[Question #8980] HPV lesion biopsy

37 months ago

Hello, I wanted to clarify a confusing situation for me. Around 5-6 years ago, I noticed a couple of lesions around my groin (I am a female) area, on my bum cheek, inner thigh, and pubic area. All flat, two of which brown coloured. I went to the gp, who stated they were moles/ a type of skin tag. I went to a sexual health clinic to get another opinion in case who said the same thing, and they froze them. I also had two very similar flat skin coloured small lesions on my face at the same time which I picked off.

None returned, but another popped up which was a brown colour and I think a doctor that I followed up with thought it was a sebhorric keratosis and I thought nothing of it, and I actually scratched it off at one point and it bled a bit and seemed to disappear, but then last year I noticed it again but didn't think anything of it.

LAst week, after shaving I caught it and it bled so i decided to have it checked again in case it was a mole that had changed. The gp instantly thought it was a wart, and sent it for biopsy. WHen he removed it, it had a long hair in the middle i noticed. This one was on my inner bum cheek, close to my bum/vagina area but not on my actual genitals. The biopsy has come back and really confused me, it says a 'squamous cell papilloma' with focal viral changes, hyperplasia, picture looks like condyloma'.

This has left me with questions I hoped you could answer -

1. firstly, my understanding is that most indiivudals within 2 years would clear the virus, and it concerns me if this was a wart why its been present for several years. Does this mean I have not cleared the virus?

2. I have never had any 'warts' or lesions on my vulva or internally, only around my skin close to my genitals or pubic area but on the normal skin part. My understanding is most occur on the inner labia in women, which makes me wonder why I have never had any there. Is it possible given the biopsy, this is a wart from a non-genital strain of hpv that I have in that a

37 months ago

3. My partner has recently separately had warts, and before discovering them we had had unprotected sex. We have only been together just under a year so my lesion precedes this, but his warts he discovered at the time we got together but mistook them for something else. Is there any possibility that it was a seraborrhic keratosis, and the viral changes picked up by pathology have detected hpv from my boyfriend?

4. Finally, if it is a condyloma that i have had for a few years, does its removal indicate I might finally be rid of it or is it likely to recur even after having it for so long, and no outbreaks in other areas? I understand any new outbreaks might be due to my exposure from my boyfriend, its just my main concern is having had this lesion for so long and it not having cleared. Thank you!

Edward W. Hook M.D.

37 months ago

Welcome to our forum and thanks for your questions. I'll do my best to help although ultimately I think it may be best to ask these same questions of the GP who biopsied your lesion. The lesions you describe several years ago sound very much like classical skin tags in your description, in location (which would be rather unusual locations for warts) and in terms of clinical course (once a person has had skin tags, they tend to get more, both at the site of prior tags and elsewhere). On occasion genital warts can have stalks and mimic skin tags however. Your most recent lesion which was biopsied was HPV related based on the description of the pathology. It may very well be that the prior lesions were not HPV - it will be difficult to know and, to be honest, of little consequence in terms of your continuing health. With this background, let me tryto address your specific questions:

1. Most HPV infections DO clear in 2-3 years. Visible warts tend to persist a bit longer than the flat warts often detected during PAP smears.. I would not be concerned that this lesion has persisted. It has not bad prognostic signs for you.

2. That certainly is a possibility although visible genital warts, most of which are caused by HPV types 6 and 11 can really occur in a variety of places. Location really does not say much about what is going on

3. I really do not have the expertise to answer this question however I would think it unusual for a seborrheic keratosis to then be additionally infected by HPV. they are very distinct processes

4. often a biopsy with clear margins will remove the infection and the wart will not return. If the lesion was going to return, it would be expected to do so within 3-6 months following the biopsy.

I hope the information that I have been able to provide has been helpful. I really would not worry about a wart which has been present more than 2-3 years- the likelihood of it causing you any health difficulties is scant. EWH

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37 months ago

Thank you so much for your response. I am doing my best to remain practical and not worry about it, I just have some follow up questions that I hope will help me just forget about it.

1. When you say most clear but visible warts persist, can I ask what that means in terms of the underlying infection. Does having a persistant visible wart reflect not having cleared the virus? Or is it possible that the virus is cleared from the body even though a wart remains for a few years?

2. It confuses me that this doesn't seem to reflect the typical pattern of genital hpv. My boyfriend had several warts concentrated very locally, which appeared 3-6 months after his last sexual contact, and then recently spontaneously regressed except one which was frozen off. With my infection, I've had none that typically look like warts, differing opinions from gps and sexual health clinics, none that regressed or returned when frozen except this one that has been on my bum cheek for around 2 years, which i scratched off and it kind of peels right off completely (after bleeding), then was completely (or visibly gone) for around a year then returned in the same place a year ago. I just wonder if this reflects the behaviour of the underlying virus at all? As I thought most recurred within 6 months and would spontaneously regress within 2 years in 80 percent of people? And I would have thought having persistant warts would be correlated with a higher amount, whereas I have had only one persistent/returning lesion?

3. I had a smear 2 years ago which tested for high risk hpv and that was negative. Is it possible then I just cannot seem to clear the low risk hpv? I know there is a lot of uncertainty between clearance and it being latent/undetectable, but do most people even with seemingly persistant hpv for more than 2 years eventually get to a stage that the body recognises it? Also, is there likely any amount of natural immunity against my exposure to my boyfriends recent virus?

4. Finally, I've read some papers about the link between having genital warts and cancer in later life. Is it likely this is due to the co-infection of other high risk stains or some confounding due to behaviour/lifestyle, or is there some other factors that can raise an individuals risk based on having had genital warts at some point?

Thank you so much :)

Edward W. Hook M.D.

37 months ago

Thanks for your follow-up question. I'll do my best to provide additional information but for many of the questions, precise answers are not available. There are over 100 different HPV types. most HPV research has focused on the so-called "high risk" (I say so-called as even for these types infection causes no untoward effects, making them relatively high risk) and the manifestations and natural history of any and all infections is variable so that while we can talk about what happens as a generalization, there will always be exceptions. On to your questions:

1. Statements regarding the clearance of HPV infections have focused on the types most associated with adverse outcomes-progression to precancerous lesions. As a generalization, visible genital warts appear to resolve less quickly than the HPV infections best detected through HPV screening. If a visible wart is present and persists, it is reasonable to assume that viable virus is present and the lesion is infectious to others.

2. Your BF's experience reflects what is most typical for visible warts and HPV in general. I should add that you do not know that the lesions you noted years ago which were identified as skin tags were necessarily HPV. Further as I pointed out, while the generalization holds that most HPV infections will regress over 2-3 years, the natural history is quite variable, that yours may have persisted in no way suggests that you are abnormal or at particularly high risk for complications.

3. I have no data to provide a factual basis to this question however I doubt that you are singularly unable to clear low risk HPV infections. HPV infections do generate natural immunity however, that immunity is quantitatively less than the immunity generated by the vaccine.

4. Most persons will get multiple HPV infections. I know of no data to suggest that someone who does not have readily cleared HPV infection is necessarily at higher risk for cancer. My advice is to continue to follow reproductive health guidelines for regular check ups and screening but not too worry that you have some sort of particular or increased vulnerability

Hope this helps. I urge you not to worry too much about your wart. EWH

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37 months ago

Thanks so much for your reply. I feel a lot better about it all. You are right that I do not know if they were hpv as actually I think they were never suggested to be, and were looked at separately by 2 GPs, 2 sexual health doctors and 2 nurses and they all thought they were skin tags/moles type lesions. Anyway, they never recurred so its only this one.

Can I ask is the biopsy definitive? When you say HPV related, that just means there is virus detected on it, but I know it doesn't say anything about the type etc. As a follow up to this, its interesting that most research is referring to higher risk types, I wasn't aware of this. Is it reasonable to assume that the low risk wart causing ones act similarly to the hpv types that cause warts on hands and feet? In the sense that I know in younger children warts seem to spontaneously disappear but for adults if they have them on their hands and feet they can take a lot longer. Is this what you mean by genital warts persisting for longer than higher risk strains?

I have actually just had a smear so will await the hpv results but there were no warts internally which is a relief. Good to know that although not as effective or reliable there is some natural immunity. Final question for my own interest more so than this current worry - I had the vaccine ceravix (i think) in 2009, the first wave of vaccines in the UK. It protected against only 2 higher risk strains, I think 16 and 18 or something like that. I was 17 at the time but had been sexually active already. Is there any data on how effective the vaccine is after potential exposure on higher risk strains?

Thank you so much for your time for these questions, I really appreciate it and its hugely alleviated my concerns.

Edward W. Hook M.D.

37 months ago

HPV can be detected in biopsy specimens in two ways- through noting the appearance of the cells as viewed under the microscope or through detection of viral DNA. From what you say above, your biopsy was evaluated visually but viral DNA was not looked for (you'll have to ask your doctor if that is the case). Either way, if the results are stated, they are pretty conclusive. It is only with DNA detection whoever that the type of HPV virus present can be detected.

I cannot comment on similarities of differences in HPV infections occurring on the hands and feet vs in the ano-genital region, sorry. Not my area of expertise.

The cervarix vaccine only covered two HPV types - HPV 16 and 18. Current vaccines now cover 9 different HPV types- 7 associated with pre-malignant changes (including types 16 and 18) and the two types that cause >90% of visible genital warts- types 6 and 11. The vaccine is highly protective, reducing the risk for acquisition of the types covered by more than 95-97% and possibly (research is not yet fully conclusive) reducing the resolution rates of existing infections. While recommendations vary, some persons opt to take the newer vaccine covering the expanded number of HPV types. This is a personal choice and by and large, other than cost and inconvenience of visits to health care providers, there are few downsides to taking the additional vaccine.

This is my 3rd response to your questions and therefore concludes this thread which will be closed shortly without further responses. Take care. EWH

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