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ORIGINAL ARTICLE
Year : 2021  |  Volume : 66  |  Issue : 1  |  Page : 44-48
Estimating the impact of extragenital warts versus genital warts on quality of life in immunocompetent Indian adult patients: A comparative cross-sectional study


Department of Dermatology, Venereology and Leprosy, GMC, Kota, Rajasthan, India

Date of Web Publication1-Feb-2021

Correspondence Address:
Suresh K Jain
Department of Dermatology, Venereology and Leprosy, GMC, Kota - 324 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_290_19

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   Abstract 


Background: Extra-genital warts (EGWs) affect 7-10% of population. Even though a plethora of studies have been conducted to assess the impact of genital warts (GWs) showing a significant impact on the quality of life but surprisingly, barely any data has been collected on the impact of EGWs on quality of life. Aims and Objective: This cross-sectional study aimed at comparing the magnitude of EGWs on health-related quality of life and various variables with that of GWs. Patients and Methods: The study consisted of two groups of immunocompetent adults, each with 100 patients aged 18 years or above, attending the skin outpatient department at our tertiary center between April 2018 and March 2019 and consented to participate. Group A consisted of patients with EGWs and group B comprised of patients with GWs. All patients were asked to fulfill the validated Hindi hard copy of the Dermatology Life Quality Index (DLQI) questionnaire. Results: The mean DLQI score of patients with EGWs was 8.73 ± 0.84 and that of patients with GWs was 5.83 ± 0.83 (P = 0.026). In group A, those affected the most were patients with warts on multiple exposed sites (mean DLQI score of 14), followed by warts on feet (mean DLQI score of 10.69), followed by warts on hands (DLQI score of 9.12), and facial warts (DLQI score of 6.80). Patients with a prior history of failed treatment and/or a longer duration of illness had a higher level of dissatisfaction. To the best of our knowledge, no such study has been conducted in the past in our country. Conclusions: EGWs inflict a severe negative impact on the quality of life. Owing to its notorious persistence and recurrence, healthcare professionals must educate patients on how to prevent the spread and recurrence, discuss details of available treatment modalities while keeping in view the psychological and sociological impact.


Keywords: DLQI, extra-genital, genital, HPV, quality of life, warts


How to cite this article:
Mohta A, Jain SK, Kushwaha RK, Singh A, Gautam U, Nyati A. Estimating the impact of extragenital warts versus genital warts on quality of life in immunocompetent Indian adult patients: A comparative cross-sectional study. Indian J Dermatol 2021;66:44-8

How to cite this URL:
Mohta A, Jain SK, Kushwaha RK, Singh A, Gautam U, Nyati A. Estimating the impact of extragenital warts versus genital warts on quality of life in immunocompetent Indian adult patients: A comparative cross-sectional study. Indian J Dermatol [serial online] 2021 [cited 2021 Nov 29];66:44-8. Available from: https://www.e-ijd.org/text.asp?2021/66/1/44/308495





   Introduction Top


Viral warts are caused by human papillomaviruses (HPVs) that infect both keratinized and non-keratinized squamous cell epithelia.[1] Myriad types of warts are caused by different serotypes of HPV. Both sexes are equally susceptible to warts and they may be transmitted by direct and indirect contact. Extra-genital wart (EGW) is a common disorder with most cases reported between the ages of 12-16 years.[2] In India, the prevalence of genital warts (GWs) has been reported to vary from 2% to 25% among sexually transmitted infection (STI) clinic attendees.[3] A recent study has reported the prevalence of GWs in India was 1.07% with a higher prevalence among men than among women.[4] A plethora of destructive and immunotherapeutic treatment options are available for EGWs, but no single treatment has a proven 100% effectiveness yet.

They are frustrating for both clinicians and patients alike. They have a negative impact on life with various troubles ranging from pain depending on their site and social unacceptability on cosmetic sites to fear of negative appraisal from partner and associated guilt and shame in the case of GWs. GWs are also known for notoriously relapsing nature. The recurrence and resistance to treatment in recalcitrant warts take a toll on patient's day-to-day life and mental status.[5]

Several studies have been published highlighting the negative impact on the quality of life and mental well-being in context with GWs[6],[7],[8] but there is still a dearth of available data over the impact of EGW on quality of life.[9] This is astounding considering the fact that there is a significant prevalence of EGWs, as encountered in our day-to-day practice. Keeping the above in mind, we aimed at conducting a study to compare the negative impact of EGWs with GWs on quality of life in immunocompetent adults.


   Patients and Methods Top


Ethical approvals

We took formal permission from Professor Andrew Y Finlay, Department of Dermatology, Cardiff University School of Medicine, Heath Park, Cardiff, UK to use the validated Hindi version of the DLQI questionnaire. The Institutional Ethical Committee of Government Medical College (GMC) and attached hospitals, Kota, Rajasthan approved this study. Written consent was taken from all the patients before enrolling them in the study.

Patients

This cross-sectional study consisted of two groups, each with 100 patients aged 18 years or above, attending the skin outpatient department of GMC, Kota?. Group A consisted of patients with single or multiple EGWs of any duration. The warts were diagnosed based on their typical clinical appearance, i.e., sharply defined, rounded lesion with a rough keratotic flat to verrucous surface surrounded by a smooth collar of thickened horn. Group B comprised of patients with single or multiple GWs.

A thorough history was taken including age, sex, involved sites, and number of lesions.

Immunocompromised patients with GWs or EGWs were excluded from the study.

The patients were asked to fill a hard copy of the questionnaire. Data collection took place between April 2018 and March 2019.

Questionnaire

This questionnaire consisted of 10 questions, each with a maximum score of 3. Each question had the following possible scores: 0-not at all or not relevant or unanswered, 1-a little, 2-a lot, and 3-very much or prevented work or studying. Therefore, the maximum score for DLQI was 30, which denoted the maximum negative impact on the skin-related quality of life.

The DLQI scores were interpreted as follows: 0-1: no effect at all on patient's life, 2-5: small effect, 6-10: moderate effect, 11-20: very large effect, and 21-30: extremely large effect.

Statistical analysis

Statistical analysis of the data was done using Statistical Package for the Social Sciences (SPSS) version 19. Mean and standard deviation were used to find the distribution of the continuous numbers while proportion or percentages were used for qualitative variables. Chi-square test and t-test were used as required. P < 0.05 was considered statistically significant.

?
   Results Top


This cross-sectional study was carried out on 100 patients with EGWs (aged 18 to 61 years, 69 males and 31 females) and 100 patients with GWs (aged 18 to 51 years, 85 males, 15 females).? No significant difference was observed between the mean ages of both the categories of patients (P = 0.725). But there was a difference in the sex distribution of the two groups, where males were more commonly affected with GWs (P = 0.012). The average number of lesions in GWs was 5.65 ± 0.77 whereas that in EGWs was 8.73 ± 0.84. The effect of quality on life progressively increased with increase in number of warts [Table 1] and [Table 2].
Table 1: Genital warts: Number of lesions vs DLQI score

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Table 2: Extragenital warts: Number of lesions vs DLQI score

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The mean DLQI score of patients with EGWs was 8.73 ± 0.84 and that of patients with GW was 5.83 ± 0.83 and the difference was statistically significant (P = 0.026) [Table 3]. The number of patients has been tabulated against the degree of impact of warts in [Figure 1] and [Figure 2].
Figure 1: DLQI questions 1.10 and comparison between answers of the two study groups

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Figure 2: Level of dissatisfaction in both groups

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Table 3: Comparative table of DLQI score

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In group A, amongst the two sexes, females were found to be more impacted by EGWs (mean DLQI score of 9.37) as compared to males (mean DLQI score of 8.46) although not statistically significant (P = 0.663). Of all the patients, 36% had warts on feet, 19% on face, 19% on limbs excluding hands and feet, 15% on hands, and the remaining 11% had warts on multiple sites. Those affected the most were patients with warts on multiple sites (mean DLQI score of 14). These patients either had a combination of palmoplantar warts or multiple warts on face and exposed sites of limbs making them cosmetically concerned and symptomatically affected due to pain. Next in line were those with warts on feet with mean DLQI score of 10.69, followed by warts on hands (DLQI score of 9.12) and face (DLQI score of 6.80) [Figure 3].
Figure 3: Correlation of site of EGW with DLQI score

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In group A, 17 patients had developed EGWs in the last 6 months (average DLQI score of 3.17), 36 between 6 months to 1 year (DLQI score of 7.92), whereas 47 patients had warts for more than 1 year (DLQI score of 11.36). In group B, 63 patients had developed GWs in the last 6 months (DLQI score of 5.23), 28 between 6 months to 1 year (DLQI score of 5.38), and 9 patients had illness for more than 1 year (DLQI score of 11.41). There was a linear correlation between the duration of illness and impact on the quality of life in both the groups [Figure 4].
Figure 4: Duration of illness vs DLQI score

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Amongst the two groups, only a minority of patients had sought any treatment in the past. These patients included those who had been treated with various modalities in the past (like chemical cauterization, radiofrequency ablation, autoimplantation or immunotherapy), followed by recurrence or little to no relief in their condition. Naturally, they had a higher level of dissatisfaction. In groups A and B, such patients were 28 (average DLQI score of 9.39) and 18 (average DLQI score of 8.35), respectively [Figure 5].
Figure 5: History of prior treatment vs DLQI score

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We followed the framework of Salah[9] and divided the questions in the DLQI questionnaire into six domains, namely, symptoms and feelings accompanying the disease, impairment of daily activities, effects on leisure times, effects on school or work, interpersonal relationships, and reflection of treatment on quality of life. The individual scores for each of the 10 DLQI questions have been tabulated and graphed in [Figure 1] and [Figure 6].
Figure 6: Graphical representation of comparison of DLQI questions 1-10 between the two groups

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Symptoms and feelings were reflected in Q1 and Q2. Patients with plantar warts reported maximum pain and stinging followed by palmar warts.

On the other hand, feeling of embarrassment and self-consciousness were associated the most with patients of warts on exposed sites, especially face, and those with GW.

Q3 and Q4 which covered the domain of day-to-day activities were observed to be negatively impacted in those with plantar warts as they experienced difficulty in walking/standing for a long time owing to pain.

Q5 and Q6 were primarily concerned with a person's leisure activities. Chiefly male patients suffer the most as they play sports. A significant proportion of patients complained that plantar and palmar warts made it difficult for them to engage in sports like cricket, etc. Second in line were those with warts on face, especially the younger patients as it made them avoid social activities and interactions.

Q7 asked about the effect on school or work. The patients confessed to playing truant at work either because of pain from plantar warts and post-radical treatments, like excision and needling or due to frustration.

Q8 and Q9 were concerned with interpersonal relationships. These questions had a higher score in GW as they directly impacted their conjugal harmony. Second in line were facial and palmar warts, which can be explained by the negative outlook of the society and the patient towards warts as an infectious disease that could get transmitted by touching, shaking hands, etc.

Lastly, Q10 dealt with the troubles associated with seeking treatment and how it shadows the quality of life. As, conventionally, no definitive antiviral therapy exists for warts, patients from both the groups, scored higher on this domain. Those with warts extensively distributed on multiple sites were affected the most and a fairly linear relationship could be drawn between the score of this question with a number of warts.

In group B, the most severely affected variables were interpersonal relationship in sexual life, symptomatology, and feeling of embarrassment.


   Discussion Top


Warts are caused by HPV infection. While EGWs are benign in nature, it is not always the case with GWs. GWs pose an increased risk of anogenital malignancies.[10]

Although EGWs have been observed to resolve on their own, the duration it takes may range from months to years. The afflicted individual may suffer not only from fear of negative appraisal, social segregation, and esthetic embarrassment at cosmetic sites but also from frustration caused by pain, persistence, and recurrence along with disfigurement.[11] This justifies the need for a definitive cure of warts and even though a plethora of management options are available for treating warts, to date there is no definitive antiviral cure.

GWs also have been established by various studies in the past to have a negative impact on patient's mental status, emotional health, and interpersonal relationships.[12],[13] In our study, these patients reported difficulty in maintaining intimacy with partner, symptomatic discomfort, as well as feelings of guilt and shame. This could be responsible for seeking earlier treatment than group A. These findings were in close agreement with the observations made by Camargo et al.[14]

Our study demonstrated a moderate impact of EGWs on quality of life with a mean DLQI of 8.73 ± 0.84, which was higher than that of GWs with a mean DLQI of 5.83 ± 0.83 (P = 0.026). Previously, a study conducted by Salah[9] reported a very strong impact of warts on quality of life using the DLQI scoring system with a mean score of 11.2 ± 2.5 in GWs and a mean of 13.0 ± 5.8 in EGWs.[9] Another study conducted by Leow et al. on patients of viral warts receiving liquid nitrogen treatment observed that patients were frustrated with the persistence and recurrence of viral warts, and time spent on treatment.[15] Woodhall et al. have also reported that GWs have a substantial impact on the health service as well as the affected individual.[16]

Keeping our findings in view, we recommend using the DLQI questionnaire to evaluate patients with warts. This may help employ a holistic approach while treating and counseling the patient.


   Conclusions Top


To the best of our knowledge, the present study is the first of its kind to compare the effect of EGWs on quality of life with that of GWs in the Indian population.

EGWs are observed to affect all domains of everyday life. Even though, unlike GWs, they are benign in nature they have been reported to have a much higher impact on everyday quality of life. Our findings demonstrate that the psychological factors should be carefully considered when treating a patient with HPV infection. Apart from that, we recommend improved communication between the patient and doctor.

Acknowledgements

The authors thank Professor Andrew Y Finlay, Department of Dermatology, Cardiff University School of Medicine, for granting permission to use DLQI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Leto Md, Santos GF Junior Porro AM, Tomimori J. Human papillomavirus infection: Etiopathogenesis, molecular biology and clinical manifestations. An Bras Dermatol 2011;86:306-17.  Back to cited text no. 1
    
2.
Clifton MM, Johnson SM, Roberson PK, Kincannon J, Horn TD. Immunotherapy for recalcitrant warts in children using intralesional mumps or Candida antigens. Pediatr Dermatol 2003;20:268-71.  Back to cited text no. 2
    
3.
Sharma VK, Khandpur S. Changing patterns of sexually transmitted infections in India. Natl Med J India 2004;17:310-9.  Back to cited text no. 3
    
4.
Khopkar US, Rajagopalan M, Chauhan AR, Kothari-Talwar S, Singhal PK, Yee K, et al. Prevalence and burden related to genital warts in India. Viral Immunol 2018;31:346-51.  Back to cited text no. 4
    
5.
Sinha S, Relhan V, Garg VK. Immunomodulators in warts: Unexplored or ineffective? Indian J Dermatol 2015;60:118-29.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Dominiak-Felden G, Cohet C, Atrux-Tallau S, Gilet H, Tristram A, Fiander A. Impact of human papillomavirus-related genital diseases on quality of life and psychosocial wellbeing: Results of an observational, health-related quality of life study in the UK. BMC Public Health 2013;13:1065.  Back to cited text no. 6
    
7.
Domenech-Viñolas M, León-Maldonado L, Ramírez-Palacios P, Flores YN, Granados-García V, Brown B, et al. Incidence, psychosocial burden, and economic impact of genital warts in Mexico. Salud Publica Mex 2018;60:624-32.  Back to cited text no. 7
    
8.
Lee Mortensen G, Larsen HK. Quality of life of homosexual males with genital warts: A qualitative study. BMC Res Notes 2010;3:280.  Back to cited text no. 8
    
9.
Salah E. Impact of multiple extragenital warts on quality of life in immune-competent Egyptian adults: A comparative cross-sectional study. Clin Cosmet Investig Dermatol 2018;11:289-95.  Back to cited text no. 9
    
10.
Munoz N, Bosch FX, de Sanjose S, Herrero R, Castellsague X, Shah KV, et al. Epidemiologic classi?cation of human papilloma virus types associated with cervical cancer. N Engl J Med 2003;348:518-27.  Back to cited text no. 10
    
11.
Ciconte A, Campbell J, Tabrizi S, Garland S, Marks R. Warts are not merely blemishes on the skin: A study on the morbidity associated with having viral cutaneous warts. Australas J Dermatol 2003;44:169-73.  Back to cited text no. 11
    
12.
Wang H, Kindig DA, Mullahy J. Variation in Chinese population health related quality of life: Results from a EuroQol study in Beijing, China. Qual Life Res 2005;14:119-32.  Back to cited text no. 12
    
13.
Vriend HJ, Nieuwkerk PT, van der Sande MA. Impact of genital warts on emotional and sexual well-being differs by gender. Int J STD AIDS 2014;25:949-55.  Back to cited text no. 13
    
14.
Camargo CC, D'Elia MP, Miot HA. Quality of life in men diagnosed with anogenital warts. An Bras Dermatol 2017;92:427-9.  Back to cited text no. 14
    
15.
Leow MQH, Oon HHB. The impact of viral warts on the quality of life of patients. Dermatol Nurs 2016;15:44-8.  Back to cited text no. 15
    
16.
Woodhall SC, Jit M, Soldan K, Kinghorn G, Gilson R, Nathan M, et al. The impact of genital warts: Loss of quality of life and cost of treatment in eight sexual health clinics in the UK. Sex Transm Infect 2011;87:458-63.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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