[Question #7812] HPV question for Dr Handsfield

17 days ago

Hi Dr Handsfield,Hope you are doing well.

I have a simple question however with a lot of backstory behind it! I have had an ongoing saga for some time regarding genital lesions (penile shaft and pubic area and in softer tissue of foreskin)  where there is an unclear pathological, clinical and HPV typing diagnosis.The morphology / pathology favours a Seborrheic Keratosis, clinically/visually I have had 2 + dermatologists tell me they look like Seborrheic Keratosis and one tell me it resembles genital warts.

I had HPV typing done on earlier samples and they came back negative for HPV (although I understand not all HPV types are tested for in the in situ hybridization HPV testing.I have the pathology reports if you need any further info - however pathology states: "The favoured diagnosis is a seborrheic keratosis (no atypia, no koliocytosis, fragments of a shaved benign squamoproliferative lesion with orthohyperkeratosis, acanthosis and uniform hypergranulosis without conspicuous clumping of keratohyaline granules and koilocytic change. Mild increase in vascularity is noted in the underlying dermis.) As previously suggested at the first review of this biopsy, however, thus, although not favoured based on the morphological changes, a viral wart cannot be entirely excluded and treatment should be guided by clinical need and clinico-pathological correlation".

My question is, is it possible to have a lesion which has been caused by HPV, and then say after a year, is it possible for the lesion to remain (not regressed) but the HPV to clear and not show up on tests?

The reason this is important to me is that it seems I may have to live with the uncertainty of having tiny bumps in the future as the clinic will not remove them if they say it is sebhorreic keratosis, and I will not be entirely sure what they are - is this a hair follicle? a  fordyce spot? A seborrheic keratosis or a condyloma? So I am concerned about partner notification - however if I knew that it was possible to have a lesion that was initially caused by HPV but the HPV has now cleared and the small lesion remains I’d feel a lot better.

Many thanks,

Toby

Edward W. Hook M.D.
Edward W. Hook M.D.
16 days ago
Welcome back to the Forum. As Dr. Handsfield explained to your 4 years ago, we are assigned questions randomly and clients are not permitted to ask for one or the other of us.  We do this, in part, because in over 30 years of working together, we have never disagreed on that factual content of of answers to questions.  I'll be answering your questions today.

I have reviewed your past interaction with Dr. Handsfield and agree with his comments.  I not that you continue to worry about HPV and trust that you have noted on other posts on this forum that we both feel that HPV infections are quite common and rarely of consequence to those who are infected.  We strongly endorse the HPV vaccine which not only is very effective in preventing new HPV infections bur in more recent studies has been suggested to augment infected person's immune responses, increasing the likelihood that any infection which is detected will resolve without complications.  

HPV infections have distinctive findings on biopsy which are listed in the report you describe and none of those were present. Further, seborrheic keratoses are not due to HPV and are unrelated benign processes.   The cautionary statement in the report you received ("As previously suggested at the first review of this biopsy, however, thus, although not favoured based on the morphological changes, a viral wart cannot be entirely excluded and treatment should be guided by clinical need and clinico-pathological correlation." is simply that and represents adefensive posturing on the part of the pathologist.  Further, seborrheic dermatoses and visible genital warts each respond well to many of the same treatments - liquid nitrogen freezing, lasers, etc.  

two out of three dermatologists feel your lesions are SKs and not warts, the other was not sure but you have a
biopsy which is not suggestive of HPV despite the pathologists hedging.  I urge you not to worry that the lesions you had biopsied were warts.  

In textbooks of genital dermatology, only a small proportion of lesions described are due to HPV or other STIs.  My advice is to accept that the lesions you have had biopsied are not HPV and to put your fears aside.  Given all the data you mention, I see no reason for even raising the possibility of partner notification.  Most unvaccinated, sexually active persons have HPV and the infection is more of a nuisance than anything else as long as persons follow routine sexual health screening and prevention guidelines.  EWH
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16 days ago
Hi Dr Hook - many thanks for your reply. There is a lot more info that I could provide i.e. my wife's latest HPV status (positive for high risk HPV) and latest smear results (normal) etc and the fact that my current dermatologist said "they look like genital warts" but happy to leave it there.

Eitherway - appreciate your answer and detailed response - however could you shed light on my main Question:

Is it possible to have a lesion which has been caused by HPV, and then say after a year, is it possible for the lesion to remain (not regressed) but the HPV actually clears so that it does not show up on tests (and not be transmissible even though a minor lesion remains)?

Many thanks,

Toby

Edward W. Hook M.D.
Edward W. Hook M.D.
16 days ago
Sorry I missed this aspect of your question.  I can't imagine that a lesion caused by persisting HPV would not show histologic pathological changes and not be detectable on tests.

Regarding the 2nd part of the question- if HPV is not detectable, can it be transmitted?, the answer is that conventional wisdom is that if HPV is not detectable, it in not transmissible...or at least extraordinarily unlikely to be transmissible (please note, this is the same sort of "waffle" that I criticized in my original answer regarding the pathologist's "...although not favored..." comment).  The answer is somewhat qualified because of the fact that it has recently been recognized that following apparent resolution of HPV infection, infected persons can still have occasional and intermittent low level shedding of the virus.   In science, as we know more and more, words like "always" and :"never" must always be qualified, as unsettling as it is.  Nonetheless the likelihood of transmission becomes vanishingly low.  EWH
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16 days ago
Ok thanks Dr Hook, so in your opinion there is no possibility that the virus can clear or diminish after 2 years but the lesion could remain?

In the following study it suggests this could be feasible: https://pubmed.ncbi.nlm.nih.gov/24556611/ -  "One explanation may be that vulvar SK have diminishing levels of HPV genetic material in the relatively older ages of the patients in our study"

I guess I was hoping that this might be possible, as it would mean that even though I had a small lesion it might not contain active HPV and therefore I could not pass it on.

Many thanks,

Toby
Edward W. Hook M.D.
Edward W. Hook M.D.
16 days ago
You are correct. That is my opinion.  If an HPV lesion is present, it should be considered infectious.

I would point out that, of the studies you mention, the most recent is more than 6 years old and the authors suggestion of a relationship is qualified by the following statement - "...Alternatively, vulvar SK may have no relationship to HPV, and strict histologic criteria may separate vulvar SK from condyloma acuminatum. In this instance, the few cases of HPV-positive vulvar SK may reflect incidental persistence of HPV in vulvar epidermis".  In my opinion and based on my own work, I think this is the most likely explanation.  

I will acknowledge that with the other major viral STI, we do  know that with time the rates and quantify of viral shedding do tend to very gradually decline over a period of years.  

If you have an HPV lesion, it should be considered potentially infectious through sexual contact.  OTOH, if the lesion has resolved, due to either treatment or through spontaneous resolution, then the likelihood of onward transmission is very, very low.  EWH
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16 days ago
Many thanks Dr. Hook, appreciate your time.
Edward W. Hook M.D.
Edward W. Hook M.D.
16 days ago
You're welcome.  I hope the information provided has been helpful. this thread will now be closed.  EWH---