Домой Бородавки Бородавки на ногах, руках, половых органах

Бородавки на ногах, руках, половых органах

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Бородавки на ногах, руках, половых органах, во рту… как их лечить?

Что такое бородавки?

Бородавки — это доброкачественные образования, которые могут появиться на:

  • коже (то есть коже рук, ног, на пальцах и т. д.);
  • и/или слизистых оболочках:
    • оральный (во рту);
    • генитальные и/или анальные (то есть на половых органах или попе).

Бородавки широко распространены в общей популяции, что представляет собой очень распространенную медицинскую проблему, особенно у детей школьного возраста и молодежи.

Бородавки не вызывают никакой опасности, однако некоторые пациенты могут испытывать зуд, дискомфорт или просто эти наросты могут быть источником смущения.

Причины появления бородавок

Бородавки возникают в результате заражения вирусом папилломы человека (ВПЧ, папилломавирусная инфекция).

Существует более 150 подтипов ВПЧ, классифицированных по 5 родам α, β, γ, μ, ν и разделенных на кожные типы и типы слизистой оболочки.

  • ВПЧ слизистой, принадлежащие к роду α, предрасположены к заражению слизистых оболочек, вызывая поражения, называемые «кондиломой» или «генитальными бородавками»; они включают доброкачественные ВПЧ или ВПЧ низкого риска (подтипы ВПЧ 6 и 11) и «онкогены» ВПЧ, которые способны со временем или если их не устранить превратится в опухолевые образования (в основном, это подтипы ВПЧ 16 и 18).
  • Кожный ВПЧ, особенно β-рода, они предрасположены к заражению кожной ткани, выделяют вульгарные и подошвенные бородавки (подтипы ВПЧ 1, 2, 4, 27 и 57) или плоские бородавки (подтипы 3 и 10).

Факторы риска

Инфекции способствуют незначительные травмы или выделения, которые облегчают проникновение и распространение вируса в кожу или слизистые оболочки; поэтому травма, даже очень маленькая, может представлять собой фактор риска, особенно когда защита иммунной системы недостаточна или незрела.

Восприимчивость к инфекции ВПЧ, на самом деле, тесно связана с иммунным статусом субъекта (человека). Состояние иммуносупрессии (угнетение иммунитета), которое возникает, например, у пациентов с трансплантацией органов или у субъектов, инфицированных вирусом иммунодефицита человека (ВИЧ), ассоциируется с распространенными клиническими формами и трудно поддается лечению.

Иногда наличие бородавок может быть первым клиническим признаком состояния начинающейся иммунодепрессии, но чаще они представляют собой простое случайное событие без последствий.

Передача и заразность

ВПЧ очень заразен, и передача происходит через прямой контакт:

  • при половом акте;
  • при поцелуях;
  • при контактах с кожей.

В случае кожного ВПЧ (бородавки на коже) переданы они могут быть:

  • прямым контактом, т.е. через контакт с инфицированной кожей;
  • косвенно, при контакте с загрязненными поверхностями, такими как полы спортивных залов, края бассейнов, общие раздевалки.

В случае слизистой ВПЧ (например, генитальные бородавки) передача происходит через прямой контакт между половыми партнерами, а также между матерью и новорожденным как во время рождения, так и после рождения; непрямая передача (например, через полотенца) не подтверждена документально.

Инфекция снижается, но не всегда устраняется лечением; передача вируса может происходить даже при отсутствии видимых кожных/слизистых поражений вплоть до нескольких месяцев после их регрессии.

Симптомы и инкубационный период

Инкубационный период ВПЧ широко варьируется от 3 недель до 9 месяцев.

Кожные бородавки различают по 4 видам:

  • Обыкновенные (вульгарные) бородавки: наиболее распространенная форма. Они выглядят как опухоли, куполообразные или в виде цветной капусты, розовато-желтоватого цвета, с шероховатой поверхностью и размерами от нескольких миллиметров до нескольких сантиметров; они в основном затрагивают заднюю часть рук и пальцев.
  • Филиформные (или типизированные): они представляют собой длинные и тонкие поражения с нитевидным внешним видом, с основанием плотной имплантации и выступающими наружу; цвет розовый/беловатый и поверхность иногда шероховатая; часто множественные, они, как правило, располагаются у мужчин в области бороды (проходят сами при бритье).
  • Плоские: небольшие круглые или овальные очаги, плоские или слегка приподнятые, имеют цвет кожи или желтоватые; часто множественные, они, как правило, расположены на лице, тыльной стороне рук, запястьях.
  • Подошвенные бородавки: они могут быть простыми или мозаичными. Простые проявляются в виде желтоватых экстрофлексированных поражений с черными точками (см. фото выше), которые соответствуют тромбозированным (т.е. окклюзированным) капиллярам вируса. Толщина является переменной, а поверхность шероховатой. В отличие от других типов бородавок, этот тип также может представлять заметную болевую симптоматику, особенно при поражениях, расположенных в областях, подверженных давлению. Мозаичные подошвенные бородавки, с другой стороны, происходят из слияния многих мелких поверхностных бородавок и обычно не являются болезненными.

Слизисто-кожные или слизистые бородавки могут быть:

  • Папулезные бородавки: небольшие куполообразные поражения того же цвета, что и кожа, часто множественные;
  • Плоские бородавки: повреждения во рту, повреждения, возникающие в результате слияния отдельных мелких эстрофлексов (папул), обычно четко разграниченных, белого цвета;
  • Повреждения типа цветной капусты: экстрофлексированные, вегетирующие, с широким, розовым основанием;
  • Острые кондиломы: беловатые или коричневые экструдированные поражения, острые или заостренные, с кератотической поверхностью.

Диагностика

Диагностика бородавок по существу основана на клиническом обследовании.

У пациентов с дефектами иммунной системы (например, после трансплантации или ВИЧ-положительных) в случае неспособности ответить на стандартные методы лечения или если бородавки являются пигментированными, твердыми и/или изъязвленными, следует исключить опухоль, вызванную персистирующей инфекцией ВПЧ, особенно в околоногтевых и аногенитальных участках путем взятия образца поражения (биопсии) и гистологического исследования.

Бородавки у беременных

Беременные женщины более подвержены риску заражения ВПЧ, чем небеременные женщины, из-за кратковременного снижения иммунной защиты, которое влечет за собой беременность; по этой причине как бородавки на коже, так и генитальные бородавки, возникающие во время беременности, могут происходить от реактивации вируса, зараженного до беременности, и от инфекции, приобретенной в основном во время беременности.

Учитывая большую вероятность рецидива, лечение должно проводиться незадолго до родов (на 8-9-й месяц), если нет особенно раздражающих симптомов (кровотечение, зуд).

Во время беременности противопоказано медикаментозное лечение (в частности препаратами Имиквимод, Подофиллотоксин) как местно, так и перорально из-за возможности системного всасывания. Вместо этого могут быть проведены физические процедуры (криотерапия, диатермокоагуляция).

Наличие бородавок во время родов не является достаточным показанием для кесарева сечения, если только поражения не препятствуют освобождению новорожденного или не вызывают сильного кровотечения.

Средства для устранения бородавок (лечение)

Возможных методов лечения бородавок много.

Специалист дерматолог выбирает соответствующее лечение на основе:

  • типа и количество папул;
  • места локализации;
  • возраста;
  • иммунного статуса пациента.

Наиболее широко используемые и проверенные методы лечения следующие:

Для вульгарных и подошвенных кожных бородавок, наиболее распространенных на руках и ногах:

  • растворы/гель на основе 10-20% салициловой кислоты, применяемые ежедневно в течение нескольких недель, чтобы способствовать отшелушиванию кожи и, следовательно, разрешению повреждений;
  • кремы с противовирусным и иммуностимулирующим действием (Имиквимод);
  • криотерапия жидким азотом (лечение, проводимое в больнице или специализированной медицинской клинике), повторять каждые 3 недели до 6 раз, чтобы заморозить и удалить пораженные участки;
  • удаление методом поверхностной хирургии (диатермокоагуляция) под местной анестезией;

Для нитевидных бородавок преимущественно используется криотерапия или диатермокоагуляция; для плоских бородавок, особенно если они расположены на лице, предпочтительно использовать кремы на основе ретиноидов, которые способствуют отшелушиванию и замене клеток кожи, не оставляя шрамов или пятен на коже.

Что касается лечения бородавок на половых органах (генитальных бородавок):

  • если участок поражения небольшой ( 3 мм), независимо от их количества, предпочтительным методом является хирургическое удаление диатермокоагуляцией;
  • если поражения многочисленны (>5), но малы, предпочтительно использовать местное противовирусное и иммуномодулирующее лечение (крем Имиквимод или его аналоги).

Прогноз и осложнения

  • В области кожи, если иммунная система субъекта работает хорошо, около 65% необработанных бородавок самопроизвольно регрессируют в течение нескольких месяцев или лет.
  • На слизистой оболочке спонтанная регрессия бородавок происходит примерно у 30% нелеченных субъектов в течение 6 месяцев и также связана в этом случае с соответствующим иммунным ответом.

Когда ВПЧ-инфекция не устраняется иммунной защитой организма или медикаментозным лечением, она может стать стойкой: вирус проникает в глубокие слои кожи и слизистые оболочки, интегрируется в клетки и изменяет их способность дифференцироваться и размножаться.

Постоянная инфекция определяет в течение нескольких лет возникновение предраковых поражений низкой степени, которые, если не устранятся иммунной системой или лечением, могут перерасти через несколько лет в предраковые поражения высокой степени, а затем, если их не устранить, в настоящие потенциально инвазивные раковые заболевания (карциномы).

Постоянные ВПЧ-инфекции α-рода были четко связаны со всеми или почти всеми карциномами, поражающими шейку матки, влагалище, вульву, половой член и анус. Кроме того, α-ВПЧ-инфекция связана со значительной долей карцином ротоглотки. В частности, среди онкогенных подтипов ВПЧ 16 наиболее часто встречается, а также ассоциируется с наивысшим риском прогрессирования опухоли.

Стойкие инфекции, вызванные ВПЧ рода β, вместо этого были связаны с предраковыми поражениями кожи и немеланомными опухолями кожи, такими как спиноцеллюлярная карцинома и базально-клеточная карцинома, особенно при иммуносупрессивных заболеваниях.

Факторы, способствующие прогрессированию опухоли:

  • персистирование инфекции ВПЧ;
  • заражение онкогенными подтипами ВПЧ;
  • возраст старше 30 лет;
  • заражение множественными подтипами ВПЧ;
  • иммуносупрессии;
  • курение.

Профилактика

Что касается кожных бородавок, профилактика основывается прежде всего на устранении/управлении факторами риска:

  • уменьшение травм, чтобы избежать инфекции и воспалительных процессов;
  • при периунгуальных бородавках избегать онихофагии (навязчивое обкусывание ногтей) и маникюрных процедур;
  • уменьшение факторов, способствующих мацерации кожи (например, желательно использовать перчатки людям, которые часто держат руки в воде);
  • использование средств защиты от инфекции (например, избегайте ходьбы босиком, используйте тапочки в таких местах, как бассейны или спортивные залы).

Что касается половых (генитальных) бородавок, риск заражения инфекцией может быть уменьшен путем ограничения числа половых партнеров. Особенно при наличии активных поражений, т. е. при очевидных повреждениях, необходимо избегать сексуальных контактов, чтобы избежать заражения других людей.

Презервативы не полностью защищают от инфекции, однако могут снизить риск заражения вирусом на 30-60%, если очаги поражения находятся в областях, защищенных латексом.

Введение четырехвалентной вакцинации против ВПЧ 6-11-16-18 увеличило возможности первичной профилактики генитальных бородавок, а также ассоциированных с ВПЧ опухолей. Недавно введенная невалентная вакцина (Гардасил 9), защищающая от ВПЧ 6, 11, 16, 18, 31, 33, 45, 52 и 58, позволит значительно увеличить охват по сравнению с четырехкомпонентной вакциной и предотвратить до 90% случаев рака, вызванного ВПЧ.

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