3. Is it known how much smoking cigarettes contributes to an outbreak of GW?  Is vaping an e-cigarette better than smoking  for purposes of GW control, or are they one in the same?  

4. When will it be safe to shave-- "man-scape"--down in the pubic region?  I am assuming once all visible GW have disappeared.

Thank you for your time and consideration.  

1a,b)  The age cap isn't arbitrary. FDA approves prescription products, including vaccines, for marketing based on data provided by the producer. New information or data that becomes available later has no effect on FDA approved use or recommendations unless and until the producer goes through the lengthy, complex and expensive process of re-applying to FDA. The only current HPV vaccine producer in the US (Merck) originally studied effectiveness only in people up to age 26, which for years was the age cap. Later they studied people age 26-45 (or 46?) and found it effective, and saw a large market increase, and so Merck applied to FDA to raise the approved age limit. Both approvals were only for prevention; for many years it was believed there was little if any effectiveness against established infection or in preventing reinfection. Over the past decade, data have emerged suggesting probable partial effectiveness in both these goals, but Merck has not applied to FDA to approve vaccination for these purposes -- probably because the data are soft and the potential additional market not very large. Hence the official (FDA) position is that Gardasil is indicated to prevent initial infection and its consequences (warts, cancer, pre-cancerous lesions), but not for management of established infection or to prevent reinfection. That said, some experts recommend vaccination in people with, say, recurrent warts, hoping to reduce the frequency of future reactivation (or they accede to patient requests to do so); and, probably more frequently, in women with recurrent abnormal Pap smears. But this is not an officially approved use of the vaccine or, to my knowledge, recommended by any authoritative agency like CDC, state public health departments, or other countries' equivalent agencies.

Whether these outcomes are different in infected persons whose immune systems have truly eliminated HPV or merely suppressed it is unknown. From a biological standpoint, I don't see how or why this would make a difference. In any case, it's a moot point, because there is no known means to distinguish such patients -- i.e. no tests or other methods to determine whose immune system has completely eliminated HPV or merely suppressed it -- until clinical evidence of reactivation shows up (e.g. recurrent warts or recurrent abnormal Pap smear).

2) It is generally believed that with or without immunization, people uncommonly are re-infected with the same HPV type(s) they already have, or have had. Recent research indicates this may happen more frequently than previously believed, but probably it's still pretty uncommon. If you have a future partner who catches (or already has) your HPV strain, with or without developing warts, I don't see vaccination as likely to modify your already very low risk of being reinfected.

The unstated implication of these issues so far is that you are wondering whether or not you should be immunized at this time. Probably yes, but not on account of your GWs or risk of their recurrence in the future. The reason is that it is probable you have not been infected with all of the 9 HPV types prevented by the vaccine, which cause ~90% of all important HPV related health problems (GWs, cancer, pre-cancer). (This assumes you'll have at least a few new sex partner in the future. Immunization is far less important if you are in or about to start a long term, mutually committed monogamous relationship.) That vaccination might also somewhat reduce the chance of future reactivation of your HPV infection, or prevent reinfection with the same type, should be viewed as a possible minor side benefit, but it's definitely not the main reason you should do it. 

3) Smoking is associated with persistence of cervical HPV infection in women and a greater speed of progression of pre-cancerous cervical lesions to overt cancer. However, I am unaware of any data on recurrent genital warts. Presumably the effect in women is due to one or more (maybe hundreds) of the chemical products of burning tobacco, which is what should be avoided, regardless of the inhalation equipment used (or cigarets per se).

4) There are no data on this, just a general belief (and common sense) by providers that local re-inoculation of HPV from warts might lead to new warts nearby. On the other hand, once a few weeks have passed -- and probably by the time warts appear, typically months after catching the HPV that causes them -- the immune system may be effective in preventing active infection in this manner. As a practical matter, your own assumption is reasonable:  OK to shaving the infected area once visible warts are gone and any tissue injury from the treatment (e.g. inflammation following freezing, imiquimod, etc) has cleared up.

Thanks for the advance thanks. I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

You referenced my question(s) may be in regards as to whether to be immunized at this time--for context purposes, I have already received my first shot of Gardisol 9 and I will complete the vax--my concern is recurrence of my GW and potential transmission to other partners/ reinfection from other partners.  Further,  I do not have any autoimmune diseases or any other condition whether it be an allergy or high blood pressure.  With that in mind--if you could clarify the below:

Regarding my first question 1(a) / 1(b) you stated "[w]hether these outcomes are different in infected persons whose immune systems have truly eliminated HPV or merely suppressed it is unknown. From a biological standpoint, I don't see how or why this would make a difference."

 "Can you explain why I have a low risk of being reinfected?"  There are strong research data showing that new infection with the same HPV type(s) someone already has is rare. As I said above, it was long thought this doesn't occur at all, but more recent data document occasional reinfection with the same HPV type, but it remains very uncommon. The presumed reason is that the body's immune response -- the same one that normally suppressed the original infection -- is quite effective against new infection with the same type of HPV.  As for the publication you linked, it appears to be high quality mathematical modeling and it is statistically sophisticated. Modeling studies can be very helpful in predicting real world epidemiology, but that's all; in itself this analysis does not necessarily mean that the truth is revealed. To my knowledge, the consensus among HPV experts is that reinfection with the same type in fact is uncommon.

"I was...shocked and appalled by my condition...." A very common theme on this forum is that this is a gross overstatement of the importance and impact of HPV. Of course any online forum like this tends to attract persons who are most concerned about the topic they ask about. However, many on the forum who ask about their HPV infections care not "shocked and appalled"; and for sure I can tell you that the vast majority of persons who attend STD clinics with GWs are pretty blasé about it and properly understand HPV in general and GWs in particular to be a relative minor health issue that for the most part is easily dealt with. The best data suggest that at least a quarter and perhaps one third or more of all people in the US experience GWs (you're not alone here!) and that most aren't so bummed out about them. That's not to underplay the clinical and public health importance of HPV, and the importance of taking reasonable steps for prevention, like immunization. But for most it isn't (and should not be) a very big deal.

 My final response and follow up before this question is closed is as follows:  in regards to clearance/suppression of HPV is there any data/studies to show that a person who is symptomatic (visible GW) with HPV 6/11 has more difficulty clearing the virus  than a person that is asymptomatic with no GW when contracting HPV 6/11 ?  I am assuming there is no way to tell due to lack of testing for an asymptomatic person but I would like your best guess based on your expertise. 

Thank you again in advance for your time and substantive, thoughtful responses. 

Thanks for the thanks. I'm glad to have helped:  that's why we're here.