Werner Ricardo Niklas, Westfechtel Lukas, Dressler Corinna, Nast Alexander
Division of Evidence-based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Sex Transm Infect. 2017 Dec;93(8):543-550. doi: 10.1136/sextrans-2016-053035. Epub 2017 Jun 21.
Anogenital warts (AGW, condylomata acuminata) and intraepithelial neoplasia (IEN) do not only impact health and social well-being, they are also associated with considerable costs for the healthcare systems. Immunocompromised and HIV-positive patients carry the highest epidemiological burden of human papillomavirus (HPV) infection and comprise a population specifically susceptible to treatment failures and recurrences. This systematic review aimed at identifying and appraising the available evidence from controlled studies of interventions for the treatment of AGW and IEN in immunocompromised patients.
We conducted a comprehensive literature search. The Cochrane Collaboration's tool was used to assess risk of bias in included studies. Our confidence in the (pooled) effect-estimates was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation approach. All evaluations were based on data independently extracted by two review authors.
Nine randomised controlled trials and two controlled studies were eligible, investigating external AGW, intra-anal and/or vaginal warts, and intra-anal and/or perianal IEN. The identified studies assessed imiquimod, cidofovir, fluorouracil, electrocautery, systemic interferon-α and interferon-β, and the combination of intralesional interferon-α and podophyllin. Four studies combined an ablational intervention with either imiquimod, cidofovir, intralesional or systemic interferon-α. One study investigated an experimental therapeutic vaccination (HPV 16 E7) at different concentrations.
The quality of the evidence ranged from 'very low' to 'moderate' and was limited by the often small samples. Evidence was available for the efficacy of electrocautery for intra-anal IEN, and imiquimod cream for external AGW. Some further interventions should be subjected to investigations in larger samples. No data on some interventions established for the treatment of AGW in immunocompetent patients such as podophyllotoxin, sinecatechins, laser ablation or trichloroacetate were available. Future trials should address these gaps and include relevant patient-reported outcomes such as health-related quality of life.
肛门生殖器疣（AGW，尖锐湿疣）和上皮内瘤变（IEN）不仅影响健康和社会福祉，还会给医疗系统带来相当大的成本。免疫功能低下和HIV阳性患者承担着人乳头瘤病毒（HPV）感染的最高流行病学负担，并且是特别容易出现治疗失败和复发的人群。本系统评价旨在识别和评估来自对照研究的现有证据，这些研究涉及免疫功能低下患者AGW和IEN的治疗干预措施。
我们进行了全面的文献检索。使用Cochrane协作网的工具评估纳入研究的偏倚风险。根据推荐分级评估、制定和评价方法评估我们对（合并）效应估计值的信心。所有评估均基于两位综述作者独立提取的数据。
九项随机对照试验和两项对照研究符合条件，研究了外部AGW、肛门内和/或阴道疣以及肛门内和/或肛周IEN。所确定的研究评估了咪喹莫特、西多福韦、氟尿嘧啶、电灼、全身干扰素-α和干扰素-β，以及病灶内干扰素-α和鬼臼毒素的联合应用。四项研究将消融干预与咪喹莫特、西多福韦、病灶内或全身干扰素-α联合使用。一项研究调查了不同浓度的实验性治疗性疫苗（HPV 16 E7）。
证据质量从“非常低”到“中等”不等，且常因样本量小而受到限制。有证据表明电灼治疗肛门内IEN有效，咪喹莫特乳膏治疗外部AGW有效。一些进一步的干预措施应在更大样本中进行研究。对于免疫功能正常患者治疗AGW所采用的一些干预措施，如鬼臼毒素、辛卡利特、激光消融或三氯乙酸，尚无数据。未来的试验应填补这些空白，并纳入相关的患者报告结局，如健康相关生活质量。
