[Question #4918] HPV/Genital Warts

25 months ago

Dear Experts,

I am an otherwise healthy male in my mid 30s (I exercise, eat healthy, don’t smoke, drink moderately, etc.) struggling with genital warts. In 2009 when I was in a long-term relationship, I had one wart on my shaft. I don’t know where I got it from, but my gf at the time had been vaccinated and never had symptoms. I had it treated, and never had a recurrence until summer 2017, although I’m wondering if this was a new infection from a new girl. From summer 2017 to early 2018, I had maybe 5 very small warts at the base of my penis. I removed them all on my own with ACV. I thought I was clear as of the second half of 2018, but then two weeks ago, I discovered I had two slightly larger ones on the back of my shaft. I remember I had dry skin around there and had a small “cut” from masturbation where they showed up so I’m thinking I inoculated myself inadvertently. I got the first Gardasil shot this past month (getting the second one soon), and will be taking medicinal mushrooms to aid my immune system.

I am single and looking for a relationship, and this is really getting me down. I want to do the right thing and inform partners, but I’m also dating less because I want to see if I can clear this. I guess I’m looking for some guidance on the following:

Is the ACV test to identify warts (turn white) accurate all the time? Might it cause non-warts to cause white?
Will Gardasil help my immune response or at least prevent re-infection/future auto-inoculation?
What do I do about telling new partners? What are the chances I give it to a new girl if I can’t see any warts?
Is it likely my summer 2017 (until now I guess) infection a new infection or the old one from 2009 acting up?

H. Hunter Handsfield, MD

25 months ago

Welcome to the forum. Thanks for your question.

First, some general thoughts. The incubation period (time to visible warts) is highly variable, and many apparently new infections are reactivations of infection actually acquired months or years earlier. Therefore, wen and from whom genital warts or any particular HPV infection is acquired is usually difficult or impossible to know. Acetic acid is not effective treatment: the much stronger bi or tri-ichloroacetic acids are often used in treatment, but acetic acid (vinegar) has little effect. (if an acid isn't strong enough to burn the skin, it's not going to clear HPV.) Local trauma or abrasion is not known to increase the chance of HPV inoculation, although it's possible this can explain the location of some warts. Genital warts are more common than many people realize. In Scandinavia, where essentially everyone's detailed health records are available for online research, 25-40% of all persons are treated at one time or another for genital warts. Less reliable data suggests rates in the US are similar, although substantial declines are now becoming evident where HPV immunization is common.

The acetic acid test (in the medical literature, often called acetowhitening) is a very poor diagnostic method, almost never used by STD experts or dermatologist to diagnose external warts and definitely not recommended for self testing by medically untrained persons. Not all warts or other HPV infections turn white, and non-wart skin conditions, or even entirely normal skin, often turn white. (It can be useful for diagnosing HPV of the cervix, to guide where to biopsy or to scrape for treatment, but doesn't work well on dry skin.)

To your specific questions:

1) Answered above. Indeed not all whitening with acetic acid is due to warts or HPV. Probably almost any condition associated with skin thickening increases the chance of whitening.

2) It's good to hear you're being immunized with Gardasil. Ideally it should be done much earlier than age mid-30s; statistically, it is likely you've already been infected with some or most of the 9 HPV types covered by the vaccine, and immunization has no effect at all on previously acquired HPV. It might be more effective than the immunity that comes from natural infection, however , so it might help prevent re-infection with previous types -- but this isn't really known yet, a research issue still in progress. But it definitely won't have any effect on the potential for reactivation of a previously acquired but dormant HPV infection.

3) In general, people with past but resolved warts or HPV have no obligation to inform future partners. Because HPV is so common, new partners are at no higher risk for infection from people have had had HPV diagnosed than with the larger proportion of the population who have been infected but not diagnosed. If you have no visible warts, you can be confident (although not certain) that the infection is no longer active and not transmissible.

4) As implied above, there's no way to know whether the wart that appeared in 2017 was from a new infection or reactivation of your old one.

A final perspective: getting genital HPV, often several times, is a normal, expected consequence of being sexually active. Happily, the large majority of infections never cause symptoms or disease. As Gardasil comes into increasingly common use, however, infection with the 9 types that cause 90% of disease (warts, cancer, pre-cancer, etc) will become increasingly uncommon. HPV disease has been radically reduced in Australia, the one country in the world with a comprehensive, population-wide immunization program in place for more than a decade. We can hope and expect the same elsewhere -- someday.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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25 months ago

Hi Dr. Handsfield,

Thank you very much for your detailed response. I have a few follow-up questions:

1. You said without any visible warts, I'm likely not contagious and have no responsibility to tell future partners (especially because they're essentially at no greater risk with me than they are others who have it, but don't know they do). I guess I want to do the right thing and inform them, but would hate to have a great woman run away because of something so common and (mostly) benign. Would you agree with my urologist that, after healing from wart removal is complete, I don't have to say anything? I'm leaning towards mentioning (for the next 3ish months, hopefully no recurrences) I had an "HPV infection" (not saying the word "wart," which is scarier/more gross sounding) but it was treated and I think I'm ok/have you been vaccinated?

2. Some doctors have told me that Gardasil might (not proven) help immune response to clear this infection and/or maybe prevent re-infection/auto-inoculation. I think I'm going to go through with all 3 shots (getting the 2nd one in two weeks). Can I hope to have at least some marginal benefit from this in helping reduce wart recurrences (my main concern)?

3. Are there any supplements I might take to help my immune system clear this infection? I'm going to start taking Immune Assist 24/7 (2.5g per day), which is a medicinal mushroom blend that supposedly is helpful against HPV.

4. Given my history with this (one single wart in 2009, 3-4 in 2017, seemingly none in 2018 (maybe 1 or 2, but I tend to think every odd looking "thing" might be a wart now), and 2 in early 2019 - do you think I can hope to someday be clear of recurrences? I seem to have a mild case/new case (from 2017), so hoping by mid/late 2019 (within the 2 year 90% clearance rate) I'll be done with worrying about this!

Thank you again for your time, I really appreciate it.

H. Hunter Handsfield, MD

25 months ago

Interesting coincidence: your situation and your questions are very similar to those of another user, question 4925. I just replied to his follow-up question which asked pretty much the same things.

1. The time to reduced infectivity of HPV after wart removal isn't known for sure, but I usually advise 6 months as a safe interval. But 3 months probably is OK. But I do think that immediately after healing is complete may be too soon. I'm not saying your urologist is wrong, and I'm pretty sure infectiousness is at least reduced at that time, but perhaps not completely. This user also hesitated to use "wart", preferring to tell his new partner that he only had HPV. But as I said there, I doubt most potential partners react much differently to these words.

2. The "some doctors" you spoke with are wrong. Research to date has found no measurable effect of the vaccine on existing HPV infections.

3. No known immune system boosting or enhancement is known to make any difference. I wouldn't waste my money on that stuff or any other unproved immune booster. No valid research shows any benefit for HPV.

4. The large majority of people with genital warts, even when recurrent, eventually stop having recurrences. Most likely you won't experience any more outbreaks.

Thanks for the thanks. I'm glad to have hellped. Let me know if you have any final questions -- you have one more comment/reply in the bank.

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25 months ago

Thanks again Dr. Handsfield. A few final questions:

You said earlier that Gardasil might help prevent re-infection/self-inoculation to previous types I was infected with (but that this is not proven yet), but then you seemed to say it wouldn’t be of any help in the second response. Should I even both with the second two shots? I think I still want to at least get 2 out of 3.
I had surgery in the fall and had infections in two of my surgical wounds, and was thus on antibiotics for a few weeks. Do you think the surgery/antibiotics might possibly explain why I had the recurrence in early January (when they actually surfaced)?
Can you elaborate on the concept of “auto-inoculation?” I know you said you didn’t think that masturbation would necessarily spread warts, but I’ve read that others have apparently found (anecdotal) that frequent masturbation without lubrication could exacerbate this.
When people say that “most people clear HPV infection,” it seems that when an infection occurs again, it’s unclear as to if it’s either the old infection reactivated or a new infection. Do you have any insight on this?
This isn’t really a question, and you’ve already done this in your previous comments (that even with recurrent warts, most infections eventually go away and stop coming back) – but I guess I’m just looking for any additional reassurance! As I said, I am single and trying to find a relationship (haven’t been dating much recently, in large part because of this), and am terrified to lose out on a great opportunity because of something so (mostly) benign.

Thank you again for all your time and information – I really appreciate it!

H. Hunter Handsfield, MD

25 months ago

1. Imunity to new infection is different than protection against reactivation of an old, prior infection. The former is prevented by the vaccine, the latter is not.

2. Antibioitics have no effect on HPV or the immune system's response to HPV. It is conceivable, however, that transiently suppressed immunity due to the illness/condition requiring surgery, or the surgery itself, could have contributed to reactivation of HPV.

3. Auto-inoculation just means self-infection at a new part of the body. Maybe repeated physical irritation could stimulate recurrence of HPV, but there is no scientific data that suggests this happens.

4. Exactly correct: it is often difficult to know if an apparently new HPV infection was recently acquired or reactivation of a prior infection. I have no other insights on it.

5. My only advice is that many sexually active people today are aware of HPV and not necessarily disturbed by the prospect of dating or having sex with infected persons. This is especially so for those who have been vaccinated. As long as you have an active infection (visible warts) and maybe for a few months after they clear, just plan on a conversation about it. For many (most?) people today, it shouldn't be a big deal.

Thanks for the thanks. That concludes the two follow-up comments and replies included with each question and so ends this thread. I'm glad the discussion apparently has been helpful. Take care and stay safe.

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