1000-2000 5 ьшò

Cryotherapy, surgery, or TCA; medications contraindicated in pregnancy: podophyllin, podophyllotoxin, sinecatechins, interferon, and imiquimod (3)[C]

Second Line

Intralesional interferon, photodynamic therapy, topical cidofovir (3)[A]

SURGERY/OTHER PROCEDURES

Larger warts may require surgical excision, laser treatment, or electrocoagulation (including infrared therapy):

–Precaution: Laser treatment may create smoke plumes that contain HPV. CDC recommendation is for the use of a smoke evacuator no <2 inches from the surgical site. Masks are recommended; N95 the most efficacious (5,6)[A]

Intraurethral, external (penile and perianal), anal, and oral lesions can be treated with fulgurating CO2 laser. Oral or external penile/perianal lesions can

also be treated with electrocautery or surgery.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

No restrictions, except for sexual contact

Patient Monitoring

Patients should be seen every 1 to 2 weeks until lesions resolve.

Patients should follow up 3 months after completion of treatment.

Persistent warts require biopsy.

Sexual partners require monitoring.

PATIENT EDUCATION

Provide information on HPV, STI prevention, and condom use.

Explain to patients that it is difficult to know how or when a person acquired an HPV infection; a diagnosis in one partner does not prove sexual infidelity in the other partner.

Emphasize the need for women to follow recommendations for regular Pap smears.

PROGNOSIS

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Asymptomatic infection persists indefinitely.

Treatment has not clearly been shown to decrease transmissible infectivity.

Warts may clear with treatment or resolve spontaneously. However, recurrences are frequent, particularly in the first 3 months, and may necessitate repeated treatments.

COMPLICATIONS

Cervical dysplasia (probably does not occur with type 6 or 11, which cause most warts)

Malignant change: Progression of condylomata to cancer rarely, if ever, occurs, although squamous cell carcinoma may coexist in larger warts.

Urethral, vaginal, or anal obstruction from treatment

The prevalence of high-grade dysplasia and cancer in anal canal is higher in HIV-positive than in HIV-negative patients, probably because of increased HPV activity.

REFERENCES

1.Gormley RH, Kovarik CL. Human papillomavirus-related genital disease in the immunocompromised host: part II. J Am Acad Dermatol. 2012;66(6):883.e1–883.e17; quiz 899–900.

2.Unger ER, Fajman NN, Maloney EM, et al. Anogenital human papillomavirus in sexually abused and nonabused children: a multicenter study. Pediatrics. 2011;128(3):e658–e665.

3.Workowski KA, Bolan GA; for Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1–137.

4.Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405–1408.

5.Bryant C, Gorman R, Stewart J, et al. NIOSH Health Hazard Evaluation Report. Bryn Mawr, PA: National Institute for Occupational Safety and Health; 1988. HETA85-126-1932.

6.Moss CE, Bryant C, Stewart J, et al. NIOSH Health Hazard Evaluation Report. Salt Lake City, UT: National Institute for Occupational Safety and Health; 1990. HETA88-101-2008.

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ADDITIONALREADING

Bauer HM, Wright G, Chow J. Evidence of human papillomavirus vaccine effectiveness in reducing genital warts: an analysis of California public family planning administrative claims data, 2007–2010. Am J Public Health. 2012;102(5):833–835.

Giuliano AR, Palefsky JM, Goldstone S, et al. Efficacy of quadrivalent HPV vaccine against HPV infection and disease in males. N Engl J Med. 2011;364(5):401–411.

Gormley RH, Kovarik CL. Human papillomavirus-related genital disease in the immunocompromised host: part I. J Am Acad Dermatol. 2012;66(6):867.e1–867.e14; quiz 881–882.

CODES

ICD10

A63.0 Anogenital (venereal) warts

CLINICALPEARLS

Condylomata acuminata are soft, skin-colored, fleshy lesions caused by HPV subtypes 6, 11, 16, 18, 31, 33, and 35.

The majority of sexually active men and women will have acquired a genital HPV infection, usually asymptomatic, at some time.

No single therapy for genital warts is ideal for all patients or clearly superior to other therapies.

9vHPV vaccine is effective in preventing HPV infection, particularly if administered prior to the onset of engaging in sexual activity. Gardasil is approved and recommended for use in males and females aged 9 to 26 years.

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CONJUNCTIVITIS, ACUTE

Frances Yung-tao Wu, MD

BASICS

DESCRIPTION

Inflammation of the bulbar and/or palpebral conjunctiva of <4 weeks’duration

System(s) affected: nervous, skin/exocrine

Synonym(s): pink eye

Geriatric Considerations

Suspect autoimmune, systemic, or irritative conditions.

If purulent, risk of bacterial cause increases with age, the combo of age >65 years and bilateral lid adherence equates to risk for bacterial infection >70%.

Pediatric Considerations

Neonatal conjunctivitis may be gonococcal, chlamydial, irritative, or related to dacryocystitis.

Pediatric ER study; 78% positive bacterial culture, mostly Haemophilus influenzae; 13% no growth; other studies showed >50% adenovirus.

Children <5 years were 7 times more likely to be bacterial than were older children or adults.

Daycare regulations sometimes require any child with presumed conjunctivitis to be treated with a topical antibiotic, despite lack of evidence (1)[A].

EPIDEMIOLOGY

Predominant age

–Pediatric: viral, bacterial

–Adult: viral, bacterial, allergic

Predominant sex: male = female

Incidence

In the United States accounts for 1–2% of ambulatory office visits

ETIOLOGYAND PATHOPHYSIOLOGY

Viral

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–Adenovirus (common cold), coxsackievirus (implicated in recent hemorrhagic conjunctivitis epidemics in Asia and Middle East)

–Enterovirus (acute hemorrhagic conjunctivitis)

–Herpes simplex

–Herpes zoster or varicella

–Measles, mumps, or influenza

Bacterial

–Staphylococcus aureus or Staphylococcus epidermidis

–Streptococcus pneumoniae

–H. influenzae (children)

–Pseudomonas spp. or anaerobes (contact lens users)

–Acanthamoeba-contaminated contact lens solution may cause keratitis (rare; ~30 cases/year in United States).

–Neisseria gonorrhoeae and Neisseria meningitidis

–Chlamydia trachomatis: gradual onset >4 weeks

Allergic

– Hay fever, seasonal allergies, atopy

Nonspecific

–Irritative: topical medications, wind, dry eye, UV light exposure, smoke

–Autoimmune: Sjögren syndrome, pemphigoid, Wegener granulomatosis

–Rare: Rickettsia, fungal, parasitic, tuberculosis, syphilis, Kawasaki disease, chikungunya, Graves, gout, carcinoid, sarcoid, psoriasis, Stevens-Johnson, Reiter syndrome

RISK FACTORS

History of contact with infected persons

Sexually transmitted disease (STD) contact: gonococcal, chlamydial, syphilis, or herpes

Contact lenses: pseudomonal or acanthamoeba keratitis

Epidemic bacterial (streptococcal) conjunctivitis reported in school settings

GENERALPREVENTION

Wash hands frequently.

Eyedropper technique: While eye is closed and head back, several drops over nasal canthus and then open eyes to allow liquid to enter. Never touch tip of dropper to skin or eye.

COMMONLYASSOCIATED CONDITIONS

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Viral infection (e.g., common cold)

Possible STD

DIAGNOSIS

HISTORY

ALERT

Red flag: Any decrease in visual acuity is not consistent with conjunctivitis alone; must document normal vision for diagnosis of isolated conjunctivitis

Viral: contact or travel

–May start with one eye and then both

–If herpetic, recurrences or vesicles on skin

Bacterial: difficult to distinguish from viral, unless contact lens user. Assume bacterial in contact lens wearer unless cultures are negative. If recent STD, suspect chlamydia or gonococcus.

Allergic: itching, atopy, seasonal, dander

Irritative: Feels dry, exposure to wind, tear film deficit may persist 30 days after acute conjunctivitis, chemicals, or drug: atropine, aminoglycosides, iodide, phenylephrine, antivirals, bisphosphonates, retinoids, topiramate, chamomile, COX-2 inhibitors

Foreign body: Redness may persist 24 hours after removal.

PHYSICALEXAM

General: common to all types of conjunctivitis

–Red eye, conjunctival injection

–Foreign body sensation

–Eyelid sticking or crusting, discharge

–Normal visual acuity and pupillary reactivity

Viral

–Palpable preauricular lymphadenopathy may be present.

–Hemorrhagic coxsackievirus-related epidemics were reported.

–Severe viral: herpes simplex or zoster: Burning sensation, rarely itching

Unilateral, herpetic skin vesicles in zoster

Palpable preauricular node

Bacterial (non-STD): may be epidemic

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–Mild pruritus, discharge mild to heavy

–Conjunctival chemosis/edema

–If contact lens user, must rule out pseudomonal (or other bacterial) keratitis

Bacterial: gonococcal (or meningococcal) hyperacute infection

–Rapid onset 12 to 24 hours

–Severe purulent discharge

–Chemosis/conjunctival/eyelid edema

–Rapid growth of superior corneal ulceration

–Preauricular adenopathy

–Signs of STDs (chlamydia, GC, HIV, etc.)

Allergic

–Itching predominant, chemosis, edema

–Seasonal or dander allergies

Nonspecific irritative

–Dry eyes, intermittent redness, chemical/drug exposure

–Foreign body: may have redness and discharge 24 hours after removal

Must document normal visual acuity

Cornea should be clear and without fluorescein uptake. Cloudy or ulcerated signifies keratitis; consult ophthalmologist.

Recommend fluorescein exam: Evert lid to inspect for foreign bodies.

Skin: Look for herpetic vesicles, nits on lashes (lice), scaliness (seborrhea), or styes.

Limbal flush at corneal margin if uveitis

If pupil is irregular (i.e., penetrating foreign body), emergent referral is warranted.

Discharge but no conjunctival injection: blepharitis

DIFFERENTIALDIAGNOSIS

Uveitis (iritis, iridocyclitis, choroiditis): limbal flush (red band at corneal margin), hazy anterior chamber, and decreased visual acuity

Penetrating ocular trauma: emergently hospitalize

Acute glaucoma (emergency): headache, corneal clouding, poor visual acuity

Corneal ulcer, keratitis, or foreign body: lesions or tear-film deficits on fluorescein exam

Dacryocystitis: tenderness and swelling over tear sac (below medial canthus)

Scleritis and episcleritis: red injected vessels radially oriented, sectoral (pie wedge), nodularity of sclera

Pingueculitis: inflammation of a yellow nodular or wedge-like area of chronic conjunctival degeneration (pinguecula)

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Ophthalmia neonatorum: neonates in the first 2 days of life (gonococcal; 5 to

12 days of life): chlamydial, herpes simplex virus (HSV), very rare N. meningitidis. Consider specialty consultation for required systemic therapy.

Blepharitis: Lid margins are inflamed producing itching, scale, or discharge, but no conjunctival injection.

DIAGNOSTIC TESTS & INTERPRETATION

Usually not needed initially for most common causes

Culture swab if STD is suspected, very severe symptoms, or patient is a contact lens user

Viral swab (10-minute test) for adenovirus is costly, requires 6 passes to acquire sample, and may not be tolerated by children.

Diagnostic Procedures/Other

Fluorescein exam for corneal ulcer or abrasion

Remove small, superficial foreign bodies with irrigation or moistened swab.

TREATMENT

GENERALMEASURES

Viral conjunctivitis does not require antibiotics and resolves spontaneously.

Clean eyelid with wet cloth up to QID.

Stop use of contact lenses while eye is red.

Patching of eye is not beneficial.

MEDICATION

First Line

Viral (nonherpetic)

–Artificial tears for symptomatic relief

–Vasoconstrictor/antihistamine (e.g., naphazoline/pheniramine) QID for severe itching

–May consider topical antibiotic (see bacterial below) if return to daycare

requires treatment

Viral (herpetic) (ophthalmology consultation)

–Ganciclovir gel: 0.15%, 5 times per day for 7 days (2)[B]

–Acyclovir: PO 400 mg 5 times per day for HSV; 800 mg for zoster for 7 days

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Bacterial (non-STI): 3 days of cool compresses before starting antibiotic is associated with no adverse effects and reduces unnecessary antibiotic use.

–After 3 days, consider topical antibiotics (NNT 7 at day 6) (immediate antibiotics shortened course by only 3 days in children): Polymyxin B– Bacitracin ophthalmic ointment: Apply 4 times per day for 5 to 7 days.

–Polymyxin B-trimethoprim solution 1 gtt 4 times per day for 5 to 7 days

–Erythromycin ophthalmic ointment: 1/2 inch BID–QID for 5 days

–Sodium sulfacetamide (10% solution) (Bleph-10): 2 drops q4h (while awake) for 5 days

–Tobramycin or gentamicin: 0.3% ophthalmic drops/ointment q4h (drops) to

q8h (ointment) for 7 days Bacterial (gonococcal)

–Neonates: Hospitalize for IV therapy.

–Adults: ceftriaxone: 1 g IM as single dose and topical bacitracin ophthalmic ointment 1/2 inch QID. Neonates 25 to 50 mg/kg IV or IM, not to exceed

125 mg, as a single dose. Chlamydia in neonates requires oral erythromycin ethylsuccinate: 50 mg/kg/day divided q6h PO for 14 days, max 3 g/day.

Allergic and atopic over-the-counter (OTC) medications are efficacious, no evidence favoring one over another (3)[A].

–Ketotifen (Zaditor, Alaway, and other generics OTC): 0.25% 1 drop BID

–Cromolyn (Opticrom): 4% QID

–Azelastine: 0.05% 1 gtt BID

–Pemirolast (Alamast): 0.1% 1 gtt QID

–Alcaftadine (Lastacaft): 0.25% 1 gtt QD

–Emedastine: 0.05% 1 drop QID

–Epinastine (Elestat): 0.05% BID

–Ketorolac (Acular): 0.1% 1 drop QID

–Olopatadine (Pataday, Patanol): 0.1% 1 drop BID or 0.2% 1 drop daily

–Bepotastine (Bepreve): 1.5% 1 gtt BID

–Lodoxamide tromethamine (Alomide): 0.1% 1 gtt QID

–Nedocromil (Alocril): 2% 1 gtt BID

–Oral nonsedating antihistamines (cetirizine [Zyrtec] 10 mg/day, fexofenadine [Allegra] 60 mg BID, etc.) may treat nasal symptoms but cause ocular drying; oral antihistamine (e.g., diphenhydramine 25 mg TID)

in severe cases of itching

Contraindications: Steroids NOT beneficial in treatment of bacterial keratitis (4)[A]. Topical immune modulators (tacrolimus, cyclosporine) should be reserved for specialist use only in the most difficult cases.

Precautions

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–Do not allow dropper to touch the eye.

–Case reports of eye irritation from gentamicin in infants, moxifloxacin in adults, sulfacetamide in allergic individuals

–Vasoconstrictor/antihistamine: rebound vasodilation after prolonged use

Second Line

Viral and allergic: numerous OTC products

Bacterial: second line (quinolones used as postop or known resistant organisms)

–Ofloxacin: 0.3% 1 gtt 4 times per day for 7 days

–Ciprofloxacin: 0.3% 1 gtt 4 times per day for 7 days

–Levofloxacin: 0.3% 1 gtt 4 times per day for 7 days

–Gatifloxacin: 0.3% 1 gtt 3 times per day for 7 days

–Moxifloxacin: 0.5% 1 gtt 3 times per day for 7 days

–Besifloxacin: 0.6% 1 gtt 3 times per day for 7 days

–Azithromycin: 1.5% 2 times per day for 3 days

ISSUES FOR REFERRAL

Refer to ophthalmology for any significantly decreased visual acuity, herpetic keratitis, or contact lens–related conjunctivitis or immunocompromised (HIV).

Refer for symptoms or worsening over 7 days (concern for severe adenoviral keratitis) (5).

COMPLEMENTARY& ALTERNATIVE MEDICINE

Usually benign and self-limited; saline flushes, cool compresses, and similar treatments help

Mandarin orange yogurt showed improvement over 2 weeks for allergic conjunctivitis in a small study.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Acute gonococcal conjunctivitis (or very rare case of meningococcal conjunctivitis) requires inpatient treatment with ceftriaxone 50 mg/kg IV everyday (pediatric), 1 g IM for one (adult) along with ophthalmologic consultation.

Admission criteria/initial stabilization

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