Bowenoid papulosis

[Derm007]

I am a dermatologist and my 30 year old single son was home visiting from Hong Kong this Christmas and showed me a brown pigmented papillomatous plaque (1x2 cm) in his left inguinal area and he also had about two dozen smaller lesions all in the inguinal crease.  A biopsy showed bowenoid papulosis.  I treated all the lesions with liquid nitrogen.  He has always used condoms and did not have any lesions elsewhere.  He broke up with his last girlfriend two months ago...he will tell her about his dx.  He will follow up with a doctor in HK but won't be back in the states for at least 6 months.  How far back does he need to go with previous partners to alert them about his oncogenic strain of HPV?  How likely is it to be HPV 16 or 18?  If he (finally) meets the woman he will marry and spend the rest of his life with, should she consider having a ViraPAP or should she consider getting Gardisil vaccine?  How long after he is clinically clear should he tell a new partner about his diagnosis?  Do you have any other advice for me to pass on to him?  I have read some of Dr. Handsfield's posts and find them very informative.  I used to run a support group for HSV for ASHA and know the committment it takes.  

[Derm007]

Dr. Handsfield:

I appreciate your response and despite your apologies I found it very useful to get your perspective on bowenoid papulosis.  I think it is probably very under reported as many cases are assumed to be genital warts and treated with destructive methods that do not allow any histologic confirmation.  I agree with your comments that all young women should get the Gardisil vaccine and all should have routine pap smears on a regular basis anyway.  

Keep up the good work!   Happy New Year to you too.  

[H. Hunter Handsfield, M.D.]

Thanks for your confidence in the forum and your kind words about our commitment to it.  But with apology, I cannot answer most of your questions -- and I suspect Dr. Hook will not be able to help much either.  STD or infectious diseases experts like us, at least in the US, rarely manage Bowenoid papulosis or keep up with the literature on it.

To my knowledge, BP is usually associated with HPV 16 or 18, but I am unaware of data on the natural course, i.e. the likely time since your son was infected.  I imagine the situation is similar to the time course of cervical dysplasia, which often appears within a few months of infection, but sometimes shows up years later.  THere is no clear need for him to inform any past partners; indeed, CDC actively recommends against ourtine partner referral for HPV of any type.  That's because there is no reliable test for subclinical infection, and no need for evaluation unless overt (warts etc) appear; and women should have regular cervical cytology anyway.  As for future partners, it is reasonable to avoid sex (or warn partners before sex) for a couple of months -- some experts say up to 6 months -- after overts warts are ablated and do not return; I imagine it makes sense to follow the same guideline for BP.

Once he forms an actual or potential long term relationship, it would be reasonable for his partner to know of his past infection.  All young women should receive Gardasil, in my opinion, regardless of past history of HPV or potential exposure to someone with a known HPV infection.  On the other hand, it probably is not practical for most couples to abstain from intercourse for the 6 month course of immunization (although substantial protection may ensue after the second dose, i.e. ~2 months).  It is equally important, or more so, that she adhere to routine pap smear screening advice -- but she needs to do that anyway.  In other words, the main reason for your son to discuss his past infection is to avoid embarrassment if/when she develops an abnormal pap or other evidence of HPV disease, not because of any serious risk to her health.  As you likely know, the large majorty of HPV infections resolve spontaneously without causing symptoms.  Even with high risk HPV types, the quantative risk of overt malignancy is rare, and the risk of invasive malignancy essentially zero with routine paps.

As for BP in particular, in the US this is more commonly the domain of dermatologists or, for some of your questions, dermatopathologists.  In some countries, however (e.g., UK, other western European countries, maybe Hong Kong) STD and dermatology remain more closely aligned, as they once were worldwide.  Someone trained in those areas might have more insight that I do.

Sorry to be of limited assistance.  Best wishes to you and your son for a happy new year.

HHH, MD