Vaccinating Providers for HPV Due to Transmission Risk in Ablative Dermatology Procedures

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J Clin Aesthet Dermatol. 2023;16(9):26–27.

by Julien Bourgeois, MD, and Lindy Ross, MD

Dr. Bourgeois is with Creighton University Health Sciences Campus in Phoenix, Arizona. Dr. Ross is with the University of Texas Medical Branch in Galveston, Texas.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.


ABSTRACT: Prior research has shown that surgical plume released in ablative procedures poses significant health risks to providers. For dermatologists, the possibility of oropharyngeal human papillomavirus (HPV) inoculation from inhalation of viral particles released in smoke has been previously documented. Despite this, there are limited guidelines of health and safety protocols for physicians performing electrodesiccation or laser surgery and many providers are still not vaccinated against HPV. Due to the occupational risk of autoinoculation, we recommend that all dermatologists be vaccinated against HPV.


Dermatologists regularly use electrosurgical and ablative laser procedures in the management of warts. During these procedures, the heating of verrucous lesions and the surrounding tissue produces smoke, known as surgical plume. Surgical plume has been shown to contain carcinogenic particulate matter, toxins, viruses, and bacteria, and in one study, human papillomavirus (HPV) DNA was detected in surgical plume in 62 percent of ablative laser procedures and 57 percent of electrosurgical procedures on human and bovine warts.1–3

Prior research has demonstrated a risk of HPV transmission to providers from inhaled surgical plume, and the HPV virus has been detected in the airways of providers after ablative procedures.4, 5 In one multicenter study, 8.96 percent of gynecologists who regularly performed electrosurgery were found to have the HPV virus present in nasal epithelial cells.6 In one case study, two incidences of HPV-positive oropharyngeal cancers were reported in physicians performing loop electrical excision procedures (LEEP).7 It is important to note that greater energy settings, like those used in LEEP or cervical electrodesiccation, as well as the use of unipolar/monopolar devices, produce a more significant surgical plume, which might increase the risk of aerosolized HPV exposure.3 While the prevalence of plume-transmitted HPV infection in dermatologic procedures is largely limited to case studies, the risk of transmission has been upheld in animal models, and the occupational risk of these procedures has been maintained in the medical literature.8 For example, two cases of HPV-positive laryngeal papillomatosis have been reported in providers treating anogenital condyloma.5

While masking and ventilation practices are helpful in minimizing surgical plume hazards, it is likely that great precautions need to be taken to limit the risk of aerosolized HPV transmission.5,9 The HPV vaccine has been shown to be both safe and effective at inducing antibody response, protecting against exposure, and decreasing the incidence and prevalence of HPV infection.10 

In the United States, the 4-valent HPV vaccine Gardasil® was first introduced in 2006. It was replaced by Gardasil®9 (Merck & Co., Inc., Rahway, New Jersey) in 2014 and has since been recommended for all people aged 9 to 26 by the American Committee on Immunization Practices (ACIP).11 Medical schools and physicians typically abide by the Centers for Disease Control Recommended Vaccines for Healthcare Workers, which only includes Hep B, Flu, MMR, Varicella, Tdap, and Meningococcal vaccination guidelines.12 

Because of these guidelines and the recency of the introduction of the HPV vaccine, many providers are currently not vaccinated against HPV despite the expanded eligibility for those aged 27 to 45. For example, in one survey of Mohs surgeons, 79.6 percent of respondents reported believing HPV can be transmitted through surgical smoke. However, only 44.9 percent of them were vaccinated against HPV.11 

The majority of extragenital, palmoplantar, and anogenital warts are caused by low-oncogenicity strains of the HPV virus (HPV 6 and 11); however, autoinoculation from genital to extragenital sites have been demonstrated, such that sites more typically associated with low-risk HPV may actually harbor high-risk strains.13 Multiple PCR studies have shown biopsy-positive, high-risk HPV strains concurrently present in low-risk locations.13,14 Because of this, dermatologists treating extragenital warts should be no less cautious of the possibility of HPV transmission. 

Due to the occupational risk of inoculation during electrodesiccation and ablation, we recommend all dermatologists are vaccinated against HPV.

Dermatologists regularly use electrosurgical and ablative laser procedures in the management of warts. During these procedures, the heating of verrucous lesions and the surrounding tissue produces smoke, known as surgical plume. Surgical plume has been shown to contain carcinogenic particulate matter, toxins, viruses, and bacteria, and in one study, human papillomavirus (HPV) DNA was detected in surgical plume in 62 percent of ablative laser procedures and 57 percent of electrosurgical procedures on human and bovine warts.1–3

Prior research has demonstrated a risk of HPV transmission to providers from inhaled surgical plume, and the HPV virus has been detected in the airways of providers after ablative procedures.4, 5 In one multicenter study, 8.96 percent of gynecologists who regularly performed electrosurgery were found to have the HPV virus present in nasal epithelial cells.6 In one case study, two incidences of HPV-positive oropharyngeal cancers were reported in physicians performing loop electrical excision procedures (LEEP).7 It is important to note that greater energy settings, like those used in LEEP or cervical electrodesiccation, as well as the use of unipolar/monopolar devices, produce a more significant surgical plume, which might increase the risk of aerosolized HPV exposure.3 While the prevalence of plume-transmitted HPV infection in dermatologic procedures is largely limited to case studies, the risk of transmission has been upheld in animal models, and the occupational risk of these procedures has been maintained in the medical literature.8 For example, two cases of HPV-positive laryngeal papillomatosis have been reported in providers treating anogenital condyloma.5

While masking and ventilation practices are helpful in minimizing surgical plume hazards, it is likely that great precautions need to be taken to limit the risk of aerosolized HPV transmission.5,9 The HPV vaccine has been shown to be both safe and effective at inducing antibody response, protecting against exposure, and decreasing the incidence and prevalence of HPV infection.10 

In the United States, the 4-valent HPV vaccine Gardasil® was first introduced in 2006. It was replaced by Gardasil®9 (Merck & Co., Inc., Rahway, New Jersey) in 2014 and has since been recommended for all people aged 9 to 26 by the American Committee on Immunization Practices (ACIP).11 Medical schools and physicians typically abide by the Centers for Disease Control Recommended Vaccines for Healthcare Workers, which only includes Hep B, Flu, MMR, Varicella, Tdap, and Meningococcal vaccination guidelines.12 

Because of these guidelines and the recency of the introduction of the HPV vaccine, many providers are currently not vaccinated against HPV despite the expanded eligibility for those aged 27 to 45. For example, in one survey of Mohs surgeons, 79.6 percent of respondents reported believing HPV can be transmitted through surgical smoke. However, only 44.9 percent of them were vaccinated against HPV.11 

The majority of extragenital, palmoplantar, and anogenital warts are caused by low-oncogenicity strains of the HPV virus (HPV 6 and 11); however, autoinoculation from genital to extragenital sites have been demonstrated, such that sites more typically associated with low-risk HPV may actually harbor high-risk strains.13 Multiple PCR studies have shown biopsy-positive, high-risk HPV strains concurrently present in low-risk locations.13,14 Because of this, dermatologists treating extragenital warts should be no less cautious of the possibility of HPV transmission. 

Due to the occupational risk of inoculation during electrodesiccation and ablation, we recommend all dermatologists are vaccinated against HPV.

References

  1. Sawchuk, WS, et al. Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol. 11989 Jul;21(1):41–49.
  2. Lewin JM, Brauer JA, and Ostad A. Surgical smoke and the dermatologist. J Am Acad Dermatol. 2011 Sep;65(3):636–641.
  3. Searle T, Ali FR, and Al-Niaimi F. Surgical plume in dermatology: an insidious and often overlooked hazard. Clin Exp Dermatol. 2020 Oct 1; 45(7):841–847.
  4. Andrew FL, et al. Human papillomavirus and surgical smoke: a systematic review. Occupational and Environmental Medicine. 2020 Dec;77(12):809–817.
  5. Palma S, et al. Airborne human papillomavirus (HPV) transmission risk during ablation procedures: A systematic review and meta-analysis. Environmental Research. 2021 Jan;192:110437.
  6. Hu X, et al. Prevalence of HPV infections in surgical smoke exposed gynecologists. Int Arch Occup Environ Health. 2021 Jan;94(1):107–115.
  7. Parker J and Clark J. HPV Positive Oropharyngeal Cancer in Two Gynaecologists Exposed to Electrosurgical Smoke Plume. Obstet Gynecol Cases Rev. 2021.8(205).
  8. Garden JM, et al. Viral disease transmitted by laser-generated plume (aerosol). Archives of dermatology. 2002 Oct;138(10):1303–1307.
  9. Katoch S and Mysore V. Surgical Smoke in Dermatology: Its Hazards and Management. J Cutan Aesthet Surg. 2019 Jan-Mar;12(1):1–7
  10. Kamolratanakul S and Pitisuttithum P. Human Papillomavirus Vaccine Efficacy and Effectiveness against Cancer. Vaccines (Basel). 2021. Nov 30;9(12):1413.
  11. Pearlman RL, et al. Adoption of Human Papillomavirus Vaccination Among Dermatologic Surgeons: A Survey Study of American College of Mohs Surgery Members. Dermatologic Surgery. 2022. 48(3).
  12. Shefer A, Friedman W, Kuhar C, et al. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Recommendations and Reports, 2011. 60(RR07):1–45.
  13. Hernandez BY, et al. Genital and extra-genital warts increase the risk of asymptomatic genital human papillomavirus infection in men. Sex Transm Infect. Published online 2011 May 20.
  14. Greer CE, et al. Human papillomavirus (HPV) type distribution and serological response to HPV type 6 virus-like particles in patients with genital warts. J Clin Microbiol. 1995 Aug;33(8):2058–2063. 

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Letters to the Editor: June 2024
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