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54 MMWR May 10, 2002 some patients is to forego treatment and await spontaneous resolution. Most patients have
Vol. 51 / RR-6 Recommendations and Reports 55 useful several weeks into therapy to determine appropriateness of medication use and response to treatment. Cryotherapy destroys warts by thermal-induced cytolysis. Health-care providers must be trained on the proper use of this therapy, because over- and under-treatment may result in poor efficacy or increased likelihood of complications. Pain after application of the liquid nitrogen, followed by necrosis and sometimes blistering, is common. Local anesthesia (topical or injected) may facilitate therapy if warts are present in many areas or if the area of warts is large. Podophyllin resin, which contains several compounds including antimitotic podophyllin lignans, is another treatment option. The resin is most frequently compounded at 10%–25% in a tincture of benzoin. However, podophyllin resin preparations differ in the concentration of active components and contaminants. The shelf life and stability of podophyllin preparations are unknown. A thin layer of podophyllin resin must be applied to the warts and allowed to air dry before the treated area comes into contact with clothing; overapplication or failure to air dry can result in local irritation caused by spread of the compound to adjacent areas. Both TCA and BCA are caustic agents that destroy warts by chemical coagulation of the proteins. Although these preparations are widely used, they have not been investigated thoroughly. TCA solutions have a low viscosity comparable with that of water and can spread rapidly if applied excessively; thus, they can damage adjacent tissues. Both TCA and BCA should be applied sparingly and allowed to dry before the patient sits or stands. If pain is intense, the acid can be neutralized with soap or sodium bicarbonate. Surgical therapy is a treatment option that has the advantage of usually eliminating warts at a single visit. However, such therapy requires substantial clinical training, additional equipment, and a longer office visit. Once local anesthesia is applied, the visible genital warts can be physically destroyed by electrocautery, in which case no additional hemostasis is required. Care must be taken to control the depth of electrocautery to prevent scarring. Alternatively, the warts can be removed either by tangential excision with a pair of fine scissors or a scalpel or by curettage. Because most warts are exophytic, this can be accomplished with a resulting wound that o<strong>nl</strong>y extends into the upper dermis. Hemostasis can be achieved with an electrosurgical unit or a chemical styptic (e.g., an aluminum chloride solution). Suturing is neither required nor indicated in most cases when surgical removal is done properly. Surgical therapy is most beneficial for patients who have a large number or area of genital warts. Carbon dioxide laser and surgery may be useful in the management of extensive warts or intraurethral warts, particularly for those patients who have not responded to other treatments. Interferons, either natural or recombinant, used for the treatment of genital warts have been administered systemically (i.e., subcutaneously at a distant site or IM) and intralesionally (i.e., injected into the warts). Systemic interferon is not effective. The efficacy and recurrence rates of intralesional interferon are comparable to other treatment modalities. Interferon is likely effective because of its anti-viral and/or immunostimulating effects. However, interferon therapy is not recommended for routine use because of inconvenient routes of administration, frequent office visits, and the association between its use and a high frequency of systemic adverse effects. Because of the shortcomings of all available treatments, some clinics employ combination therapy (i.e., the simultaneous use of two or more modalities on the same wart at the same time). However, some specialists believe that combining modalities may increase complications without improving efficacy. Cervical Warts For women who have exophytic cervical warts, high-grade squamous intraepithelial lesions (SIL) must be excluded before treatment is initiated. Management of exophytic cervical warts should include consultation with a specialist. Recommended Regimens for Vaginal Warts Cryotherapy with liquid nitrogen. The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation. OR TCA or BCA 80%–90% applied to warts. A small amount should be applied o<strong>nl</strong>y to warts and allowed to dry, at which time a white “frosting” develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate (i.e., baking soda), or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary. Recommended Regimens for Urethral Meatus Warts Cryotherapy with liquid nitrogen OR Podophyllin 10%–25% in compound tincture of benzoin. The treatment area must be dry before contact with normal mucosa. This treatment can be repeated weekly, if necessary. The safety of podophyllin during pregnancy has not been established.
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Ipce Newsletter E 17 I p c e N E W
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Ethics and ... Ethics The guideline
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Report of the Meeting Report of the
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Report part 2 2. Presentations and
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Report part 2 What are Governments
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Report part 4 this is not ethical.
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Report part 4 Freedom and rights ar
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Psychiatric Association Debates Lif
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Psychiatric Association Debates Lif
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Online Sex Abuse Cases not ... [Bac
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Extreme sentences demanded trips to
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Psychiatric Association Debates Rec
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Online Sex Abuse Cases Not Characte
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False Allegations of Child Abuse
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Is pedophilia a mental disorder cho
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Injuries Indicative of Abuse Class
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THE MEDICO-LEGAL TECHNICAL WORKING
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TABLE OF CONTENTS Introduction 7 Ou
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OUR GOALS It is the genuine hope of
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DEMOGRAPHIC DATA DEMOGRAPHIC DATA P
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EXTERNAL GENITALIA URETHRA AND PERI
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FORENSIC EVIDENCE AND LABORATORY RE
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APPENDICES � Appendix A: Abuse Do
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APPENDIX B: ADAMS CLASSIFICATION SY
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CLEAR EVIDENCE OF BLUNT FORCE OR PE
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Redundant Hymen: *Abundant hymenal
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The Smoking Gun: Archive < 1 2 3 4
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"The International Traffic in Girls
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"The Age of Consent," June 1886 Doc
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"Protection of Girlhood," October 1
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Petition of the WCTU, 1888 Document
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Petition of WCTU, Image Previous Do
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"Seduction a Felony," Sept 1888 off
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Campbell, "Poverty and Vice," 1890
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Campbell, "Why an Age of Consent?"
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Henry B. Blackwell, "The Case of Ma
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"The National Colored Woman's Congr
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"The Morality of Sex," 1913 Documen
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Campaign to Raise the Legal Age of
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The MMWR series of publications is
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2 MMWR May 10, 2002 Throughout this
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