continue to haunt my conscience so I wanted to ask a few questions to clarify some things and hopefully further put my mind at ease.

1) I see many people in online forums warning about HPV 'shedding' asymptomatically. Similarly, an NP from Planned Parenthood told me, "well we never really know when the virus is shedding". This sounds like how people talk about HSV. Do you think they are getting the two viruses confused? I can understand how HPV might "shed" asymptomatically immediately before or after warts, but from my understanding, it doesn't typically shed randomly, years after initial infection in the way HSV does...

2) I recently read something very interesting that seemed to make a lot of sense to me, but I have not heard anything about it from legitimate sources. If HPV lives in the epithelium, and those cells can get destroyed whether through natural regeneration, accident, ablation, Aldara, LEEP etc, would that not mean that the virus also gets eliminated from the body (if the infected cells are properly targeted)? It is incredibly frustrating to see how many people online say stuff like, "hpv is a VIRUS meaning it NEVER leaves the body!!" I've never studied virology but this to me seems a bit simplistic. If it is a virus that lives in the skin, and skin regenerates and regrows regularly, wouldn't that mean the virus can in fact leave the body? What about if you've had this dormant virus or virus particles or viral DNA or whatever hanging out in your vulva skin for 11 years, where you're wiping multiple times daily (I have a small bladder), is there a possibility that after so many years of wiping friction, regrowth, and regeneration, virus particles would leave along with the dead skin cells they infected back when the infection was active? Might be a stretch I know...

Thanks in advance dear doctors
Edward W. Hook M.D.
Edward W. Hook M.D.
45 months ago
 Welcome to our forum thank you for your thoughtful question. My sense is  that you have a better understanding of HPV biology then many of the so-called online "sources" or some of the clinicians that you have spoken with.   Virtually all HPV  therapy is based on distruction of infected tissue. Once the tissue (and therefore the virus in the tissue) has been destroyed it is no longer viable or Infectious to others.    In addition, your own experience over the past decade serves to reinforce the fact that you are no longer infectious to sexual partners.   I encourage you to believe your experience and the understanding that you have rather than buying into the hyperbole regarding chronic HPV infections. 

I should also acknowledge that there is a possibility that in the past you may have had a genital HPV infection which did not cause visible warts.  That said such infections are widespread and do not constitute a reason to notify partners of the ( in your case, unproven, possibility).

With regard to your specific questions:

 None of this also replaces the possibility that you may have had cervical infection which 

1.  The concept  of asymptomatic HPV infection or felt reflects the fact that persons who are untreated can have HPV infection without visible lesions. In such situations the virus is present and potentially transmissible.  Further, as you suggest, in terms of a symptomatic shedding,  the nurse practitioner you spoke with seems to be confusing HSV biology with the biology of HPV.  Further, as mentioned above, the fact that your HPV was treated changes the situation as well. 

2.  Please see my comments above.

 Your concerns reflect the unfortunate impact of the Internet on appreciation and understanding of complex biological situations such as HPV. All too much information found on the Internet is taken out of context, misinterpreted, or on some occasions, just plain wrong being analogous to "fake news".  I urge you to have confidence in your own experience, and the understanding that you have summarized above. I see no reason for you to worry about infecting sexual partners, nor any reason for you to feel obligated to inform partners of the HPV infection which you had  over a decade ago. 

I hope these comments are helpful and reassuring to you.  EWH
---
45 months ago
Hi Dr. Hook,

Thank you for your kind and prompt response. 

I do know I've had probably multiple other infections aside from the initial warts, as I've gone on and off with the LGSIL smears and positive high-risk HPV tests. I've come to terms with the abnormal paps and have informed partners in the past of them, but I think the warts with their yuck factor carry the most emotional burden and I'm most reluctant to talk about, especially considering it was so long ago. 

Just to reiterate and clarify... do you believe/agree that with medical treatment designed to kill virus-infected skin cells, that the virus itself can slough off as well, effectively leaving the body for good? I am really looking for a clear answer as to whether it is possible for hpv to physically leave the body post-infection. This is just in reaction to people who vehemently argue that as a virus, it never leaves. Additionally, could you also address more specifically my example of going potty over the past 11 years -- do you think there is a possibility the cells of my vulval skin could die and regenerate naturally by themselves and/or via regular wiping, effectively getting rid of any/many/all remaining virus particles or DNA? In the same vein, but on the other hand, would it be more likely for tiny virus particles to persist in the body undetected if they were never medically treated and the infection retreated on its own via natural immune response? In other words, how effective is explicit medical treatment in ridding the body of the virus by killing infected skin cells vs. virus retreating on its own after time? Is there any reading you can suggest that sheds light on how treatments/immune response work to rid the body of hpv infection? I understand that I am (at least practically) cured of the strain that caused my warts, but any further reassurance that there is a possibility the virus may have actually physically left my body is a giant weight off my mind.

Last, it's so great having you and Dr. Handsfield to speak to here, I'm sure you've heard it a million times before but it really is an invaluable service to many anxious souls turning to the internet in search of fair, unbiased answers rooted in logic and science. Are there any other initiatives that you know of by other medical professionals working to shed light on the social aspects of this virus? There are so many gray areas both scientifically and ethically that those of us unfortunate enough to be aware of our infection have to live in some kind of anxious purgatory trying to figure out what to do in an effort to protect and inform both ourselves and our partners, while struggling to find a happy guilt-free balance between both. I truly believe HPV itself is not a big deal - the problem is far more psycho-social than it is physical. Is anyone else out there aside from the two of you doing any kind of social/activist work to shed light on this sticky social situation, that either directly or indirectly effects us all?

All the best
45 months ago
Also did you mean to complete this sentence: 
 "None of this also replaces the possibility that you may have had cervical infection which ....?"

Cheers
Edward W. Hook M.D.
Edward W. Hook M.D.
45 months ago

As I said in my original reply "Once the tissue (and therefore the virus in the tissue) has been destroyed it is no longer viable or Infectious to others.    In addition, your own experience over the past decade serves to reinforce the fact that you are no longer infectious to sexual partners."  Thus the virus is destroyed and no longer present, therefore it cannot be transmitted.  On the other hand when the body's immune response eliminates detectable HPV as it does in nearly every one with the infection over time, small amounts o viral DNA remains detectable with sophisticated detection methods.  It is this "persistence" that people so often fixate upon and lead to discussion f chronic HPV.  Most (but admittedly not all) experts agree that once the body has reacted to and eliminated detectable HPV, persons are no longer infectious.  My advice, based on your response to therapy, your experience over the past decade is to assume that the virus that caused your visible warts has "left your body". 

As you point out, this is more of a psycho-social issue than a medical one.  Even if the virus were present and detectable, its true medical importance would only be its association with cancer in a tiny fraction of persons witht he infection.  For those people, routine PAP smears and other recommended reproductive health care is designed to detect, treat and therefore prevent the bad outcome that we want to avoid. 

Finally, sorry about the incomplete sentence.  You anticipated my response in your reply however, I meant to state"None of this also replaces the possibility that you may have had cervical infection which might persist and intermittently be detectable.  The appropriate response is to do just what you have done and to get regular health care checks which assess you for risk of LSIAL or other sentinel events."   I would also point out that all LSIL is not due to HPV and that HPV can be present without cause LSIL (or SIL of any grade).  Your follow-up seems to impl that you are aware of this anyway.  EWH

---
45 months ago
So if I am understanding correctly, with treatment aimed at destroying hpv-infected tissue, the virus itself can actually slough off with the destroyed tissue, whereas when the immune system alone eliminates hpv infection, small, insignificant bits of viral DNA can or will persist. Maybe this is more a question for a dermatologist, but do you think it possible with natural skin regrowth and regeneration over many years, that these small bits of DNA hanging out in the skin could be sloughed off along with dead skin cells? Thanks for helping put this in layman's terms for me.

You said, "I would also point out that all LSIL is not due to HPV" This is the first I've heard this. I have heard that abnormal paps, specifically ASCUS, are not necessarily attributable to HPV, but never that LSIL is not necessarily due to HPV. What else can be the cause of LSIL, out of curiosity?

Ok that's all, thank you again.
Edward W. Hook M.D.
Edward W. Hook M.D.
45 months ago

The issue of residual virus/DNA depends on whether or not the treating doctor destroyed all of the tissue containing virus, allowing normal cells to regrow in their place. HPV infections and warts for sure are sort of "iceberg-like" in the infection may extend into the visibly (but not microscopically) uninvolved skin surrounding the wart.  Thus when warts are treated with destructive therapy, providers try to include a "margin" of visibly normal cells which might contain virus even though the skin looks normal.  I hope this makes sense.  Think of the iceberg analogy. 

Certainly for ASCUS but also for some LSIL other inflammatory processes (infection are most common) can cause abnormalities which are sometimes classified as LSIL.  Remember that even with published and agreed upon guidelines, interpretation of PAP smears has a subjective element and there is a bit of overlap between classes (such as ASCUS and LSIL).  This has been shown in numerous studies of PAP smear interpretation.

I hope my responses have been helpful.  As for Forum Guidelines, .  we are permitted up to three replies per question.  Thus this thread will be closed later today.  If there are further questions you will need to start a new question.  Take care. EWH

---
45 months ago
Dr. Hook,

If I may just persist quickly (no pun intended)! With all due respect, I feel as if I've asked the same question a few times but am not getting a response to it. I do appreciate the iceberg analogy, but it is not addressing a question I've been asking. What I am wondering is if: years beyond clearance of infection, with natural skin cell death and regrowth, is there a possibility that remaining persistent viral DNA particles hanging out in the skin can slough off along with dead skin cells? 

Best
Edward W. Hook M.D.
Edward W. Hook M.D.
45 months ago

Final answer.  I have answered this question to the best of my ability but it is really a "what if" question.  If the destructive treatment destroys all cells containing HPV the virus and its DNA will be gone.  If the treatment is not complete, I suppose there could be residual, quiescent DNA present.  No real way to know. 

The thread will be closed now.  EWH

---