Condyloma acuminatum (CA) is also called condyloma acuminatum, genital warts, vulvar condyloma or venereal warts. Because the clinical manifestations are spiny and the surface is moist, it is more common to call condyloma acuminatum. The disease is a sexually transmitted disease caused by human papillomavirus (HVP), such as epidermoid hyperplasia of genitals, perineum and anus. As early as 1954, it was proved that condyloma acuminatum is a sexually transmitted disease. In recent years, the incidence of condyloma acuminatum is on the rise, and it is very likely to cause cancer. It ranks third in the United States and second in China, so it has attracted more and more attention. Condyloma acuminatum belongs to the category of "eternal sores", "warts" and "withered tendons and arrows" in traditional Chinese medicine. As early as in the chapter Ling Shu and Meridian, there were records of "verrucous orders", "perennial sores" and "withered tendons and arrows", which were also called "scabies" in ancient times and "cauliflower sores" among the people. Epidemiological studies show that sexual behavior is closely related to HPV infection. The incidence of condyloma acuminatum is the highest among sexually active people.

Etiology:

Pathogen: The pathogen of condyloma acuminatum is human papillomavirus, which was observed by electron microscope in 1949. The only host of human papillomavirus (HPV) is human, and experimental animals, including rodents, cannot be infected. HPV is not only the pathogenic factor of condyloma acuminatum, but also related to tumor. HPV DNA sequences are regularly detected in cervical squamous cell carcinoma, penile carcinoma, vulva and perianal carcinoma. Patients with condyloma acuminatum can also be infected with cytomegalovirus, and at the same time, the infection rate of genital herpes simplex (HSV) is high, and most of them have no clinical symptoms. HSV-2 infection accounts for the majority, and HSV-1infection also accounts for a certain proportion, suggesting that cytomegalovirus and herpes simplex virus infection in patients with condyloma acuminatum may occur at the same time in HPV pathogenesis, which requires simultaneous detection and treatment. Source of infection: Patients with condyloma acuminatum, subclinical infections and virus carriers are the sources of infection of this disease. The infectivity is the strongest when the disease period is 3~5 months, and decreases with the extension of the disease course. Male patients with an average illness period of three and a half months are prone to condyloma acuminatum, while male patients with an average illness period of 12 months are not prone to condyloma acuminatum. The subclinical genital infection of HPV has no typical skin lesions, and the male shows small sessile warts, and the white epithelium is locally coated with 5% acetic acid. HPV carriers usually have no clinical symptoms and signs after infection. They are often diagnosed as HPV carriers through laboratory tests. Transmission route: the disease is mainly transmitted through sexual contact. According to statistics, more than half of the female partners of men with genital warts are infected. Autoinoculation from other parts of the body to the genitals is extremely rare. More than 90% of patients are infected through sexual contact. During sexual intercourse, if the skin and mucous membrane are slightly scratched, the virus is more likely to spread, so those with long foreskin are more susceptible to infection. According to statistics, 2/3 of people who have sexual contact with this disease have the same disease; Oral-genital intercourse can cause condyloma acuminatum in oropharynx. A few can be infected through underwear, public baths, bath towels, door locks, banknotes and other contaminated items. Or spread through close contact with non-sexual behavior in the family. Infants with condyloma acuminatum are mostly infected by the mother with condyloma acuminatum during childbirth, and a few of them are spread by blood or placenta. In addition, children with condyloma acuminatum are also infected through close contact with their parents. Traditional Chinese medicine believes that the occurrence of condyloma acuminatum is due to disharmony of qi and blood, uncleanness of sexual intercourse, feeling the evil of filth and turbidity, fighting with common cold and condensing the skin; Or due to liver deficiency and blood dryness. If pathogenic toxin persists for a long time, according to the body constitution and the rise and fall of pathogenic factors, spleen deficiency and dampness will occur, or blood deficiency and wind dryness will cause blood to be weak, or factors like fat and sweetness, which will lead to damp-heat betting in the liver meridian, and the dampness and filth will be condensed with foul poison, which will cause the vulva and the anus to stagnate, resulting in warts, and the poison will spread to other places and become scabies. Damp-heat toxin and pathogen are knotted, and adhesion is difficult to get rid of, so the condition is lingering and difficult to heal repeatedly.

Symptoms, signs and complications: The incubation period of condyloma acuminatum is generally 3 weeks to 8 months, or even longer, with an average of 3 months. Because of the long incubation period, there are often repeated sexual behaviors during this period, so it is difficult to calculate the exact date of infection. The disease can occur at almost any age, and the incidence rate is high among sexually active people aged 20-40, with males slightly more than females. Clinically, the shortest incubation period is 7 days and the longest is more than one year. Except for itching, bleeding or pain caused by friction or various mechanical stimuli such as infection and erosion, there are generally no obvious conscious symptoms. 1. Exogenous warts are vegetation visible to the naked eye. At the beginning, the lesions are single or small, latent and soft, reddish, long and pointed at the top, sometimes filiform and pedicled, and gradually increase, with different sizes, such as papillary, cauliflower-like or cockscomb-like vegetation. The surface of the wart is uneven, rough, white, red or light gray, and the damage in the dry parts of the genitals is often small and flat, similar to flat warts in other parts. The damage in high temperature and wet parts is often filiform or papillary, and some of them fuse into lumps. There are often purulent secretions accumulated between cracks, which are easy to be combined with bacterial infection to form erosion and stench, and some rotten surfaces are easy to bleed when touched. Scratching due to dampness and itching leads to self-inoculation, which promotes the growth and spread of skin lesions. Condyloma acuminatum in the throat is characterized by multiple small papules on the posterior pharyngeal wall, soft palate and tongue, which are filiform, reddish and higher than tongue coating at first, and gradually increase to be flat, dirty gray and sessile. Condyloma acuminatum in throat often presents sore throat, dry mouth, bad breath and progressive hoarseness. Condyloma in rectum can be found with pain, acute diarrhea and heavy blood in stool. According to statistics, the most common male sites are coronary sulcus, prepuce frenum, glans penis, urethral orifice, penis, scrotum and anus. It can also occur in the breasts, armpits, groin and oropharynx outside the genitals. Occasionally invade the urethra, bladder or rectum. A few people have never had anal sexual intercourse, but also suffer from perianal condyloma acuminatum, which is mainly due to the humid environment in the anorectal area, which is suitable for HPV growth and reproduction. 2. The subclinical infection of condyloma acuminatum refers to the lesions that epithelial cells have been infected by HPV, but can not be directly identified by naked eyes. However, when 3~5% acetic acid solution is applied externally or wet for 5~ 10 minutes, it turns white in the HPV infected area, which is called "white acetate phenomenon", and then the skin lesions can be seen with naked eyes or a magnifying glass. Can be single or accompanied by condyloma acuminatum. Men are mostly small and flat sessile warts with a diameter of 1~3 mm, and most of them are single or several. Mostly in the coronary sulcus, foreskin can also be seen in perianal and anal parts. This test needs to exclude false positive reactions such as epithelial thickening caused by chronic inflammation, and false positive whitening shows unclear and irregular boundaries. 3. The latent infection of HPV refers to the clinical symptoms, no skin lesions in the infected area, negative acetic acid phenomenon, and no HPV infection in histopathological examination. However, HPV DNA is confirmed by highly sensitive methods, including in situ hybridization and PCR, which is called latent HPV infection. Because PCR can only detect the DNA of HPV in the specimen, but it can't locate it, it can't be sure whether the virus is on the mucosa or invading epithelial cells. Therefore, a considerable number of latent infected people should be virus carriers. 4. The clinical manifestations of genital epithelial infection with HPV vary greatly. In fact, the typical clinical manifestations of condyloma acuminatum are only a small part of the people infected with HPV, and most of them are in the state of HPV carriers or subclinical infection. Whether the genital epithelium shows clinical manifestations after HPV infection depends on the type of HPV, the infected site and the state of the body, especially the state of cellular immunity. There are more than 20 HPV subtypes that can cause condyloma acuminatum, mainly HPV6, 1 1, 16, 18 and 33 types. Male prepuce frenulum and coronary sulcus, which are easily damaged during sexual contact, have defects in immune function, especially those with defective cellular immune function are prone to condyloma acuminatum, and the wart body grows faster. 5. Several special parts of condyloma acuminatum (1) male urethral orifice: Although it is not a common part of condyloma acuminatum, it is difficult to treat and easy to relapse. The clinical manifestations are warty excrements at the urethral orifice, and the surface can be smooth or papilloma-like, with flushed color and moist surface. It is not easy to find in clinic. Hematuria and dysuria can be seen. Blood is often found in patients' underwear, and warts are found when checking the urethral orifice before being diagnosed. Sometimes HPV can retrograde up the urethra, causing infection of urethral epithelium. At this time, urethroscopy is needed. (2) Around the anus: The skin around the anus is wrinkled and rubbed when walking, so condyloma acuminatum often occurs frequently. At first, there are many papules, and then they grow like warts. It can be large pedicled cauliflower-like, and it is more common to have flat patches with small papillae on the surface. Due to secondary infection, secretions often have an unpleasant smell. (3) Oral lip and pharynx: Condyloma acuminatum occasionally occurs in the mucosa epithelium of oral cavity and throat, showing small, flush, soft and papillary wart, mostly occurring in oral sex. 6. Giant condyloma acuminatum refers to condyloma acuminatum with a huge shape, even the size of a fist, with a papilloma-like surface. After secondary infection, the secretion is purulent and smelly. It is common in male foreskin mucosa and glans penis. Giant condyloma acuminatum is a verrucous carcinoma in essence, which is a pathological change of low-grade malignant squamous cell carcinoma. Although it rarely metastasizes, the damage can penetrate deep and invade the urethra to produce many sinuses, from which pus and urine are discharged.

Treatment: Although there are many treatment methods for condyloma acuminatum, so far it is still limited to removing the wart visible to the naked eye, and it is difficult to eradicate papillomavirus, so condyloma acuminatum often recurs after treatment. A large number of studies show that the effective rate of various treatment methods is between 20% and 94%. But the recurrence rate is high, and the lowest recurrence rate is usually 25% within 3 months. The course of disease is shorter than one year, and the treatment success rate of condyloma acuminatum with small skin lesions is high. Because many patients need a course of treatment, rather than one treatment, it is very important to draw up a treatment plan. The side effects of treatment should not be greater than the disease itself, and should be based on the choice of patients, available resources and the experience of clinicians. Western medicine treatment methods 1. Physical therapy, which often includes CO2 laser, electrocautery, cryosurgery and microwave therapy. 2. Local drug therapy (1)0.5% podophyllotoxin tincture. (2) 10%~25% podophyllotoxin. (3)3% phthalamide. (4) 5% 5-fluorouracil. (5)30%~50% trichloroacetic acid. (6) Acyclovir ointment. (7) rhodomycin. (8)5% miquimod cream. (9) Thiatipai. (10) colchicine. (1 1) interferon. 3. Systemic drug therapy, which is ineffective when used alone, can be used as adjuvant therapy by other means. (1) Interferon: 1 100,000 units to 3,000,000 units injected subcutaneously or intramuscularly, every other day1time or twice a week has certain effect, but the curative effect varies greatly from report to report. Interferon is expensive, so it is generally unnecessary to use it. For patients with condyloma acuminatum with low immune function, it can be used. This method can make some intractable warts subside and is suitable for recurrent authors. The preparations used are interferon α, interferon β and interferon γ. At present, there are recombinant interferons, which are selected according to the needs. (2) Levamisole: It has immunomodulatory effect and can enhance the function of lymphocytes. In view of the low cellular immune function of some patients with condyloma acuminatum, this medicine is used. Oral administration of 50mg each time, three times a day, for 3 days, stopping 1 1 day is 1 course of treatment, which can be taken continuously for several courses. Levamisole has no direct therapeutic effect, and it can be considered for patients with recurrent attacks and low immune function. (3) Transfer factor: 2ml each time or 1~2U, subcutaneous injection, twice a week, 6 times as 1 course of treatment. (4) thymosin: 10~20mg, intramuscular injection, every other day 1 time, 4 weeks for 1 course of treatment. (5) dinitrochlorobenzene immunotherapy: Practice has proved that patients with condyloma acuminatum for a long time (1 year or more) have decreased cellular immune function and often have recurrent attacks. Immunotherapy can sometimes achieve satisfactory results. Dinitrochlorobenzene may promote the production of specific anti-wart immunity and restore the reduced cellular immune function to normal. Generally, 2% dinitrochlorobenzene acetone solution is first used to sensitize normal skin or wart of forearm to produce contact dermatitis. After 1~2 weeks, 0. 1% dinitrochlorobenzene acetone solution or ointment is applied externally to stimulate treatment until the skin becomes inflamed. The time for the wart to subside varies from 1~6 months. (6) Autologous wart tissue vaccine: once a week 1 time, for one week 10, the effective rate is about 75%. (7) Uterine: Uterine 1.72μg intramuscular injection, weekly 1 time, continuous 10 times. After injection of Uterine, both T cells and NK cells increased, and the recurrence rate of condyloma acuminatum decreased significantly. (8) Psychological intervention: Appropriate psychological intervention plays a positive role in preventing recurrence of condyloma acuminatum and regulating immune function. Specific measures include: individual or collective conversation between doctors and patients, counselling, persuasion, dispelling doubts, encouragement, sympathy and STD health education and other psychological counseling. Generally weekly/kloc-0 times, lasting for 3 months, monthly summary, timely adjust the patient's mentality. Appropriate psychological intervention can not only adjust the patient's bad mentality in time, but also play a positive role in regulating the patient's immune system, indicating that physical or drug therapy alone is not enough for patients with condyloma acuminatum who have recurred many times. 4. Surgical treatment (1) wart scraping method: routine disinfection, anesthesia with 1% lidocaine at the base of condyloma, and then scraping the wart tissue from the bottom with a blunt spoon. (2) Surgical excision method: It is suitable for large condyloma acuminatum. The main body of the wart is excised by surgery, and local medicine or freezing method is adopted after the wound heals. Some patients' foreskin is too long, and there are many condyloma acuminatum lesions on the foreskin, so circumcision is recommended. (3) Ligation: It is suitable for small single pedicled lesions. (3) Treatment methods of traditional Chinese medicine: TCM syndrome differentiation and treatment are divided into the following types according to the progress of the course of disease: (1) Damp-heat type of liver meridian: wart occurs on the affected part, which looks like nipple cauliflower, and the surface is uneven. After rubbing, it is wet and soaked, and it stinks, accompanied by indigestion, abdominal distension, anorexia, irregular stool, slippery pulse, red tongue, yellow and greasy fur. Treatment should clear away heat and promote diuresis, with detoxification. The prescription of Longdan Xiegan Decoction is: Gentiana scabra 12g, Bupleurum, Scutellaria baicalensis, Gardenia, Plantaginis (bag), Alisma orientalis, Cortex Phellodendri, Rhizoma Atractylodis, Radix Glycyrrhizae 10g, Akebia Akebia 6g, Herba Artemisiae Scopariae, Semen Coicis, Radix Isatidis and Folium Isatidis10g. . Chinese patent medicine can choose Longdan Xiegan Pill, 6g each time, 3 times a day. (2) Damp-toxin aggregation type: it can be seen that the course of disease is longer or recurs, and the wart body is larger, shaped like cockscomb. After it is broken, the smelly juice is rotten, even bleeding, and the smell is not close. The nearby scrotum is swollen, the mouth is dry and bitter, and the stool is dry or rotten. The pulse is thready, the tongue is red and the coating is yellow and slightly greasy. Treating dampness and clearing heat, detoxicating and resolving hard mass. You can choose the agent of clearing away heat and toxic materials and promoting diuresis, such as modified decoction for removing dampness. The selected medicines are Rhizoma Dioscoreae Septemlobae 30g, Coicis Semen 30g, Cortex Phellodendri 10g, Poria Poria 10g, Cortex Moutan 10g, Rhizoma Alismatis 10g, talc 30g, Radix Glycyrrhizae 6g, Rhizoma Atractylodis 15g, and Folium Isatidis. Chinese patent medicine can choose Banlangen granule, each time 1 bag, three times a day. (3) Stagnation of blood stasis and toxin: the wart body grows hard and does not heal for a long time, with dark red or purple skin, cauliflower-like or cockscomb-shaped, foul-smelling secretion, mild or no symptoms, purplish tongue and astringent pulse. Treatment is to promote blood circulation, remove blood stasis, soften hard mass and disperse hard mass. Add and subtract with Taohong Siwu Decoction. Nucleus, Carthamus tinctorius and Angelica sinensis each 10g, Radix Paeoniae Rubra 20g, Radix Rehmanniae Preparata 15g, Rhizoma Chuanxiong 10g, Radix Isatidis, Prunellae Spica, Radix Arnebiae and raw oyster each 30g, Nivespae, dried centipede and raw licorice each 10g. Chinese patent medicine can be rhubarb beetle pill or Guizhi Fuling pill. (4) Syndrome of toxic love due to spleen deficiency: The condyloma acuminatum is characterized by recurrent attacks, repeated treatments, mental fatigue, pale complexion, anorexia, loose stool, long urine, pale tongue and deep and thin pulse. Treatment is to strengthen the spleen, remove dampness, detoxify and dissipate stagnation. Modified with Chushi Weiling Decoction. The selected drugs are Beiqi 40g, Codonopsis pilosula 30g, Atractylodes macrocephala 15g, raw Coicis Semen 30g, Poria 20g, Rhizoma Atractylodis 12g, Fructus Forsythiae 15g, Herba Artemisiae Anomalae 20g, Portulaca oleracea, Hedyotis diffusa, Radix Isatidis 30g each, and Radix Glycyrrhizae 10g. . Chinese patent medicine can be selected from Shenlingbaizhu Powder and Banlangen Granule. External traditional Chinese medicine treatment (1) external washing 1 No.1 prescription: Radix Isatidis, Cortex Phellodendri, Radix Arnebiae, Coicis Semen, Herba Equiseti, Semen Persicae, Carthami Flos, Rhizoma Ligustici Chuanxiong, Concha Ostreae, and dried alum 5g each. Decocting water is about 300~400ml, fumigating and washing every day 1 time, 15 days is 1 course of treatment. (2) External Wash Formula No.2: 30g each of Equisetum equisetum, Rhizoma Cyperi, Radix Isatidis, Radix Sophorae Tonkinensis, Alumen, Stemona, Radix Sophorae Flavescentis and Fructus Cnidii, and decocted with water to wash the affected part. (3) External Wash Formula No.3: Equisetum Equisetum, Cyperus rotundus, Mume Fructus, Carthami Flos, Folium Isatidis, Senecio Senecio and Cortex Phellodendri each 30g, daily 1 dose, and decocted water to wash the affected part. (4) External Wash Formula No.4: 20g each of Folium Artemisiae Argyi, Radix et Rhizoma Rhei, Radix Sophorae Flavescentis, Fructus Cnidii, Rhizoma Atractylodis, Radix Isatidis, Cortex Phellodendri, Xu Changqing and Herba Portulacae, and alum 15g. Decoct water daily 1 dose, first smoke the affected area, and then scrub the wart body with clean gauze dipped in liquid medicine after cooling, twice a day. (5) External Wash Formula No.5: Nitrate 12g, Borax and Alum 9g each, washed with boiling water, wet-applied while hot or externally washed the affected area. Acupuncture treatment (1) filiform needle method: take Ashi point. After disinfection, a 2-inch silver needle was inserted vertically from the highest point of the wart, and the method of diarrhea was applied. Without leaving the needle, 2~3 drops of blood were bled. Then, at the base of the wart, it is 15 degrees, 4 needles are obliquely pricked, and the needle is kept for 15 minutes, every 2 days 1 time, which is suitable for warts with concentrated warts. (2) Moxibustion: Take Ashi point. After local anesthesia, put the moxa stick on the wart, light it and let it burn out. Finally, apply 2% gentian violet solution and cover it with sterile gauze, usually 1 time. There are very few residual warts left, and after an interval of 10 days, moxibustion is performed according to the above method. It is suitable for wart with small wart scattered in individuals. (3) Ear acupuncture: The acupoints are lung, cheek, external genitalia and sympathetic, each time 1~2 points, once a day/kloc-0 times, and the needle is kept for half an hour. (4) Acupoint injection method: take Changqiang point. Routine disinfection, using 2ml of Radix Isatidis injection, slowly push injection after acupuncture, 3 days 1 time, suitable for lesions around anus. Introduction to the prescription (1) The effective prescription for stubborn wart is: Scutellaria baicalensis Georgi, Coptidis Rhizoma, Cortex Phellodendri and Gardenia each 10g, Flos Lonicerae, Herba Violae, Gongyingge 15g, Radix Isatidis, Radix Arnebiae Rubra, Fructus Forsythiae each 18g, Bombyx Batryticatus, Caulis Akebiae and Semen Plantaginis. (2) Condyloma prescription: Magnetitum (first), Raw Oyster (first), Equisetum equisetum, Lily each 30g, Radix Gentianae, Nidus Vespae, Rhizoma Curcumae, Patrinia each 10g, Portulaca oleracea 60g, Radix Arnebiae 15g. Oral administration daily 1 dose. (3) Qingyou decoction: Radix Isatidis, Cortex Phellodendri, Radix Arnebiae, Coicis Semen, Rhizoma Curcumae, Alumen, Semen Persicae, Carthami Flos, and Rhizoma Cyperi, 30g each, add water 1500ml, decoct in water for 30min, then filter the residue to get juice, and steam locally for 5min while it is hot. When the temperature drops to the tolerable level of skin and mucosa, sit in a basin or soak the affected area for 20min while it is hot. Take a pair of medicine every day, decoct and fumigate once in the morning and evening, and 20 days is a course of treatment. (4) Oral administration of traditional Chinese medicine combined with acupoint injection: After operation, 30g of Radix Astragali, Coicis Semen, Radix Isatidis, Herba Houttuyniae, Rhizoma Smilacis Glabrae, Radix Paeoniae Rubra and Flos Lonicerae were taken orally, and each dose of Chinese angelica 10g, Rhizoma Atractylodis Macrocephalae, Radix Arnebiae, Rhizoma Curcumae 15g and Radix Salviae Miltiorrhizae 20g was taken orally. Acupoint injection: 2ml of placental tissue fluid was injected alternately at Zusanli point on both sides once a day. Oral administration of traditional Chinese medicine combined with acupoint injection for 30 days is a course of treatment. The recurrence rate of condyloma is only 17.5%.