hpv-kling2ALAN KLING, M.D

Dr. Alan Kling is recognized as one of the foremost specialists in the field of HPV infections. Throughout his years as an HPV specialist, Dr. Kling has contributed to research and lectured at various medical schools, including Columbia, Cornell, Mount Sinai, NYU, and Yale as well as having been a part of a number of national panels on HPV and HPV prevention. His extensive research has allowed him to keep up with the latest HPV treatment protocols and to educate others in the field as well. While HPV is an important field of dermatological study for many physicians, Dr. Kling has clearly separated himself from the pack, making him the top HPV treatment specialist in NYC today.

Dr. Kling's private practice offices are located at his Park Avenue practice on the Upper East Side and in Park Slope, Brooklyn.

Q: What do genital warts look like?
A: Genital warts (condyloma or condyloma acuminata) are flesh-colored or brown growths that may appear on the penis, anus, rectum, vulva, vagina, in the perianal area, pubic area, on the groin or on the thighs. They can present in many ways and look remarkably different although they are caused by the same virus. Genital warts may present as large or small growths that are distributed either singly or in clusters. They can have a rough uneven surface and look like pieces of cauliflower or can present as small growths with a smooth surface. Genital warts can range from being flesh-colored to light, medium or dark brown. They are all very contagious. They can be large and noticeable or small, inconspicuous and hardly noticeable at all.

Q: What does the term “papilloma”, as in human papilloma virus (HPV) mean?
A: The term “papilloma” refers to a projecting finger-like growth. This is one of the more common ways that genital warts can present.

Q: What are genital warts?
A: Genital warts are a dense collection of the HPV virus which grows in the external genital area.

Q: Will genital warts give me symptoms?
A: HPV infections and genital warts are usually not associated with symptoms. A person may occasionally have localized itching or irritation, but this is not common. Even when a person does see a small growth in the genital area, it usually is asymptomatic. Large genital warts can get irritated and itch, but this is more the exception.

Q: Are genital warts easy to see?
A: Many people who have genital warts are not aware that a growth is present or if they did see a growth they may have thought that it was a normal and nothing to worry about. The presentation of warts that have enlarged and rub up against clothing or folds of the skin and cause symptoms of irritation or itch is relatively infrequent.

Q: Does this mean that the person that I might have gotten it from did not know that they had an HPV infection?
A: Most people who have an HPV infection are not aware of the fact that they have an infection at all and are unintentionally infecting their partners.

Q: What is an acetic acid soak?
A: Acetic acid (5%) in a vinegar-type of solution that is applied on moistened gauze to the genital areas. Genital warts my absorb the vinegar and turn white, making them easier to see and identify. The application of acetic acid is a screening test and is not firmly diagnostic. Factors that can make an area turn more white include any type of rubbing, irritation, allergies, and benign skin rashes The only way to know for certain what a certain growth or skin change is would be to do a diagnostic biopsy.

Q: How concerned should a person be if they have many warts in their genital area that are growing quickly in both size and number?
A: Genital warts that present as an extensive number of growths are more likely to be associated with the low risk strains. The low risk strains are extremely contagious but have an extremely low chance of progressing into cancerous or precancerous conditions.

Q: What risk are these genital wart growths to my partner?
A: Genital warts presenting in this manner tend to be extremely contagious. You must use condoms to protect your partner or refrain from sexual contact until you get them treated and removed.

Q: Can genital warts ever go on into cancer, or cause cancer in my partner?
A: Genital warts are usually caused by the low risk strains of HPV. 10% -20% of genital infections are “mixed infections” that include both the low risk and high risk strains. If high risk strains are present in the genital warts they could pose a risk to your partner.

Q: How common are genital warts?
A: Genital warts (also referred to as venereal warts or condylomata) are the most commonly recognized form of genital HPV infection. Approximately 1% of sexually active people in the United States have genital warts at any one time.

Q: How many cases occur each year in the United States?
A: Nearly 1 million new cases of genital warts occur each year in the United States. 90% of all genital warts are caused by the low-risk HPV6 and 11 strains.

Q: How would I know if I have genital warts?
A: Many people with genital warts frequently do not have symptoms and are unaware that they have any growths at all. A person may realize in retrospect after the genital warts have been identified that these growths had been present for a long time although they thought that they were normal and nothing to worry about.

Q: When do genital warts cause symptoms?
A: Genital warts can cause symptoms if they enlarge, rub against clothing and get irritated or infected. They rarely bleed.

Q: Are genital warts dangerous?
A: Genital warts are generally not dangerous. The vast majority of genital warts are caused by low risk strains of HPV. 90% of these strains are specifically associated with the low risk HPV 6/11 strains. Genital warts can on occasion be caused by the high risk HPV 16/18 strains, which do have the potential to progress into precancerous or cancerous growths.

Q: Can any genital warts be caused by high risk strains?
A: A very small percentage of growths presenting as genital warts are caused by high risk strains. In addition, 10% -20% of genital warts are caused by mixed infections which are caused by high and low risk strains.

Q: Are genital warts contagious?
A: Genital warts are usually highly contagious.

Q: Is there any way to visually tell whether the genital warts are made up of high risk or low risk strains?
A: The genital growths associated with the high risk strains are called bowenoid papulosis. Bowenoid papulosis lesions are usually smaller and fewer in number compared to genital warts caused by the low risk strains. The genital growths associated with the low risk strains tend to be greater in number, larger in size, and are highly contagious. The only way to document with certainty whether the growth contains high or low risk strains is to do a biopsy and to get HPV DNA typing.

Q: What percentage of cases of genital warts are associated with high risk strains that look like they may be more aggressive?
A: A study was performed where several thousand cases of genital warts in men whose female partners had an HPV infection were biopsied. 6% of the biopsies showed microscopic signs consistent with squamous cell carcinoma (bowenoid papulosis). The vast majority of these biopsies contained the high risk strains.

Q: What should I do if I see new growths in my genital area?
A: You need to be evaluated by your doctor, have them treated and use protection at all times. You need to be mindful of the fact that condoms do not protect against those areas not covered by the condom. In addition, condoms can break, can ride up against the shaft of the penis and leave the base of the penis exposed. Nonetheless, condoms represent the best barrier method of protection currently available.

Q: Can I do nothing if I have genital warts and just wait to see if they go away?
A: Most genital warts go away on their own without treatment. Although you can always wait and see what happens, you need to be mindful that there are potential downsides associated with doing nothing.

Q: What is the downside of not treating the genital warts and waiting to see if they go away on their own?
A: Genital warts are highly contagious. There is a chance that they will spread to new previously uninfected areas on the patient, resulting in an even more extensive infection covering a larger surface area. The infected patient will now have a greater chance of infecting their partner, require more treatment sessions and may experience more recurrences of the infection.

Q: How will not treating the genital warts affect my partner(s)?
A: You may infect your current and/or future partner(s) during the time that you are waiting to see if the warts will go away on their own. The greater the number of growths and the larger the area involved will result in a greater risk of infecting a partner. The new locations where the infection spread will become additional future sources of asymptomatic infection even if the visible growths go away or the infection may progress into larger genital warts.

Q: How would I know if I had a mixed infection consisting of both high and low risk strains?
A: The only way to know whether you have high or low risk strains is to have the growth(s) biopsied and to have your doctor request that HPV DNA typing be done on the specimen.

Q: Where can genital warts occur?
A: The more common locations where genital warts can occur include the penis, vulva, vagina, anus, rectum, buttocks, groin, pubic area, thighs and on the lower abdomen.

Q: What are the most common low risk strains?
A: The strains of HPV are referred to by number rather than by a name. The two most common strains of low risk HPV are 6 and 11 (6/11). These two strains represent 90% of the all the low risk genital strains which exist.

Q: What is the medical term for genital warts?
A: Condyloma acuminata.

Q: Can low risk strain ever turn into a cancer?
A: Low risk strains cannot change their chemical structure and turn into high risk strains. The chances of a low risk strain turning into cancer are very low. 10% -20% of genital warts are mixed infections which include both high and low risk strains. The high risk strains in the mixed infection can cause cancerous or precancerous growths.

Q: How frequently will an HPV infection result in genital warts?
A: 1% of HPV infections result in genital warts.

Q: How often does cancer of the penis occur in men?
A: Cancer of the penis is rare in the United States. When cancer of the penis does occur, it almost invariably occurs on an uncircumcised man.

Q: Can genital warts lead to cervical cancer?
A: Genital warts generally do not lead to cervical cancer. 90% of genital warts are caused by the low risk HPV strains 6 and 11, which have a very low risk of progressing into a cancer of the cervix.

Q: What are “mixed” infections?
A: Up to 20% of infections are “mixed infections” which may contain both high and low risk strains of HPV. Although some of the growths detected may look like classical genital warts, they may also be harboring the high risk 16 and 18 strains.

Q: Can genital warts lead to other types of cancers?
A: High risk strains in genital warts can grow into cancers of the anus,, rectum, oropharynx , penis, cervix, vulva and vagina.

Q: Are there any circumstances under which a genital wart can become a cancer?
A: A classic genital wart that is a mixed infections containing both high and low risk strains of HPV can progress into a cancer or pre-cancer. Women and men with mixed infections need to continue to be monitored.

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