[Question #7049] HPV transmission and immuniy

8 months ago

Dear Doctors,

Thank you for providing this service. I found these threads and other ASHA resources very helpful. Gladly chipping in.

I recently began having sex with a new partner, we're both over 30 and have tested negative for other STIs. We both know we have been infected with HPV in the past. I first became aware of my infection around 2018 when I developed warts on the shaft and foreskin of my penis. I treated these with Imiquimod which cleared them after several months. However, the warts came back on the underside of my penis and the Imiquimod dosage caused a bad reaction and ulceration on my scrotum. I stopped using the drug and waited several months to have them removed by cryotherapy last November. That cleared them up but more grew back around that area around six months ago and two weeks ago I treated them with cryo. About a week after the treatment I began having sex with my partner without a condom. However, this week as I continued to heal, I noticed one of the nasty buggers resurface. I intend to apply a small dosage of Imiquimod very carefully to the last wart as cryo again seems like overkill. However, I don’t want to be disingenuous with my partner that I may still be infections despite having ditched the condom. My question is this: given that my partner also had a past infection, are we just swapping HPV strains? Could I be giving her warts? And given her past infection, is she potentially immune or resistant? Should we avoid oral sex and resume condom use while the wart is present? And lastly, should I be concerned with using Imiquimod while sexually active, or is a good scrubbing after every dose enough to prevent spreading it? 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
8 months ago
Welcome. Thanks for your confidence in our services.

First, you and your partner definitely are not "swapping HIV strains". That probably never happens:  people are immune, or at least highly resistant, to new infection with HPV types they already have experienced. Couples do not "ping pong" their mutal HIV infections back and forth. Second, the new appearance of a wart probably doesn't increase whatever risk your partner was at. When a wart appears, the HPV infection responsible for it almost always has been present for weeks if not months. Even if the cryotherapy you had a couple weeks previously undoubtedly destroyed the wart(s), but it doesn't eliminate HPV. A corollary here is that the HPV infection responsible for warts probably always involves the surrounding skin we well as the warts themselves. If your goal was to prevent transmission of that particular HPV infection to your partner, you would have had to avoid sex for 3 months or more after the last apparently successful cryo.

This doesn't imply you shouldn't have had sex. Had I been in your situation, I would have discussed my warts with my partner, as you apparently did; and if she agreed, would proceed with the sexual relationship. As a seually active person with prior partnerships, there's a good chance her own past HPV infection(s) included the type (usually HPV 6 or 11) causing your warts. As already noted, in that event, she immune to a new infection. And even if not, many people with wart-causing HPV infections never experience actual warts; and if she does, and being on the lookout, she can be treated early. Your experience has been somewhat atypical:  you've been unlucky in having persistent recurrence of warts for a long time, but that doesn't mean she would be at risk for the same thing.

I don't see any problem continuing to use imiquimod, except to avoid sex in the next several hours after treatment; or wash with soap and water before sex -- to avoid exposing your partner to the drug, which could be irritating. There is certainly no need for "a good scrubbing". If you're hoping that would reduce the chance of HPV transmission, I doubt it would make any difference; indeed, might even increase transmission risk by exposing deeper tissues with higher viral load.

Finally, I definitely would not avoid oral sex -- by either of you for the other -- on account of HPV. The large majority of oral exposures don't apparently result in virus transmsision; and when it happens, generally there are no symptoms. There's been a lot of media attention to some oral cancer (specifically, pharyngeal squamous cell cancer) due to HPV, but in fact it's quite rare -- a few thousand cases a year among tens (hundreds?) of millions who have had oral exposures to HPV.

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

HHH, MD
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7 months ago
Thank you doctor, your answer is very straightforward and helpful. If I may, I'd like to know a little more about the drug Imiquimod itself. I have the 5% cream, but I'm trying to treat the area only around the last remaining wart. I'm being careful to isolate area of the treatment and potential side effects. I applied it to two spots at first, then decided to target only the definite wart and covered it with a small bandage to avoid contaminating other areas. I applied it 2 or three times this past week. As a result however, I developed redness and dryness on different areas of my penis, foreskin, and one part of my scrotum where I did not apply the cream. Perhaps these are areas that I touched with contaminated fingers? Even so, I was surprised to get that reaction where I didn't apply the drug, whereas the area around the wart didn't suffer the same. The redness and dryness led to some painful irritation and flaking of the skin over a wide area and I stopped the treatment until it healed, but it is taking some time. I'm afraid these side effects will worsen if I keep using the cream without letting these areas of skin recover. Any idea how exactly its affecting me? I have also been applying it to an area on my hand where I have normal warts, per the recommendation of the prescribing doctor. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
7 months ago
Sorry, but I really can't say if the redness and "dryness" you describe is due to the imiquimod itself, or perhaps an allergic reaction of some sort. The doctor who prescribed it probably would have better advice; he has examined you (and can do so again), whereas I cannot. You could try an alternate treatment, like podofilox (Condylox®) or sinecatechins (Veregren®), which are just as effective. Or speak with your doctor about cryotherapy with liquid nitrogen and/or electrocautery. These are dont in the doctor's office, which is perhaps an inconvenience; but they eliminate the warts immediately, usually without requiring repeated treatments.

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7 months ago
Thanks Dr. case closed!