A papilloma is a benign (non-cancerous) tumor arising from an epithelial surface and usually known to grow in an outward direction. Commonly, a papilloma refers to squamous cell papillomas which appear as frond-like tumors that can develop almost anywhere on the body with squamous epithelium:
Most of these lesions are caused by Human Papillomavirus (HPV). They are contagious upon contact with the exception of cutaneous papilloma, which is also called an acrochordon or more commonly known as a skin tag. Most of these lesions are usually self-limiting in immunocompetent individuals.
The majority of papillomas are caused by human papillomavirus (HPV). There are over 170 subtypes of the virus. Usually, types 6, 7, and 11 are mostly associated with papillomas and are called low-risk types as they don't usually cause precancerous lesions and rarely progress into cancer. HPV has been found to cause papillomas to arise almost anywhere in the body with stratified squamous epithelium, like the skin, conjunctiva, oropharynx, larynx and upper trachea as well as the anogenital tracts.
Studies conducted have found HPV6/11 in 96% to 100% of all Genital wart lesions. Infection is very contagious through direct and sexual contact. Genital HPV is spread by sustained direct skin-to-skin contact. Vaginal, anal, or oral sex are the most common ways of spread. Several studies conducted have shown that most skin tags or cutaneous papillomas of the head and neck to be non-contagious, unlike warts despite containing low-risk forms of HPV DNA, especially of type 6/11. However, a study conducted by Pezeshkpoor et al. had found no significant association between skin tags and HPV. This is why we term non-viral growths as acrochordons.
There is evidence of vertical transmission of human papillomavirus from mothers to their infants. This may lead to the development of several papillomas in the larynx and upper trachea called Recurrent Respiratory Papillomatosis. It is a serious condition, as the papillomas may eventually enlarge causing obstruction of the airway.
It is worth noting that some papillomas are non-viral in origin as in the inverted papilloma of the urinary tract which has strongly been associated with smoking. Nasal papillomas may be caused by local irritation and trauma to the mucosa, and some cutaneous papillomas have been associated with skin irritation. An example of this was cutaneous papillomas that had occurred in rats, mice, and hamsters following the local application of powerful carcinogens where they are believed to arise from the stratified squamous epithelium. In addition, there are types of papillomas in which the mechanism responsible for their occurrence isn't fully understood, as in intraductal (breast duct) papillomas and choroid plexus papillomas.
The global prevalence of HPV infection, the main cause of papillomas, is around 11% to 12%. However, reliable surveillance figures are difficult to obtain regarding the prevalence of warty lesions. For non-genital warts, two large population-based studies found prevalence rates of 0.84% in the US and 12.9% in Russia, with prevalence being highest in children and young adults. For genital warts, the annual incidence was found to be between 0.1 to 0.2% of the population in developed countries. The highest prevalence was found amongst teens and young adults.
Acrochorda or skin tags have been reported to have a prevalence of 46% in the general population with a higher prevalence among older age groups, unlike warty papillomas. They are more common in the obese and tend to grow in areas of skin-to-skin contact. They have an equal distribution among males and females.
Papillomas arise from the skin or some mucosal surfaces depending on the different types of Human Papillomavirus involved and their affinity to different sites. For example, conjunctival papilloma is caused by HPV infection type 6, 11, 16, 33, and 45, which is somewhat dissimilar to genital warts caused by types 2, 3, 6, 11, 16, 18, and 30-32 and cutaneous papillomas (types 1-4 and 26-29).
Infection is established in the basal cell layers of the epithelium, but this involves the expression of a limited part of the viral genome. It's not until the basal cells develop and move externally through the different layers of the skin of the stratum spinosum and granulosum, that the virus begins to replicate itself, and the lesion becomes infectious.
Normally papillomavirus infects the epidermis in sites near the site of entry, but self inoculation often occurs, and the virus can infect farther sites. This phenomenon is known as the Koebner phenomenon. It has been observed that the immune system has an important role in controlling the spread of the virus, as, despite the virus infecting the intraepidermal cells that are considered "hard-to-reach" by the immune system, it was found that papillomas tend to reactivate and are more extensive in immunocompromised individuals.
Papillomas take origin from an epithelial surface. Complex folds of proliferating epithelium can be observed and are accompanied by a growth of supporting connective tissue and blood vessels. Typical examples are found in the skin, e.g., the common wart. Under the light microscope, these benign tumors show:
Single or multiple solid papules are observed. On the skin, it may appear as a rough solid papule, often covered with hyperkeratinized skin. Those arising on mucosal surfaces appear as a soft, pedunculated mass (supported on a stem or stalk) with numerous finger-like projections. The projections may be long and pointy or short and rounded if keratin has built-up around the lesion. Less keratinized lesions are pink or red in color and resemble a raspberry, whilst heavily keratinized lesions are white and look like the head of cauliflower.
Usually, most squamous cell papillomas are diagnosed upon examination and require no further investigations, especially in immunocompetent individuals where they are self-limiting and don't transform to malignant lesions. However, in those considered to have a higher risk of turning malignant, e.g: anogenital and oropharyngeal tract papillomas, they may undergo excision and a biopsy is sent for histopathological investigations if there is any question as to the diagnosis or if there is a concern for dysplasia.
Although genital warts are usually caused by low-risk HPV subtypes, 5% to 20% of the individuals affected have been found to carry other sexually transmitted diseases. It is always important to suspect high-risk HPV infections that cause precancerous lesions in those individuals with genital warts and early screening should be initiated. Screening for cervical dysplasia/malignancy is typically accomplished through speculum examination and Pap smear.
Sometimes painless cutaneous papillomas may be left untreated and regress with time. They seem to not increase in size over time, and the potential for malignant transformation is low in immunocompetent individuals. If treatment is indicated, it varies depending on the type, size, and location of the papilloma.
There is a wide range of diseases characterized by an overgrowth of the epithelial tissue giving solid papules on the skin that have to be differentiated from papillomas.
The prognosis of papillomas caused by HPV infection is usually good in immunocompetent individuals, but recurrences may occur. Some subtypes of HPV may cause vulvar intraepithelial dysplasia, cervical dysplasia, and cervical cancer. Although these subtypes don't typically cause papillomas, they are commonly present side by side with genital papillomas.
In immunocompromised individuals, papillomas often increase and spread more rapidly, and there is a higher risk of papillomas transforming into malignancy.
Rarely are papillomas able to cause serious and life-threatening complications. This mainly depends on the anatomical site of the lesion.
Here are important points to take care of to prevent papilloma:
HPV is the most common cause of papillomas of the mucous membranes and skin. There are over 175 subtypes of HPV, and some are associated with an increased risk of malignancy.
For the most part, HPV is acquired by direct contact of other infected individuals or livestock, and one of the best ways to decrease the morbidity of this infection is through education.
Patient counseling by the pharmacist is important to educate individuals about the different treatments available for warts, their benefits, and adverse effects.
It is important to educate teens who are about to start being sexually active about safe sex by their school nurse or trained teachers.
Furthermore, it is necessary to let parents know the importance of vaccinating their children before being sexually active.
Encourage sexually active females with genital warts to undergo the pap smear to determine the presence of cervical dysplasia and high-risk HPV infections. Patients with genital warts should avoid sexual activity until their warts are treated.
Patients should avoid touching their warts to avoid self inoculation.
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