|Whitney High, M.D
With the rate of sexually transmitted diseases (STDs) increasing exponentially around the globe, dermatologists are being forced to stay on top of the latest diagnostic techniques and therapeutic options available to care for these patients.
During Friday's "Sexually Transmitted Infections: The Current Standard of Diagnosis and Care," session, speaker Whitney A. High, M.D., reviewed the signs and symptoms of STDs in addition to comparing and contrasting the conditions to other dermatological illnesses that may involve the genitalia.
Dr. High, associate professor of dermatology and pathology at the University of Colorado Health Sciences Center, Denver, covered a list of common and not-so-common STDs — herpes, HPV, HIV, syphilis, Chlamydia/LGV, gonorrhea, chancroid, trichomonas and scabies to name a few — as well as the present standard-of-care and current therapeutic guidelines for treating each.
"There is a long and interesting history regarding dermatologists and the treatment of STDs," Dr. High said. "For instance Dr. Julius Wagner-Jauregg won the 1927 Nobel Prize for Medicine for using malaria, which produced prolonged fevers, to treat syphilis."
According to recent reports, there are significant increases in the presentation of most all of the major STDs each year.
"There will be record numbers of patients coming to us with Chlamydia this year," Dr. High said. "Reports show a 5.5 percent increase, coupled with a 5.6 percent increase in the rate of gonorrhea and a 13.8 percent increase in the number of patients presenting with syphilis. Of those patients presenting with STDs, 50 percent are between the ages of 15 and 24 years."
Two viral subtypes of the herpes simplex virus — HSV-1 and HSV-2 — are the number one cause of genital ulcers worldwide.
"Herpes is ubiquitous in adults," Dr. High said. "The latency in the ganglia leads to recurrent flare-ups that present whenever one's immunity is taxed. Herpes genitals often see lesions that look like ‘dew drops on a rose petal' or ‘scalloped ulcerations,' which can be perplexing for those physicians who are not used to seeing lots of herpes."
The direct fluorescent-antibody (DFA) technique and polymerase chain reaction (PCR) test are the go-to avenues for detecting HSV, Dr. High said.
"DFA is rapid and it allows for the differentiation of HSV subtypes," he said. "PCR is four times more sensitive than other tests and is increasing in popularity. Many labs have discontinued the use of culture altogether and instead have switched to PCR."
With regard to treating HSV, Dr. High said that while acyclovir (ACV) is a solid and cheap method for treating herpes, recent shortages of the drug are increasing the popularity and use of the more-expensive drugs Valacyclovir and Famciclovir.
Ninety percent of the time, condyloma is caused by HPV 6 or 11, while HPV 16 and 18 are the subtypes that cause cervical cancer. Of the treatments available, Dr. High said imiquimod is the most popular — having been specifically designed to get rid of these warts. The vaccines currently available are effective, but treat different types of HPV.
"Gardasil covers 6, 11, 16 and 18 and is really seeking to prevent genital warts first and ultimately cervical cancer," he said. "Ceravix, which was just recently approved, covers 16 and 18 and is great at blocking cervical cancer, but does nothing for condyloma."
Dr. High said Chlamydia's importance couldn't be understated.
"It is the No.1 cause of nongonococcal urethritis (NGU)," he said. "But they are getting very close to developing a vaccine, which is great.
"At present, the best treatment option is a one-time dose of azithromycin, which is taken in the office under a physician's supervision. One hundred milligrams of doxycycline can be used over a course of seven days, but that is a less plausible option because of the age of the average patient and unlikelihood that these kids will take the medicine correctly."
Dr. High also reported that syphilis is unfortunately resurging in many areas of the United States.
"There is a high concentration of the disease on Native American reservations," he said. "As for cities, San Francisco is at the top of the list, followed by cities like Dallas and St. Louis."
On the upside, primary syphilis has never developed a resistance to penicillin, so treatment remains effective.
Overall, the social policy issues surrounding STDs continue to be a concern, Dr. High said.
"The number of STD cases continues to grows exponentially," he said. "A 2007 report from the UK National Health Service showed an increase of 300 – 2,000 times for CT, GC and syphilis, which was mirrored by the rise in binge drinking among the younger segment of the population.
"Of those in the study, 40 percent were sexually active 13- to 14-year-olds who reported being drunk or high at the time of their first sexual intercourse."