International Journal of

Molecular Sciences

Review
HPV Infections—Classification, Pathogenesis, and Potential
New Therapies
Beata Mlynarczyk-Bonikowska * and Lidia Rudnicka

Department of Dermatology, Medical University of Warsaw, 02-091 Warsaw, Poland; [email protected]

* Correspondence: [email protected]

Abstract: To date, more than 400 types of human papillomavirus (HPV) have been identified. Despite
the creation of effective prophylactic vaccines against the most common genital HPVs, the viruses
remain among the most prevalent pathogens found in humans. According to WHO data, they are the
cause of 5% of all cancers. Even more frequent are persistent and recurrent benign lesions such as
genital and common warts. HPVs are resistant to many disinfectants and relatively unsusceptible to
external conditions. There is still no drug available to inhibit viral replication, and treatment is based
on removing lesions or stimulating the host immune system. This paper presents the systematics of
HPV and the differences in HPV structure between different genetic types, lineages, and sublineages,
based on the literature and GenBank data. We also present the pathogenesis of diseases caused by
HPV, with a special focus on the role played by E6, E7, and other viral proteins in the development
of benign and cancerous lesions. We discuss further prospects for the treatment of HPV infections,
including, among others, substances that block the entry of HPV into cells, inhibitors of viral early
proteins, and some substances of plant origin that inhibit viral replication, as well as new possibilities
for therapeutic vaccines.

Keywords: HPV; systematics; pathogenesis; vaccines; pharmacological therapy

1. Introduction
Citation: Mlynarczyk-Bonikowska, B.;
Human papillomaviruses (HPVs) are small, envelopeless viruses containing circular
Rudnicka, L. HPV Infections—
double-stranded DNA. More than 400 types of HPV are known, of which, depending on
Classification, Pathogenesis, and
Potential New Therapies. Int. J. Mol.
the database, more than 180 to more than 220 are fully classified. HPVs are among the most
Sci. 2024, 25, 7616. https://doi.org/
common pathogens affecting humans and genital HPV infection is considered the most
10.3390/ijms25147616 common sexually transmitted disease. It is estimated that approximately one in ten sexually
active women with normal cytology may be affected by current genital HPV infection. By
Academic Editors: Mattia Mori
the age of 45, the probability of HPV infection for sexually active individuals is assessed
and Ilaria Vicenti
to be over 80% [1–3]. Although the majority of those infected remain asymptomatic and
Received: 10 May 2024 eliminate the infection, some individuals may experience persistent or recurrent benign
Revised: 2 July 2024 lesions, while others may develop precancerous lesions and cancer. According to the WHO,
Accepted: 8 July 2024 HPV infections are responsible for approximately 5% of all cancers worldwide, and every
Published: 11 July 2024 year 625,600 women and 69,400 men develop cancer due to HPV infection [4]. Almost all
cases (99.7%) of cervical cancer are caused by HPV and 80% of all cancers caused by HPV
are cervical. However, HPV infections are also responsible for a large proportion of anal
(71–90%), vaginal (65–74%), penile (43–63%), vulvar (43–74%), and head and neck cancers
Copyright: © 2024 by the authors. (10–70%) [5,6].
Licensee MDPI, Basel, Switzerland.
This article is an open access article 2. A Brief Historical Overview of HPV Research
distributed under the terms and
The first descriptions of genital and cutaneous warts appeared as early as ancient
conditions of the Creative Commons
times (i.e., by Hippocrates and by Celsus). In 1842, Italian physician Rigoni-Stern published
Attribution (CC BY) license (https://
a study in which he showed that cervical cancer is more common in sexually active women.
creativecommons.org/licenses/by/
4.0/).
This gave grounds to look for a link between cervical cancer and sexually transmitted

Int. J. Mol. Sci. 2024, 25, 7616. https://doi.org/10.3390/ijms25147616 https://www.mdpi.com/journal/ijms

Int. J. Mol. Sci. 2024, 25, 7616 2 of 33

diseases as early as the 19th century. However, no such correlation was found until the
second half of the 20th century. In 1891, Payne demonstrated the infectious nature of
common warts and in 1907 Ciuffo showed the viral etiology of these lesions. In 1949,
Strauss and others found HPV particles in skin warts using electron microscopy. A series
of studies conducted by Rous and subsequently by Syverton in the 1930s and early 1950s,
using the cotton-tailed rabbit as a model, demonstrated an association between CRPV
infection and the development of cancer in these animals. In 1957, the viral etiology of
lesions occurring in epidermodysplasia verruciformis (EV) was demonstrated and in later
years the link between HPV infection and the formation of skin cancers in the course of
this disease was confirmed. The research was conducted, among others, by Jablonska, who
headed our clinic at the time. In 1965, Crawford, Klug, and Finch described the structure of
HPV ds DNA isolated from skin warts. In the early 1970s, Zur Hausen put forward the
hypothesis that cervical cancer is caused by HPV infection; he later received a Nobel Prize
in 2008 for proving this [7,8].

3. Classification of HPV
The name human papillomavirus covers the papillomaviruses (PVs) found in humans.
The classification of PVs is based on the analysis of differences and similarities in the viral
DNA sequence. Of particular importance is the sequence encoding the L1 capsid protein,
for which the similarity between subfamilies should be no more than 45% and between
genera no more than 60%. However, in practice, a phylogenetic algorithm based on the
comparison of L1, L2, E1, and E2 sequences, and sometimes sequencing of the whole viral
genome, is often used. New types of PVs should differ in their L1 gene sequence from
previously known types by at least 10%. If the L1 sequence differs by 2–10%, we can speak
of subtypes, and if it differs by less than 2%, we speak of variants. For grouping genetically
similar viruses within a type, the terms lineages and sublineages are also used (e.g., in
GenBank). Accordingly, animal papillomaviruses are classified into the same genera as
human papillomaviruses, and the genetic similarity between some human and animal
papillomavirus types may be greater than between some human-infecting types. The most
clinically important HPVs, including high-risk mucosal HPVs such as HPV 16, 18, 26,
31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, 82 and low-risk mucosal HPVs such as
HPV6, 11, 40, 42, 44, 54, 55, 61, 62, 71, 74, 81, 84, 89 (CP6108), 90 as well as skin-wart-
causing HPVs such as HPV 1, 2, 3, 7, 10, 27, 57, 73, are classified as alphapapillomaviruses.
Betapapillomaviruses include HPVs associated with epidermodysplasia verruciformis
(EV) like HPV 5 and 8 [9–11]. Table 1 shows the systematics of HPVs according to the
International Committee on Taxonomy of Viruses [12], which were compared with the
contents of various databases [13–15]. The lineages and sublineages of HPV types based on
the literature and GenBank accession no. of each HPV are also included. The table includes
HPV types categorised into 49 species within 5 genera. An expanded version of Table 1
including links to GenBank can be found in Supplementary Table S1.

Table 1. Classification of HPVs. High-risk mucosal HPVs are circled in yellow. HPVs classified as
oncogenic and probably oncogenic are not underlined; those which are possibly oncogenic are under-
lined in green. Low-risk mucosal HPV types are circled in green. In gray with green underlining are
HPV types classified as possibly oncogenic in patients with EV [16]. ICTV—International Committee
on Taxonomy of Viruses, TB—Taxonomy Browser, IRHC—International Human Papillomavirus
Reference Center, PaVe—The Papilloma Virus Episteme.

Viruses (Superkingdom); Monodnaviria (Clade); Shotokuvirae (Kingdom); Cossaviricota (Phylum); Papovaviricetes (Class);
Zurhausenvirales (Order); Papillomaviridae (Family); Firstpapillomavirinae (Subfamily)
genus Alphapapillomavirus
species Alphapapillomavirus 1 [17–19]
type HPV32, 42
Int. J. Mol. Sci. 2024, 25, 7616 3 of 33

Table 1. Cont.

Viruses (Superkingdom); Monodnaviria (Clade); Shotokuvirae (Kingdom); Cossaviricota (Phylum); Papovaviricetes (Class);
Zurhausenvirales (Order); Papillomaviridae (Family); Firstpapillomavirinae (Subfamily)
species Alphapapillomavirus 2 [18,20–24]
type HPV3, 10, 28, 29, 77, 78, 94, 117, 125, 160; the TB [13] database also includes HPVXS2
species Alphapapillomavirus 3 [17,25–33]
type HPV61 sublineage A1, A2, lineage B, C, HPV62, 72, 81, 83, 84 , 86, 87, 89 , 102, 114

species Alphapapillomavirus 4 [18,34–36]

type HPV2, lineage 2a and 2c; HPV27, lineage b; HPV57, lineage b and c
species Alphapapillomavirus 5 [18,26,37–39]
HPV26 lineage A, HPV51 sublineage A1 to A4, B1, B2, HPV69 sublineage A1 to A4, HPV82 sublineage A1 to A3, B1,
type
B2, C1 to C5

species Alphapapillomavirus 6 [18,26,40,41]

HPV30: sublineage A1 to A3 and lineage B, HPV53: lineage A, B, C, and sublineage D1 to D4
type
HPV56: sublineage A1, A2, and lineage B; HPV66: lineage A and sublineage B1, B2

species Alphapapillomavirus 7 [18,26,39,42–52]

HPV18 sublineage A1 and A2 (Asian-Amerindian), A3 to A5 (European), B1 to B3 (African), and lineage C (African)

HPV39 sublineage A1, A2, and lineage B; HPV45 sublineage A1 to A3, B1, B2
type HPV59 sublineage A1 to A3, B, and lineage B
HPV68 lineage a, sublineage A1, A2, lineage B, and b, sublineage C1, C2, sublineage D1, D2, lineage E, and
sublineage F1, F2

HPV70 lineage A and B; HPV85 lineage A; HPV97 lineage A

species Alphapapillomavirus 8 [17,18,29]

type HPV7; HPV40; HPV43 ; HPV91
species Alphapapillomavirus 9 [18,26,43,53–69]
HPV16 sublineage A1 to A3 (European), A4 (Asian), B1 (African-1, Afr1a), B2 African-1, Afr1b), B3 and B4, C1
(African-2, Afr2a) AF472509, C2, C3, C4, D1 (North American, NA1), D2 (Asian-American, AA2), D3
(Asian-American AA1), and D4
type
HPV31: sublineage A1, A2, B1, B2, C1 to C4; HPV33: sublineage A1 to A3, B1, C1

HPV35: sublineage A1, A2; HPV52: A1, A2, B1, B2, B3, C1, C2, D1, E1

HPV58: sublineage A1 to A3, B1, B2, C1, D1, D2; HPV67: sublineage A1, A2, B1

species Alphapapillomavirus 10 [17,70–85]

HPV6: lineage A, 6a (classified as sublineage B3), 6b (classified as lineage A, 6c, 6e, 6vc (classified as sublineage B1),
and sublineage B1, B2, B3, B4, B5
type
HPV11: sublineage A1, A2, A3 (isolate C185), A4 (isolate LT4), and lineage B; HPV13 ; HPV44; HPV74

The TB database [13] also includes HPV55

species Alphapapillomavirus 11 [18,26,86]
Int. J. Mol. Sci. 2024, 25, 7616 4 of 33

Table 1. Cont.

Viruses (Superkingdom); Monodnaviria (Clade); Shotokuvirae (Kingdom); Cossaviricota (Phylum); Papovaviricetes (Class);
Zurhausenvirales (Order); Papillomaviridae (Family); Firstpapillomavirinae (Subfamily)
HPV34 sublineage A1, A2, lineage B, and sublineage C1, C2
type HPV73 sublineage A1, A2, and lineage B

In addition, the TB database [13] includes HPV177

species Alphapapillomavirus 13 [26,39]
type HPV54 lineage A, B, C

species Alphapapillomavirus 14 [29,30,39]

type HPV71 ; HPV90; HPV106
genus Betapapillomavirus
species Betapapillomavirus 1 [18,87–97]
HPV5: lineage b; HPV8 , 12; HPV14: lineage D; HPV19, 20, 21, 24, 25, 36, 47, 93, 98, 99, 105, 118, 124, 143, 152

type In addition, the [13] database includes HPVRTRX7, HPVV001/Slovenia/2010

In addition, the [14] database includes HPV195, 196, 206, which in ICTV [12] appear as unclassified Betapapillomavirus
HPVmRTRX7
species Betapapillomavirus 2 [18,20,90,98–109]
HPV9, 15, 17, 22, 23, 37; HPV38: lineage b; HPV80, 100, 104, 107, 110, 111, 113, 120, 122, 145, 151, 174
type In addition, the [14] database includes HPV182, 198, 209, 227
In addition, the [13] database includes HPVFA75/KI88-03
species Betapapillomavirus 3 [18,110]
type HPV49, 75, 76, 115
species Betapapillomavirus 4 [111]
HPV92
Betapapillomavirus 5 [93,102,112]
type
HPV96, 150
In addition, the [13,14] databases include HPV185
genus Gammapapillomavirus
species Gammapapillomavirus 1 [113–115]
type HPV4, 65, 95,173, 205
species Gammapapillomavirus 2 [116,117]
type HPV48 {NC_001690}; HPV200
species Gammapapillomavirus 3 [118]
HPV50
type
In addition, the [13,14] databases include HPV188
species Gammapapillomavirus4
type HPV60 [119]
species Gammapapillomavirus5
type HPV88 [120]
species Gammapapillomavirus 6 [121–124]
HPV101, 103, 108
type
In addition, the [14] database includes HPV214, 226
Int. J. Mol. Sci. 2024, 25, 7616 5 of 33

Table 1. Cont.

Viruses (Superkingdom); Monodnaviria (Clade); Shotokuvirae (Kingdom); Cossaviricota (Phylum); Papovaviricetes (Class);
Zurhausenvirales (Order); Papillomaviridae (Family); Firstpapillomavirinae (Subfamily)
species Gammapapillomavirus 7 [33,95,96,125–128]
type HPV109, 123, 134,138,139,149, 155, 170
In addition, the [13,14] databases include HPV186, 189, 193
Furthermore, the [14] database includes HPV203, 225, 229
species Gammapapillomavirus 8 [33,95,123,127,129]
HPV112, 119, 147,164, 168

type Furthermore, the [13,14] databases include HPV176

In addition, the [14] database includes HPV211, 224, which in ICTV [12] appear as unclassified
Betapapillomavirus HPVmICB1.
species Gammapapillomavirus 9 [123,126,130]
HPV116, 129
type
In addition, the [14] database includes HPV 215, 216
species Gammapapillomavirus 10 [95,126,131,132]
HPV121,130, 133, 142, 180
type In addition, the [13,14] databases include HPV191
Furthermore, the [14] database includes HPV221, 231
species Gammapapillomavirus 11 [96,114,117,127,133,134]
HPV126, 136, 140, 141, 154, 169, 171, 202
type In addition, the [13,14] databases include HPV181
Furthermore, the [13] database includes HPV230
species Gammapapillomavirus 12 [115,126,127,135–137]
HPV127, 132, 148, 157, 158, 165, 199
type
In addition, the [13,14] databases include HPV210
species Gammapapillomavirus 13 [123,126,132,138]
type HPV128, 153
In addition, the [14] database includes HPV213, 219
species Gammapapillomavirus 14 [126]
type HPV131
species Gammapapillomavirus 15 [96,114,139,140]
HPV135, 146, 179
type In addition, the [13,14] databases include HPV192 a
In addition, the [14] database includes HPV230
species Gammapapillomavirus 16 [96]
type HPV137
species Gammapapillomavirus 17 [96,123,132]
HPV144
type
In addition, the [14] database includes HPV212, 220
species Gammapapillomavirus 18 [141]
type HPV156
species Gammapapillomavirus 19 [127,132]
Int. J. Mol. Sci. 2024, 25, 7616 6 of 33

Table 1. Cont.

Viruses (Superkingdom); Monodnaviria (Clade); Shotokuvirae (Kingdom); Cossaviricota (Phylum); Papovaviricetes (Class);
Zurhausenvirales (Order); Papillomaviridae (Family); Firstpapillomavirinae (Subfamily)
HPV161, 162, 166
type
In addition, the [14] database includes HPV222
species Gammapapillomavirus 20 [127]
HPV163
type In addition, the [13,14] databases include HPV 183 a
Furthermore, the [14] database includes HPV194
species Gammapapillomavirus 21 [129]
type HPV167
species Gammapapillomavirus 22 [114]
HPV172
type
In addition, the [14] database includes HPV223
species Gammapapillomavirus 23 [131]
type HPV175
species Gammapapillomavirus 24 [142,143]
type HPV178, 197; in addition, the [14] database includes HPV190, 208
species Gammapapillomavirus 25 [139]
type HPV184
species Gammapapillomavirus26
type HPV187
species Gammapapillomavirus 27 [117]
type HPV201; in addition, the [14] database includes HPV228
genus Mupapillomavirus
species Mupapillomavirus 1 [144]
type HPV1; in the [13] database, it appears under the name HPV1a
species Mupapillomavirus 2 [113]
type HPV63
species Mupapillomavirus 3 [145,146]
type HPV204
genus Nupapillomavirus
species Nupapillomavirus 1 [147]
type HPV41

There are numerous distinctions between the ICTV and the Taxonomy Browser, IRHC,
and PaVE databases. First of all, they differ in the number of HPV types classified. In
the ICTV [12] database, there are 183 HPV types (numbering 1–45; 47–54; 56–63; 65–78;
80–175; 178–180; 184; 187; 197; 199–202; 204–205), while 204 HPVs (numbering 1–45, 47–63,
65–78, 80–182, 184–189, 191–193, 195–197, 199–202, 204–205, 209–210, 230) and HPVRTRX7,
HPVXS2, HPVV001/Slovenia/2010, and HPVFA75/KI88-03 are classified in the Taxonomy
Browser [13]. Unclassified Gammapapillomaviruses in this database include HPV190, 194,
and KC5. Unclassified Papillomaviridae include HPV64, 198, 203, 211–216, 219–222, 226,
228, 229, MM8, HANOA 464, JC9710, JC9813, JEB2, and me180, Xc, Xd, Xf, Xg, Xh, AZ1_1,
mSD2, and mSK_220.
Int. J. Mol. Sci. 2024, 25, 7616 7 of 33

There are 225 HPV types in the IRHC [14] database (numbering 1–45, 47–54, 56–63,
65–78, 80–216, 219–231) and 199 classified HPVs in the PaVE [15] database (numbering
1–45, 47–54, 56–63, 65–78, 80–156, 159–202, 204, 228, 229). HPV157, 158, 203, 205, 207–208,
210–216, 219–225 occur as unclassified Gammapapillomaviruses. Unclassified Betapapapil-
lomaviruses include HPV206 and 209.
In addition, there are numerous differences in the classification of the different types.
In the IRHC [14] database, HPV46, 55, 64, 79, 217, 218 do not appear, because they have
been reclassified to HPV20, 44, 34, 91, 182, 189, respectively. In ICTV [12] and PaVE [15],
they do not appear. According to the TB database, HPV55 belongs to the species Alphapa-
pillomavirus 10 and HPV64 belongs to unclassified Papillomaviridae. HPV158, according
to TB [13] and ICTV [12], is classified as Gammapapillomavirus 12 and, according to IRHC,
is classified as Gammapapillomavirus 1, and in the PaVE [15] database occurs as unclas-
sified Gammapapillomavirus. According to the IRHC database, HPV230 is classified as
Gammapapillomavirus 15 and according to TB [13] it is classified as Gammapapillomavirus
11 and in PaVE [15] and ICTV [12] it does not occur. Only the TB database [13] includes
HPVXS2 (alphapapapillomavirus 2), HPVV001/Slovenia/2010 (betapapapillomavirus 1),
and HPVFA75/KI88-03 (betapapapillomavirus 2). In ICTV, IRHC, and PaVE, these types
are not present.
Viruses classified in IRHC [14] and in PaVE [15] as HPV1 and HPV206 occur in TB as
HPV1a and HPVRTRX7, respectively. HPV1 is present in ICTV [12] and HPV206 is absent.
HPV198 (Betapapillomavirus 2), HPV214 and HPV226 (Gammapapillomavirus 6), HPV203
and HPV229 (Gammapapillomavirus 7), HPV211 (Gammapapillomavirus 8), and HPV215
and HPV216 (Gammapapillomavirus 9) are present in IRHC [14]; HPV221 (Gammapapillo-
mavirus 10), HPV212 and HPV220 (Gammapapillomavirus 17), and HPV222 (Gammapa-
pillomavirus 19) do not occur in ICTV [12] and are classified as unclassified HPV in the
TB [13] database. Occurring in IRHC [14] and PaVE [15], HPV194 (Gammapapillomavirus
20) and HPV190 (Gammapapillomavirus 24) are not present in ICTV [12] and are present
as unclassified Gammapapilomavirus in the TB [13] database.
HPV227 (Gammapapillomavirus 2), HPV225 (Gammapapillomavirus 7), HPV224
(Gammapapillomavirus 8), HPV231 (Gammapapillomavirus 10), and HPV223 (Gammapa-
papillomavirus 22) are not present in the IRHC [14] database in ICTV [12] and are present
as unclassified Gammapapapilomavirus in the PaVE [15] database, with the exception of
HPV231, which is not present in the database. In the TB [13] database, these viruses appear
as unclassified HPV isolates ICB2, MTS4, ICB1, CDCHPVTL_S18, and MTS3.

4. General Characteristics and Structure of HPV

Human papillomaviruses (HPVs) are small (55 nm in diameter) non-enveloped, ep-
itheliotropic viruses that carry double-stranded, circular DNA containing from 7100 bp
(HPV48; GenBank acc.no. NC_001690) to 8104 bp (HPV83, GenBank acc.no. AF151983).
HPV18 variants contain 7824 bp to 7857 bp (GenBank acc.no. KC470225, AY262282) and
HPV16 variants contain 7885 bp to 7909 bp (GenBank acc.no. HQ644257, HQ644298).
HPVs have an icosahedral capsid consisting of 72 capsomers. A single HPV virus
capsomer consists of five L1 proteins of 55 kDa. Variable copies but less than 72 molecules
(typically 20–40 molecules) of minor capsid protein L2 are incorporated within the viral
particle. The estimated molecular mass of HPV L2 is approximately 55 KDa. However, due
to some posttranslational modification, L2 typically exhibits an apparent molecular weight
of 64–78 kDa as determined by SDS-PAGE analysis [43,116,148–153].
The structure of the capsid and the lack of an envelope give HPVs low susceptibility
to external agents. HPV is transmitted through direct contact and through certain objects.
Mucosal HPV is mainly transmitted by sexual contact but there is also the possibility of
extra-sexual infection. Vertical transmission is possible (from mother to child in the womb
and more often perinatally). Studies in an animal model (mouse tail) have shown that
HPV can remain on the fomite surface and retain infectivity for up to 8 weeks, and up to
1 year in exfoliated epithelial cells. During transfer from fomite to another surface, the
Int. J. Mol. Sci. 2024, 25, 7616 8 of 33

viral titer drops by 10 times, which significantly reduces infectivity. It is worth noting
that disinfectants containing ethyl alcohol, isopropyl alcohol, or octenidine are ineffective.
HPVs are also resistant to desiccation, retaining 30% infectivity after 7 days of dehydration.
However, these viruses are susceptible to ortho-phthalaldehyde and hydrogen peroxide, as
well as to UVC [154–156].

HPV Genome
The HPV genome can be divided into three regions: E (early), L (late), and LCR (long
control region). The E region encodes early proteins (E1–E2, E4–E7 genes) responsible
for replication (E1 and E2 genes), transcription (E2 gene), viral release (E4 gene), and
creation of an environment favorable to virus replication including evasion of the host
immune system and maintenance of epithelial cell proliferation (E5, E6 and E7 genes). As
a result of transcription, additional proteins E6ˆE7, E1ˆE4, and E8ˆE2 (E8 is a fragment
of E1) are formed from intragenic promoters [157]. The E8ˆE2 protein can functionally
replace the E5 protein [106]. The L region encodes the L1 and L2 capsid proteins, while the
non-coding LCR (long control region) contains cis regulatory elements and is involved in
the regulation of viral replication and viral gene expression. Depending on the HPV type,
the viral genome contains 5–11 ORFs (open reading frames). The HPV108 genome encodes
only 5 proteins: E7 (99 aa), E1 (626 aa), E2 (390 aa), L2 (517 aa), and L1 (513 aa), while in the
HPV41 genome 11 proteins are encoded: E6 (156 aa), E7 (114 aa), E1 (614 aa), X (77 aa), E2
(387 aa), Y (72 aa), E4 (101 aa), E5 (78 aa), L2 (554 aa), L1 (583 aa), and Z (76 aa). Atypical
ORFs encoding X (100 aa) and Y (107 aa) proteins are also found in HPV81, those encoding
L3 protein (110 aa) in HPV5b, those encoding E10 protein (37 aa) in HPV101, and those
encoding two L1 proteins (504 aa and 532 aa) in HPV3. In the Alphapapillomavirus genus,
7–9 ORFs are most common (in HPV16 and HPV18, there are eight ORFs: E7, E6, E1, E2,
Int. J. Mol. Sci. 2024, 25, x FOR PEER REVIEW 8 of 35
E4, E5, L2, L1). The structure of the HPV genome, using HPV16 as an example, is shown in
Figure 1.

Figure 1.1.HPV
Figure HPVgenome
genomeE E(early)—orange,
(early)—orange, L (late)—green
L (late)—green gens,
gens, LCRLCR (long
(long control
control region)—blue,
region)—blue, P97,
P97, P670,
P670, PE8—promoters,
PE8—promoters, pAE—early
pAE—early polyadenylation
polyadenylation sites, pALs—late
sites, pALs—late polyadenylation
polyadenylation sites
sites [158].
[158].
It is worth noting that the genes encoding E1, E2, and L2 are the most conserved. L1 is
moreItvariable
is worththan
noting
L2. that the genes encoding
The remaining OTFs areE1, E2, and L2 by
characterized aremuch
the most conserved.
higher L1
variability.
is more
This variablein
variability than
theL2. The
case of remaining
E5–E7 may,OTFsamongare other
characterized by much higher
things, determine variabil-
the oncogenic
ity. This variability
potential in theand,
of the viruses caseinofthe
E5-E7
casemay, among
of E4, other
also the things,
affinity determine
for the oncogenic
specific regions or the
route of transmission
potential of the viruses[159]. Protein
and, in variants
the case of E4, occurring in different
also the affinity typesregions
for specific and lineages
or the
within
route ofa type can affect
transmission not only
[159]. Proteinpathogenicity including
variants occurring in oncogenicity
different types and affinity
and to
lineages
specific localizations but also immune response and the effectiveness of prophylactic
within a type can affect not only pathogenicity including oncogenicity and affinity to spe- and
therapeutic vaccines
cific localizations butand potential
also immune drugs. A summary
response and theofeffectiveness
the major HPV types’/subtypes’
of prophylactic and
genome
therapeutic sizevaccines
and the and
number of amino
potential acids
drugs. in the E1–E2,
A summary of theE4–E7,
major andHPVL1–L2 proteins is
types’/subtypes’
shown
genomeinsize Supplementary
and the number TableofS1.
amino acids in the E1–E2, E4–E7, and L1–L2 proteins is
shown in Supplementary Table S1.

5. HPV Replication Cycle

The gateway to infection is a wound or micro-damage to the epithelium, which al-
lows the virus to reach the basal layer. HPV can only infect dividing keratinocytes of the
basal layer, e.g., in the healing process of an injury. Initially, the major capsid protein L1
Int. J. Mol. Sci. 2024, 25, 7616 9 of 33

5. HPV Replication Cycle

The gateway to infection is a wound or micro-damage to the epithelium, which allows
the virus to reach the basal layer. HPV can only infect dividing keratinocytes of the basal
layer, e.g., in the healing process of an injury. Initially, the major capsid protein L1 binds
to laminin-332 in the basement membrane. Next, the L1 protein is cut off by kallikrein-8
(KLK8), leading to a change in its conformation. The next step is the fusion of L1 with
heparan sulfate proteoglycans (HSPGs) on the cell surface of the epithelial or epidermal
basal layer. Further conformational change of L1 and L2 associated with the interaction
between positively charged lysine residues in L1 and negatively charged HSPGs and then
with the action of cyclophilin B (CyPB) leads to the exposure of the N-terminus of the
L2 capsid protein. This allows the exposed L2 fragment to be cleaved by furin, leading
to a decrease in the affinity of the capsid protein for HSPGs. Subsequently, L2 binds to
the S100A10 subunit of the annexin A2 heterotetramer on the cell membrane, leading to
clathrin-independent endocytosis of HPV into the cell [160,161]. The results of some studies
suggest that HPVs may differ in the ways they enter cells. The penetration of HPV 18, 31,
and 45 but not HPV 16 is dependent on glycosaminoglycans (GAGs) and can be inhibited
by carrageenan, a polysaccharide derived from algae containing 15–40% ester-sulfate that
blocks the interaction between viruses and GAGs [162].
At further stages, viral DNA is released from the capsid with the participation of
cyclophilins, although the disassembly of the capsid is probably not complete. The L1–L2–
viral DNA complex binds to cytoplasmic trafficking factors and is transported through the
structures of the Golgi apparatus toward the cell nucleus, into which it enters using the
moment of nuclear membrane disintegration at the beginning of mitosis. Vesicles containing
viral DNA, L2, and probably L1 are then transported along microtubules, connect to mitotic
chromatin, and at the end of mitosis become part of newly formed promyelocytic leukemia
nuclear bodies (PML NBs) which protect the viral DNA from destruction by host restriction
enzymes. The initiation of viral gene transcription is likely to be influenced by interactions
with some PML NB-forming proteins, including Sp100. The first to be expressed are the
HPV E1 and E2 genes which, among other things, leads to the activation of viral DNA
replication [162].
The E1 protein has helicase activity and forms a complex with E2, resulting in increased
specificity to the target DNA sequence. In infected cells of the basal layer, only a small num-
ber (about 50–100) of copies of the HPV genome are produced (initial amplification), then
these copies are duplicated during cell division (maintenance amplification). One infected
cell remains in the basal layer, while other cells continue to enter the suprabasal layer. A
large number (thousands per cell) of virus copies are produced, only as the epithelial cells
differentiate, in the upper layers of the epithelium (vegetative amplification) [161,163,164].
E2 is in the first place involved in the regulation of viral gene expression, including
E5, E6, and E7. Expression in and above the basal layer of E5, E6, and E7 creates the
right conditions for HPV replication by, among other things, stimulating cell proliferation,
inhibiting cell apoptosis, and evading the host immune response. Unfortunately, similar
conditions can also promote the development of precancerous conditions and cancer. A
more detailed description of these proteins can be found in the section on carcinogenesis.
The L1 and L2 genes are expressed in terminally differentiated cells in the upper
layers of the epithelium, which are associated with encapsidation. Late proteins for HPV16
are synthesized from the p670 promoter and for HPV18 from the p811 promoter [43].
The expression of late HPV genes is regulated by a variety of mechanisms including
polyadenylation, alternative splicing, and may also be regulated at the translational level.
The subsequent release of viral particles is mediated by the E4 protein, which disrupts the
cellular network of cytokeratin filaments. E4 also causes cell cycle arrest and is involved in
the assembly of virions [165–167]. The life cycle of HPV is shown in Figure 2.
 ers of the epithelium, which are associated with encapsidation. Late proteins for HPV
are synthesized from the p670 promoter and for HPV18 from the p811 promoter [43]. T
expression of late HPV genes is regulated by a variety of mechanisms including poly
enylation, alternative splicing, and may also be regulated at the translational level. T
subsequent release of viral particles is mediated by the E4 protein, which disrupts
Int. J. Mol. Sci. 2024, 25, 7616 10 of 33
cellular network of cytokeratin filaments. E4 also causes cell cycle arrest and is involv
in the assembly of virions [165–167]. The life cycle of HPV is shown in Figure 2.

Figure 2. The life Figure

cycle of HPV.
2. The lifeWhite arrows—expression
cycle of of early E1, of
HPV. White arrows—expression 2, early
4, 6, E1,
7, and
2, 4, late L1, 2late L1, 2 H
6, 7, and
HPV genes. genes.

6. Mechanisms of Precancerous and Neoplastic Lesions in HPV Infection

Early viral proteins such as E5, E6, and E7 play the most important role in the patho-
genesis of neoplastic lesions arising from HPV infections.
The E5 protein is responsible for the control of cell growth, differentiation, and immune
modulation. It is expressed in the early phase of replication. Small, hydrophobic, single E5
proteins are formed, which diffuse across the membrane, bind to platelet-derived growth
factor receptors (PDGFR) and epidermal growth factor receptors (EGFR), enhancing their
signaling, leading to the inhibition of apoptosis and stimulation of proliferation. The E5
protein is present in all high-risk mucosal HPV types; it promotes tumor progression as an
early oncoprotein, but it does not occur in Betapapillomaviruses, including those classified
as possibly carcinogenic (HPV5 and 8)—EV-associated HPVs [168,169].
The E6 protein (150–160 amino acids, about 18 kDal) is a major oncoprotein. It inhibits
apoptosis and differentiation. It affects cell shape, polarity, mobility, and signaling [170].
The E6 protein binds to the cellular anti-oncogene p53, leading to its inactivation. In the
case of oncogenic HPV, like HPV16, E6 binds to the ubiquitin ligase E6AP at a site of the
latter’s short amino acid sequence LxxLL. The E6–E6AP complex then binds to p53, leading
to the degradation of p53 by the ubiquitin-related system. E6 binds to p53 at a specific site,
different from DNA or cellular protein attachment sites, which means that E6 can bind
to both free and bound p53 [171,172]. One study found that the ability to degrade p53
through the ubiquitin-binding system was also possessed by HPV71, which is classified as
non-oncogenic. This indicates that this feature alone does not determine the oncogenicity
of the virus and that several mechanisms need to act simultaneously [173].
E7 binds to the retinoblastoma tumor suppressor protein pRb and to smaller proteins
such as p107 and p130, inhibiting their action and, in the case of oncogenic HPV, leading
to accelerated degradation. This results in the activation of the pRb-blocked transcription
factor E2F, which in turn causes the infected cell to enter S phase (DNA replication). E7,
only in the case of oncogenic HPVs, furthermore binds to the non-receptor protein tyrosine
phosphatase PTPN14, leading to its degradation, which in a pRb-independent mechanism
inhibits keratinocyte differentiation and promotes their immortalization [174,175].
Int. J. Mol. Sci. 2024, 25, 7616 11 of 33

E6 and E7 may also interact with other metabolic pathways involved in cell differentia-
tion and proliferation. An important role in cell immortalization is played by the activation
of telomerase by E6 and, to a lesser extent, E7 proteins produced by oncogenic HPV. The
viral proteins act by increasing the expression of the catalytic subunit of telomerase, so-
called human telomerase reverse transcriptase (hTERT) [165,176]. Oncogenic HPVs’ E6,
unlike non-oncogenic ones, have a PDZ-binding motif (PBM) on their carboxy terminus.
PDZs are a group of 80–90 amino acid domains named after the first three proteins dis-
covered to possess them: Post Synaptic Density 95 (PSD95), the Discs Large (Dlg), and the
Zona Occludens 1 (ZO-1). This group contains, among other things, proteins like DLG1,
SCRIB, and MAGI1/2/3 that influence cell polarity—the asymmetric spatial organization
of cell structures found, for example, in epithelial cells. Other proteins containing this
domain can also influence cell shape (including by affecting tight junctions) and numer-
ous signal transduction pathways including TGF (transforming growth factor)-β and PI3K
(phosphatidylinositol-3-kinase)/AKT signaling. The association of E6 with PDZ may play
roles in sustaining epithelial cell proliferation and the HPV replication cycle and also in
tumor transformation. In addition, E6 has the ability to stimulate the Wnt/β-catenin and
Notch metabolic pathways. Among other things, E6 and E7 proteins may also activate the in-
tracellular signal transduction pathways PI3K/AKT/mTOR and JAK/STAT. The metabolic
pathways listed above play a role in the pathogenesis of many cancers [170,177,178].
In most cases of HPV infection, the DNA remains in an episomal form, unintegrated
into the host DNA, allowing the virus to replicate efficiently. It has been postulated that
the integration of viral DNA into cellular DNA may be an indirect consequence of the
entrapment of HPV episomes within cellular chromosomal structures. The integration
appears in the course of persistent HPV infection, and causes the inhibition of the HPV
replication cycle. Persistent infection affects no more than 10% of individuals infected with
oncogenic HPV. The integration of the HPV genome into the cellular genome has been
demonstrated to play a crucial role in the development of cancer. Studies have shown that
the site of integration, as well as the size and region of the viral DNA, can vary among
individuals. Changes in the number of copies of the genetic material and rearrangements
within and between chromosomes are also possible. Loss of ORF for E2, a protein acting as
a repressor for E6 and E7, has been described. As a result, the oncoproteins E6 and E7 are
overexpressed [178,179].
It is worth noting, however, that integrated HPV 16 DNA was detected in about 74%
and not in all cases of cervical cancer caused by HPV 16, and in head and neck cancers the
percentage was even lower, suggesting that integration of viral DNA is not a prerequisite for
carcinogenesis associated with HPV infection. Recently, a role for an alternative pathway of
carcinogenesis has been suggested, in which HPV16 remains in an episomal form and there
is increased expression of E2/E4/E5. The activation of EGFR by E5 can lead to activation of
the receptor tyrosine kinase c-met, with potential oncogenic effects. E5 also inhibits EGFR
degradation, increasing the presence of this receptor on the cell surface. In oropharyngeal
cancer, the activation of fibroblast growth factor receptor (FGFR) and possibly also mTOR
kinase has also been demonstrated. A better understanding of the above mechanisms may
allow more effective treatment of HPV infections and the cancers they cause [180].

7. Immune Response and Immune Evasion by the Virus in HPV Infections

HPV infections are usually limited to the epidermis or mucosal epithelium; viral
particles do not enter the blood and the replication cycle does not involve cytolysis, which
reduces contact with the host immune system and therefore the immune response to
infection. On the other hand, the epidermis and mucosal epithelium form an effective
mechanical barrier and only when they are damaged can HPV infection occur [181].
It has been shown that the production of specific antibodies is of primary importance
in the prevention of HPV infection, whereas cell-mediated immunity plays a greater role
in the eradication of an existing infection or the resolution of lesions. In the course of
a natural infection, antibodies are produced in 50–80% of women and 2–51% of men,
Int. J. Mol. Sci. 2024, 25, 7616 12 of 33

usually after 6–12 months of infection. The concentration of antibodies is usually low, and
they do not play a major role in the immune response against HPV infection. In contrast,
prophylactic HPV vaccines induce a much higher concentration of antibodies and thus
effectively prevent infection [182].
Persistent and recurrent HPV infection is favored in those with congenital or acquired
cellular immunodeficiency, e.g., in HIV-infected patients and those taking immunosuppres-
sive drugs such as transplant recipients. Such individuals are more likely to be infected
with both the mucosal and cutaneous types of HPV and, in the case of oncogenic HPV
infections, precancerous and neoplastic lesions are more likely to develop [183].
Innate and adaptive immunity are important in HPV clearance. HPV genetic material
is recognized by toll-like receptors TLR 2, 3, 7, 8 and 9, resulting in increased production
of interferons α and β. HPV DNA also acts on other pattern recognition receptors (PRRs)
such as absent in melanoma 2 (AIM2), which leads to increased production of caspase
and interleukin 1, and on interferon-γ (IFN-γ)-inducible protein 16 (IFI16), which restricts
replication and transcription of HPV genes [181]. Also important in the early response to
HPV infection are natural killer (NK) and natural killer T (NKT) cells. However, the most
important role in the resolution of existing lesions appears to be played by cellular adaptive
immunity. Specific CD 8+ and CD4+ T-cell infiltrate is found in spontaneously resolving
HPV lesions. The specific response is directed against various HPV antigens, but especially
against the E6, E7, and E2 proteins. Approximately 90% of all HPV infections are eliminated
by the immune system and this process has been studied quite extensively. For E6 and E7
of HPV 16 and 18, the peptide sequences of the individual epitopes are known to stimulate
an effective cytotoxic T-lymphocyte response against HPV infection. These sequences can
be used in the development of therapeutic vaccines. It is also known in the context of
which HLA the viral antigens are presented [184]. The mode of antigen presentation in the
context of the HLA may determine the nature and effectiveness of the immune response
against HPV. In the case of HPV16, the E5 protein has been shown to reduce HLA class I
expression specifically on the surface of infected cells, hindering their recognition by CD8+
T cells, which is one mechanism of immune evasion. E5 acts selectively by reducing the
expression of HLA-A and B but not HLA-E. Antigen presentation in the context of HLA-E
can lead to suppression of the immune response including NK cell function [185]. On the
other hand, certain MHC alleles including HLA-DRB1*1501 and, HLA-DQB1*0602 have
been shown to be associated with a higher susceptibility to persistent HPV infection and a
higher incidence of cervical cancer. In addition, it appears that the presence or absence of an
effective immune response may be influenced by the presence of different protein variants in
the HPV type, either due to different genetic subtypes or due to differences in transcription
and translation levels. Treg lymphocytes may play an important role in suppressing the
immune response against HPV. Persistent genital HPV infection, including HPV 16, as
well as cervical cancer and enlarging and recurrent genital warts after treatment correlate
with an increased number of Treg lymphocytes, suggesting the involvement of these cells
in the maintenance of HPV infection. It has been shown that the E7 protein of HPV16
can induce these cells. On the other hand, the presence of Treg is a favorable prognostic
factor in patients with HPV-associated oral cancer, which may mean that the role of this
lymphocyte subpopulation is not unequivocal and may differ between HPV-associated
diseases [186–188]. HPV can also affect the immune system by modifying the expression of
certain host genes. The E7 protein of oncogenic HPVs increases the activity of the host DNA
methyltransferase DNMT1. In this way, HPVs affect the host immune system by increasing
DNA methylation, leading to decreased expression of certain genes, e.g., of the chemokine
CXCL14. Another mechanism by which oncoprotein E7 acts on the expression of host genes
important for the immune response is through histone modification. Thus, among other
things, the production of TLR9 is inhibited. Furthermore, E6 and E7, by inhibiting K310
acetylation of p65, can inhibit signal transduction by the transcription factor NF-κB which
can, among other things, inhibit the production of pro-inflammatory cytokines such as IL-1,
IL2, IL-6, IL8 IL-12, and TNF-α [189].
Int. J. Mol. Sci. 2024, 25, 7616 13 of 33

Interestingly, despite the greater number of immune evasion mechanisms described,

high-risk HPV viruses are more likely to be eliminated and less likely to cause lesions
than low-risk viruses. A study of more than 600 female students found that 20% of those
infected with HPV 16 or 18 developed CIN 2 and 6.7% developed CIN 3 within three years,
while 64.2% of those infected with HPV6 or 11 developed genital warts [190].
The effectiveness of the immune response may also be influenced by the microenviron-
ment and coexisting infections. Persistent HPV infection and intraepithelial neoplasia are
more common in women with vaginal dysbiosis, Gardnerella vaginalis infection, and also
with sexually transmitted diseases, especially C. trachomatis infection. Topical or oral probi-
otics are likely to play a protective role and even increase the likelihood of spontaneous
resolution of CIN-type lesions [191–193].

8. HPV’s Association with Various Diseases

It has been confirmed that Beta, Gamma, Mu, and Nu HPV cause epidermal infections
and Alpha HPV causes epidermal and mucosal epithelial infections. Beta and Gamma often
cause asymptomatic infections, especially in immunocompetent individuals. Different
Alpha types are associated with different diseases. The key questions in the pathogenesis
of HPV infections are what determines the tropism of viruses to specific areas and, in
particular, what determines that a particular virus is oncogenic. Undoubtedly, the genetic
variability of the viral proteins has an influence, especially E4 in the case of site affinity
and E5–E7 in the case of oncogenicity [159]. Moreover, it has been shown that different
genetic variants of HPV 16 and 18 may differ in pathogenicity due to, among other things,
differences in the action of the E6 protein [43]. However, the association of individual HPV
types to specific locations or specific diseases is not an absolute rule as, for example, the
HPV 2 that usually causes common warts as well as the carcinogenic HPV16 can be found
in genital warts. Many different types of HPV have also been found in focal epidermal
hyperplasia lesions. HPV 16 and 18, but not HPV 6 and 11, were found more frequently in
cancers and colorectal polyps than in the healthy intestinal epithelium, which may suggest
a possible involvement of oncogenic HPVs in the pathogenesis of these diseases [194].
The association of different types of HPV with selected skin or mucosal lesions is
shown in Table 2.

Table 2. The association of different types of HPV with selected skin or mucosal lesions.

Type of Skin/Mucosal Lesions HPV Types References

usually HPV2, 27, 57, 63, furthermore HPV 1, 4, 10, 41, 65, 88, 95,
plantar warts [195,196]
60, 65, 66
common warts HPV 27, 57,2,1,4 [159,196]
flat warts HPV3, 10, 26, 27, 28, 29, 77, 78, 94, 114, 41 [196]
usually (90%) HPV 6 and 11, less commonly HPV 2, 16, 18,
genital warts (Condyloma acuminatum) [159,197]
30–33, 35, 39, 41–45, 51–56, and 59
HPV 16 (mostly), HPV18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59
cervical intraepithelial neoplasia, and cancer (carcinogenic), 68 (probably carcinogenic), 26, 53, 66, 67, 69, 70, [16]
73, and 82 (possibly carcinogenic)
mainly HPV13 and 32, but infection or co-infection with other
focal epithelial hyperplasia HPVs including HPV6, 11, 16, 18, 31, 39, 40, 51, 52, 55, 58, 66, 68, [198]
69, 71, 74, and 90 has also been reported
warts and probably NMSC in EV and HPV5, 8 (possibly carcinogenic)
immunocompromised patients; HPV9, 12, 14, 15, 17, 19–25, 36–38, 47, 49, 75, 76, 80, 92, 93, 96,
[199]
in the general population usually asymptomatic 98–100, 104, 105, 107, 110, 111, 113, 115, 118, 120, 122, 124, 143,
but also may be associated with NMSC 145

Although Beta and Gamma HPVs usually cause asymptomatic infections and are
sometimes considered part of the healthy skin microbiome, in the case of certain genetic
Int. J. Mol. Sci. 2024, 25, 7616 14 of 33

conditions (such as mutations in the EVER genes) and in immunosuppressed individuals,

they can cause skin lesions and, in the case of beta HPVs, also contribute to the devel-
opment of non-melanoma skin cancers (NMSCs). There is an increasingly well-founded
hypothesis that the above-mentioned groups, but also to some extent in healthy individ-
uals, Beta HPV infection is a factor in the formation of NMSCs under the effect of sun
exposure. Exposure to ultraviolet radiation causes immunosuppression, which favors
HPV persistence. Interestingly, Beta HPV DNA was found more frequently in the UV-
exposed epidermis. On the other hand, HPV infection has a negative effect on the repair
mechanisms and regulation of cell proliferation in the UV-exposed epidermis. HPV Beta
DNA is detected in 30–50% of NMSCs in immunocompetent individuals and up to 90% of
NMSCs in immunosuppressed individuals. HPV 5 and 8 are detected in nearly 90% of skin
cancers in EV patients [10,183,199,200]. It is additionally worth noting that, according to
the hit-and-run theory, the absence of the virus in tumor lesions does not completely rule
out its involvement in pathogenesis. On the other hand, it is possible to speak of a so-called
innocent bystander, a situation in which the pathogen is more frequently detected in tumor
lesions than in healthy tissue, but is not the cause of the lesions [179].

9. Prophylactic Vaccines
All available HPV prophylactic vaccines contain recombinant L1 proteins of HPV,
spontaneously forming virus-like particles (VLPs). The first vaccine, Gardasil, containing
the L1 proteins of HPV 6, 11, 16, and 18 was approved by the FDA in 2006. Another
vaccine is Cervarix, containing HPV 16 and 18. Cervarix has been shown to induce higher
antibody titers than Gardasil, which does not seem to affect the effectiveness of vaccines
against the viruses whose antigens they contain. However, this may affect the likelihood
of cross-protection against certain types of oncogenes not covered by vaccines. As shown,
cross-protection against HPV 31 was 77.1%, and 42.6% and against HPV 45 was 79% and 7.8%
for bivalent and quadrivalent vaccines, respectively [201]. In 2014, Gardasil-9 against HPV
6, 11, 16,18, 31, 33, 45, 52, and 58 was introduced. Until 2015, the majority of HPV vaccines
administered in the United States were 4vHPV vaccines. As of 2016, the 4vHPV vaccine is no
longer available in the US and has been completely replaced by the 9vHPV vaccine [202].
According to the clinical studies, the efficacy of Gardasil, Gardasil-9, and Cervarix
in preventing cervical, vulvar, and penile intraepithelial neoplasia (CIN, VIN, and PIN)
caused by the viruses covered by the vaccine is more than 90% (approaches 100% in some
studies and groups). In the case of Gardasil/Gardasil-9, the effectivity is 89–98% for genital
warts. A study in sexually active adolescent girls and women, from different ethnic groups,
aged 14–24 in the United States showed that the prevalence of HPV types covered by the
4-valent vaccine decreased by more than 80% between 2015 and 2018, compared to the
years before the introduction of the vaccine 2003–2006. This indicates that the vaccine is
highly effective in preventing HPV infections and, presumably, also cancers caused by
these viruses. There was also a decrease in the incidence of new cases of CIN 2 and cervical
cancer, which was greatest (by 29% in 2011–2015 compared to 2003–2006) in the youngest
age group (15–24 years). A study in Australia, where approximately 73% of adolescent girls
had been vaccinated by 2010, showed a decrease in condyloma incidence in the population
aged 15 to 30. The largest decrease was in women under 21 years of age (from 11.5% in
2007 to 0.9% in 2011) [203,204].
The development of cheaper methods of producing vaccines has allowed their in-
creased use. In recent years, three more vaccines have been registered, two in China (HPV
16 and 18) and one in India (HPV 6, 11, 16, and 18). Phase III clinical trials have been
completed in China for a further two vaccines (HPV 6, 11, 16, and 18, and HPV 6, 11, 16,
18, 31, 33, 45, 52, and 58). The non-inferior HPV type-specific immune response to that of
Gardasil and acceptable safety profiles of the above vaccines have been shown. All of the
above vaccines have a much greater capacity to induce an immune response, including the
production of blocking antibodies and cellular immunity, than natural infections [205,206].
The current prophylactic vaccines registered in various countries are shown in Table 3.
Int. J. Mol. Sci. 2024, 25, 7616 15 of 33

Table 3. Currently available prophylactic HPV vaccines.

Method of Producing HPV Registration

Vaccine (Manufacturer) HPV Types Included Adjuvant Vaccine Schedule
Proteins Year
I.M.
9–14 years:
Gardasil® 6 (20 µg), 11 (40 µg), 16 (40 µg), Amorphous aluminium Saccharomyces cerevisiae (yeast)
2006 0, 6 months
(Merck & Co., Rahway, NJ, USA) 18 (20 µg) quadrivalent hydroxyphosphate sulphate (225 µg Al) expressing L1
from the age of 15
0, 2, 6 months
I.M.
AS04: Utilizing a baculovirus expression
Cervarix® 9–14 years:
16 (20 µg), 18 (20 µg), 3-O-deacylo-4′ -monofosforylolipid A system, with the use of insect Hi-5
(GlaxoSmithKline, Tsim Sha Tsui, 2007 0, 6 months
bivalent (MPL) 50 µg, adsorbed on aluminium Rix4446 cells derived from
Hong Kong) from the age of 15
hydroxide (0.5 mg Al3+ ) Trichoplusia ni.
0, 1, 6 months
I.M.
6 (30 µg), 11 (40 µg), 16 (60 µg),
9–14 years:
Gardasil9® 18 (40 µg), 31 (20 µg), 33 (20 µg), Amorphous aluminium hydroxy Saccharomyces cerevisiae (yeast)
2014 0, 6 months
(Merck & Co.) 45 (20 µg), 52 (20 µg), 58 (20 µg) phosphate sulphate (0.5 mg Al) expressing L1
from the age of 15
nonavalent
0, 2, 6 months
I.M.
9–14 years:
Cecolin® (Xiamen Innovax 16 (40 µg), 18 (20 µg) Escherichia coli (bacteria) expressing 0, 6 or
Aluminium hydroxide (208 µg Al) 2020
Biotechnology, Xiamen, China) bivalent L1 0, 1, 6 months
from the age of 15
0, 1, 6 months
Walvax recombinant HPV I.M.
vaccine (Hanghai Zerun 9–14 years:
16 (20 µg), 18 (40 µg) Pichia pastoris expressing L1
Biotechnology, Shanghai, China; Aluminium phosphate (225 µg Al) 2022 0, 6 or 0, 2, 6 months
bivalent (yeast)
Subsidiary of Walvax from the age of 15
Biotechnology, Shanghai, China) 0, 2, 6 months
I. M.
9–14 years:
Cervavac® (Serum Institute of 6 (≥20 µg), 11 (≥40 µg), 16 (≥40 Hansenula polymorpha expressing L1
Aluminium (Al3+ ) ≥ 1.25 mg 2022 0, 6 months
India, Pune, India) µg), 18 (≥20 µg) quadrivalent (yeast)
from the age of 15
0, 2, 6 months
Int. J. Mol. Sci. 2024, 25, 7616 16 of 33

Another direction of investigation involves the development of prophylactic vaccines

based on the use of the L2 protein. L2 could provide broad-spectrum protection against
different HPV types due to its high preservative content. However, L2 has lower immuno-
genicity than L1 and has no ability to form virus-like particles on its own. VLPs L1 HPV16,
VLP bacteriophage MS2 VLP-16L2 (aa17-31), and adeno-associated virus AAVLP-HPV,
among others, are used as L2 carriers to improve its properties. Another possibility is to
conjugate L2 with immunostimulating agents, e.g., Pyrococcus furiosus thioredoxin. There
are several L2-based vaccines at the in vitro and animal trial stage that are likely to enter
the clinical trial phase in the near future. At the clinical trial stage are some peptide vac-
cines containing L2 or prophylactic-therapeutic vaccines containing L2 conjugated to E6-E7
oncogenic HPVs [207,208].

10. Therapeutic Vaccines

The question arises whether currently approved prophylactic vaccines can be used as
therapeutic vaccines. A study performed in a group of women after cervical conization for
HSIL-type lesions showed that 4.3% of those who received bivalent or quadrivalent vaccine
and 9.8% of unvaccinated women had recurrent lesions. The difference was statistically
significant. A further study showed 58.7% efficacy of quadrivalent HPV vaccine in women
with CIN 1-3. In another study, women with CIN 1-3 were vaccinated with a bivalent
vaccine showed a vaccine efficacy 60 days after treatment of 88.2% for CIN 2-3 and 42.6%
for CIN 1. There are also studies that have found a reduced risk of recurrence of anal
intraepithelial neoplasia (AIN) in MSM and recurrence of vulvar lesions. None of the
studies reported serious adverse reactions to the vaccines. All these results encourage
the use of the vaccines in patients after the removal of lesions caused by HPV. On the
other hand, a meta-analysis showed only a probable reduction in recurrence after surgical
removal for CIN, especially CIN 2-3 caused by HPV 16 and 18, and insufficient evidence
of such a relationship for other HPV-caused lesions. This may be due to too small study
groups in the latter case and requires further research. Even more so, there is no evidence
of HPV elimination or cessation of HPV-induced lesions by prophylactic vaccines. The
mechanism of action of vaccines in women with previously removed HPV lesions is not
fully understood, and in particular it is uncertain whether it consists only in protection
against reinfection or also in the elimination of existing infection. There is no doubt that,
as in the case of uninfected people, anti-L1 antibodies are produced to block the entry of
HPV into cells. However, this highly effective mechanism does not work on viruses already
inside cells. Vaccine-induced cell-mediated immunity may also play a role [209–212].
Therapeutic vaccines most often contain E6 and/or E7, and possibly E5 or E2 in the
form of proteins or DNA or RNA encoding them. The problem is the low immunogenicity
of these proteins and their ability to inhibit the host immune response. HPV genes/proteins
contained in therapeutic vaccines are usually modified to increase immunogenicity and
to eliminate oncogenic and immunosuppressive properties. The therapeutic vaccines can
be divided into: (1) those containing a small DNA molecule (plasmid), (2) vector vaccines
using other microorganisms (viruses and bacteria) to deliver HPV DNA, (3) RNA vaccines,
(4) peptide vaccines, and (5) vaccines using autologous cells of the host immune system
that present HPV antigens. A number of therapeutic HPV vaccines are currently in clinical
trials. The trials mostly involve patients with HPV-dependent premalignant lesions and
cancers, but there are also attempts to use some of them for persistent, recurrent benign
lesions [213,214].
Table 4 shows selected therapeutic vaccines undergoing clinical trials used as a
monotherapy or in combination with other vaccines in HPV-infected patients with precan-
cerous or benign lesions.
Int. J. Mol. Sci. 2024, 25, 7616 17 of 33

Table 4. Selected therapeutic vaccines undergoing clinical trials.

Vaccine Name Number of

Antigen/Other Vaccine Type of
(Manufacturer If Administrations, Research Stage Results References
Components Vaccine
Available) Method of Delivery,
CIN 2/3 lesions caused by HR HPV ceased in
DNA -modified HPV 16 E6
24% of the 129 women who received the vaccine
TG4001 Tipapkinogen and DNA, 3 subcutaneous
phase II and in 10% of the 64 women receiving placebo. [215]
Sovacivec E7 and human IL-2 in virus-vectored injections
The result was statistically significant. The
vaccinia virus Ankara (MVA)
vaccine was well tolerated.
In 1051 of 1176 women with CIN (89%) and in all
180 PIN men who received the vaccine, the
phase III [216]
lesions resolved completely. 81% of the women
Cross-reactive E2 (bovine tested had eliminated oncogenic HPV.
DNA,
MVA E2 papilloma virus) in vaccinia 6 site-specific injections
virus-vectored In 13 (43%) of the 29 patients studied, respiratory
virus Ankara (MVA)
papillomatosis resolved completely; in the others,
phase II the lesions recurred between 8–12 months after [217]
vaccination, but resolved without further
recurrence after re-administration.
Regression of CIN 2/3 lesions confirmed by
phase II histopathological examination in 53 (49.5%) of
[218]
NCT01304524 107 patients receiving the vaccine versus
Modified E6 and E7 HPV-16 11(30.6%) of 35 patients receiving placebo.
VGX-3100 DNA 3 IM injections with
and -18 in two synthetic
(Inovio Pharmaceuticals) plasmid electroporation In total, in the REVEAL 1 and 2 studies, cessation
plasmids/pVAX
phase III of CIN lesions and elimination of the virus was
[213]
NCT03721978 found in 68 of 272 (25.0%) women receiving the
vaccine and in 13 of 132 (9.8%) receiving placebo.
64 patients with CIN, histopathologically
confirmed resolution of lesions in 52% (33/64) of
patients after 20 weeks from the first
GX-188E Tirvalimogene Modified E6 and E7 HPV-16 DNA 3 IM injections with
Phase II administration of the vaccine and in 67% (35/52) [219]
teraplasmid and -18 in Plasmid/pGX27 plasmid electroporation
after 36 weeks. HPV was eliminated in 73% and
77% of patients who had resolved lesions after 20
and 36 weeks, respectively.
Int. J. Mol. Sci. 2024, 25, 7616 18 of 33

Table 4. Cont.

Vaccine Name Number of

Antigen/Other Vaccine Type of
(Manufacturer If Administrations, Research Stage Results References
Components Vaccine
Available) Method of Delivery,
HPV eradicated and lesions resolved after 6
pNGVL4a- months in 5 (45%) and after 12 months in 7 (64%)
Sig/E7(detox)/HSP70 2 doses of pBI-11 + 1 of 11 HPV16+ vaccinated women with ASC-US,
pBI-11 DNA plasmid Phase II [220]
plasmid encoding HPV16 dose of TA-CIN, I.M. ASC-H, or LSIL/CIN. Patients additionally
L2E7E6 fusion protein vaccinated with the protein vaccine TA-CIN
(recombinant HPV-16 L2 E6 E7).
No statistically significant differences in
4 rounds of oral resolution of CIN 2/3 lesions between the 20
Heat-attenuated recombinant
live-bacteria- vaccination, daily for 5 patients receiving the vaccine and the 20 patients
GLBL101c Lactobacillus casei expressing Phase II [221]
vectored days at weeks 1, 2, 4, and receiving placebo. However, complete resolution
modified HPV16 E7
8 of lesions in 2 patients in the vaccine group and
none in the placebo group.
CIN 2/3 lesions resolved in 13 (31.7%) of 41
patients receiving the high dose of vaccine and in
Lacticaseibacillus paracasei 4 rounds of oral 5 (12.5%) of 40 patients receiving placebo. For
live-bacteria-
IGMKK16E7 expressing on cell surface, vaccination daily at Phase II patients infected only with HPV16, the incidence [222]
vectored
full-length HPV-16 E7 weeks 1, 2, 4, and 8. of resolution of lesions was 40.0% (12 of 30) in
those receiving the vaccine and 11.5% (3 of 26) in
those receiving placebo.
4 rounds of oral
Lactobacillus casei Phase I—19 patients with HPV16 and CIN 3
live-bacteria- vaccination- daily for 5
BLS-M07 expressing on cell surface, Phase I/IIa infection—safe, immunogenic; phase IIa—lesions [223]
vectored days at weeks 1, 2, 4, and
full-length HPV-16 E7 resolved in 6 of 8 patients studied.
8.
HPV-16 E6 synthetic peptides 25 patients with HPV-16 positive (pre-)malignant
HPV-16 E6 synthetic conjugated to Amplivant 3 administrations, lesions. Safe, immunogenicity increases with
peptide Phase I [224]
peptides (optimized Toll-like receptor intradermally increasing dosage, but mild side effects (flu-like
2 ligand) symptoms) are more frequent.
After 3 months response in 12 of 20 patients and
Overlapping long peptides 9 3 or 4 administrations complete regression of lesions in 5 of 20 patients.
ISA 101 from the E6 HPV 16 protein peptide subcutaneously at Phase II After 12 months, response in 15 of 19 patients [225]
and 4 from E7 in incoplete 3-week intervals with VIN 2/3 receiving the vaccine, complete
regression of lesions in 9 of 15.
Int. J. Mol. Sci. 2024, 25, 7616 19 of 33

These are mainly DNA vaccines in the form of plasmids or in viral and bacterial
vectors, although there was also a first-phase study on peptides. Methods of vaccine
administration and number of doses varied, which could also affect efficacy. Phase III
clinical trials for the use of vaccine VGX-3100 containing two plasmids encoding optimized
E6 and E7 of HPV16 and 18 in patients with CIN 1/3 showed resolution of cervical lesions
in 23.7%. Another DNA vaccine is GX-188E containing plasmid encoding modified E6/E7
and Fms-like tyrosine kinase-3 ligand (Flt3L). II phase clinical trials. pBI-11, pNGVL4a-
CRT/E7(detox) [184,226]. MVA E2 is a vector vaccine containing E2 bovine papillomavirus
(BHV) in vaccinia virus. Due to the high similarity of this protein between different
papillomaviruses, cross-reactivity is expected. Phase III studies have shown resolution of
cervical intraepithelial neoplasia-type lesions in 89% of vaccinated women and elimination
of the virus in 81%, a very promising result [184].
There are also numerous studies on patients with HPV-induced cancers. Here, thera-
peutic vaccines (including many of those listed in Table 4 are usually used in combination
with chemotherapy or other cancer drugs such as immune checkpoint inhibitors (ICIs). Re-
search concerns cervical cancer as well as HPV-caused head and neck cancers of the vulva,
penis and anus. The studies which will not be discussed in detail here. Of the vaccines not
mentioned earlier, studies include the use of MEDI0457/INO-3112, a vaccine containing
3 plasmids encoding the genes for E6 and E7 of HPV 16 and 18 and as an adjuvant the gene
for IL-12 for the treatment of head and neck cancers and recurrent/metastatic cervical, anal,
and penile cancers [227,228]. Another studies involved the ADXS11-001 LM-LLO vaccine
containing attenuated Listeria monocytogenes-designed to secrete an antigen-adjuvant fusion
protein consisting of a truncated fragment of Listeria monocytogenes listeriolysin O—LLO
fused to HPV16 E7. An I/II phase clinical trial in patients with HPV-associated cancers
showed encouraging results. A Phase III trial in patients with cervical cancer is currently
underway. The likely mechanism of action is that the bacterium infects antigen-presenting
cells, produces the HPV-LLO protein inside them, which is then presented to cytotoxic T
cells [229].
Vaccines based on autologous immune cells modified to present HPV antigens seem
to be a very interesting solution. However, their wider introduction is currently practically
impossible due to the need to produce the vaccine individually for each patient, which
significantly increases the price and makes it difficult to control vaccine quality. In 2008, the
safety and immunogenicity of a vaccine containing autologous dendritic cells presenting
E7 HPV 16 and 18 was demonstrated in phase IB/IIA [207].
At the moment, RNA vaccines for the treatment of HPV infection are still in the
preclinical testing stage. Recently, the results of preclinical study of 3 capable or incapable
self-replicating therapeutic vaccines containing lipid nanoparticle (LNP)-encapsulated
mRNA for a chimeric protein resulting from the fusion of E7 HPV and HSV1 glycoprotein
D were published. Demonstrated immunogenicity and efficacy on an animal model [230].

11. Drugs Currently Used in the Treatment of HPV Infection

Numerous surgical methods are used to treat HPV infections, including liquid nitrogen
cryotherapy, electrocoagulation, laser therapy, curettage, surgical excision, trichloroacetic
acid and photodynamic therapy-which which are beyond the scope of this article. The
non-surgical treatment of HPV-induced lesions include topical application of substances
with cytotoxic effects or stimulating the host immune system to eliminate the virus.
Preparations containing salicylic acid or a combination of salicylic acid and5-fluor-
ouracil are also often used in the treatment of cutaneous warts. Topical or intralesional
5-fluorouracil alone can be used in various HPV caused lesions. The latter drug inhibits
thymidylate synthase which leads to inhibition of DNA replication. An additional mecha-
nism is incorporation into DNA and RNA, which leads to inhibition of their synthesis. All
these mechanisms ultimately lead to the death of rapidly dividing cells, e.g., tumor cells
or HPV-infected cells. Topical 5 fluorouracil is available as a 5% carcinomas cream or in
combination with 10% salicylic acid as a 0.5% solution [231,232].
Int. J. Mol. Sci. 2024, 25, 7616 20 of 33

Topical cantharidin and also the combination of 30% salicylic acid, 1% cantharidin and
5% podofixiloxin are sometimes used in the treatment of dermal warts, especially refractory
foot warts. Another therapeutic option is intralesional injection of bleomycin, which has
antimitotic and cytotoxic effects on rapidly dividing cells mainly through induction of
DNA strand breaks [231–233].
Podophyllotoxin is an antimitotic compound isolated from the roots and rhizomes of
plants belonging to the Podophyllum species, such as Podophyllum peltatum and Sinopodophyl-
lum hexandrum Royle. Podophyllotoxin binds to the tubulin subunit of spindle microtubules,
inhibiting their polymerization and producing an antimitotic effect that causes cell cycle
arrest at metaphase. Podophyllotoxin may cause local tissue necrosis, which can halt HPV
activity. Podophyllotoxin is used topically to treat genital warts in the form of a 0.5%
solution (FDA approved in 1990) or gel, or a 0.15% cream [231].
Imiquimod is a nucleoside analogue and acts as an agonist for TLR 7, an intracellular
PRR whose natural ligand is single-stranded RNA. Through TLR7, imiqumod acting on
various intracellular signal transduction pathways leads to increased production of numer-
ous cytokines, including IL 1, 2, 6, 8, 12, 18 and, most importantly, with regard to antiviral
activity, also IFN α,β and γ. In addition, imiquimod interferes in a TLR-independent
manner with adenosine receptor signaling pathways and reduces adenylyl cyclase activity,
leading to negative feedback inhibition and maintenance of the inflammatory response.
Finally, high concentrations of imiquimod have the ability to induce apoptosis through
the activation of caspase. Imiqiumod in the form of a 5% cream was registered by the
FDA in 1997 and is recommended for the treatment of anogenital warts and solar keratosis,
Bowen’s disease and superficial basal cell carcinomas. It is also used to treat lesions other
than genital warts caused by HPV, including vulvar, penile, anal and cervical intraepithelial
neoplasia, as well as skin warts [234–236].
Sinecatechins are an aqueous extract of green tea (Camellia sinensis) leaves containing
a mixture of several different substances, mainly polyphenols of which epigallocatechin
gallate (EGCG) is the most abundant (>65%). Others include epicatechin (>10%), epi-
gallocatechin (<10%), epicatechin gallate (<10%) and the remaining catechins and other
compounds present in smaller amounts (<10%). Studies on the mechanism of action of
sinecatechins have focused on epigallocatechin gallate. This action is multidirectional
and includes inhibition of E6 and E 7 HPV expression, activation of caspase, inhibition of
telomerase activity altered Bcl-2 expression and in consequence inhibition of proliferation
(cell cycle arrest in G0/G1 phase) and induction of apoptosis. It also inhibits angiogenesis
by suppressing STAT3 activation. EGCG also inhibits DNA methyltransferase leading to
increased expression of certain genes including interferon-stimulated genes which may
be associated with antiviral and antitumor effects, as well as immunomodulatory effects,
among others. Antioxidant activity may also be important, both directly by reducing
reactive oxygen and nitrogen species and indirectly by inhibiting inflammatory reactions
(e.g., NF-kB pathway, AP-1, as well as cyclogenases and lipogenases). ECGC also stimulates
the production of antioxidant enzymes such as superoxide dismutase, catalase and glu-
tathione. An ointment containing 15% standardized green tea extract (Polyphenon® E) was
approved by the FDA in 2006 for the treatment of anogenital warts. Cases of successful use
in other HPV-caused lesions like facial warts and foot warts have been described [232,237].
Cidofovir (CDV) is an analogue of cytosine monophosphate, which is converted to
diphosphate under the influence of a cellular kinase and then incorporated into viral DNA,
inhibiting its synthesis. In the case of viruses possessing their own DNA polymerase, the
mechanism of action is a competitive inhibition of this enzyme. However, in the case of
HPV using cellular DNA polymerase, one can speak more of causing the death of infected
cells as a result of apoptosis cells than of a direct antiviral effect. The drug in topical (usually
at a concentration of 1–3%) or intralesional form is used to treat a variety of lesions caused
by HPV, but its availability is limited [236,238].
An interesting option for the treatment of HPV-caused lesions is intralesional non-
specific immunotherapy using candida antigens, Measles, Mumps, and Rubella (MMR)
Int. J. Mol. Sci. 2024, 25, 7616 21 of 33

vaccine, Bacillus Calmette-Guérin (BCG) or tuberculin purified protein derivative (PPD).

The likely mechanism of action is to stimulate PRRs especially TLRs and consequently
stimulate the production of various cytokines especially interferons. Intralesional im-
munotherapy is mainly used in refractory common warts, but there are also descriptions
of use in genital warts. For treatment of common warts, the percentage of people whose
lesions resolved completely in the various groups studied was 26–92% for MMR, 39–88%
for candida antigens, 23.3–94.4% PPD and 33.3–70% for BCG [195,239].
Another method recently reported to be effective in refractory HPV-positive lesions is
intralesional injection of vitamin D. In this case, the likely mechanism of action involves
the regulation of keratinocyte proliferation and, at the same time, the inhibition of the
production of certain cytokines such as interleukin-6 (IL-6), IL-8, and tumor necrosis
factor (TNF)-α and the stimulation of the production of IFN gamma. A study of patients
with common warts showed higher efficacy of intralesional vitamin D than intralesional
BCG [240].

12. New Drug Therapy

Most research on new HPV drugs is still at the in silico and in vitro stage.
E1 is one of the few HPV proteins showing enzymatic activity, making it a potential
target for new drugs. It is also characterized by low variability between HPV types. In
recent years, in silico studies have been carried out to find potential E1 inhibitors among the
already known substances included in the drug database. The best results were obtained
with Cinalukast, Lobeglitazone, and Efatutazone. The authors suggest that the chemical
structures of these substances could provide a basis for the design of E1 inhibitors [241].
In earlier studies, small-molecule chemical indandione has been shown to be able to
inhibit the interaction between E1 and E2 HPV, raising hopes for its future use as an anti-
HPV drug [242]. Several substances have also been identified that inhibit HPV 16 and
18 replication in vitro by inhibiting the cellular enzymes poly [ADP-ribose] polymerase
1-PARP1 and tyrosyl-DNA phosphodiesterase 1-Tdp1 [243]. Another potential group of
drugs that inhibits in vitro the initiation of HPV replication by acting on E2 or E1–E2 are
pyrrole-imidazole polyamides [244].
There are also in silico in vitro studies on the inhibition of ion channel formation by
E5 proteins by alkylated amino sugars. Moreover, there is an inhibition of some of the
metabolic pathways stimulated by E5 and, as a consequence, a decrease in cell proliferation
and stimulation of cell differentiation [245].
Numerous studies address the inhibition of E6 and E7 both by blocking the production
of these proteins and inhibiting their action. Some focus on inhibiting the expression of these
proteins by small interfering RNA (siRNA), or antisense deoxynucleotides. Other studies
are investigating the inhibition of these proteins and their actions at the post-transcriptional
stage. This can be achieved by various means, including the use of ribozymes, intrabodies
targeting E6 proteins, flavonoid-derived compounds, peptides, small-molecule substances,
and others [244]. One study using Structure-Based Virtual Screening (SBVS) identified a
potential small-molecule drug that inhibits the binding of the of HPV18 E7 and the cellular
PTPN14 (Protein Tyrosine Phosphatase Non-Receptor Type 14). This results in inhibition
of PTPN14 degradation and increased levels of PTPN14, resulting in the inhibition of
Yes-associated protein (YAP) and the inhibition of cell proliferation. The substance may be
used to treat cancers caused by HPV [246].
Interesting results were also obtained with 3-hydroxyphthalic anhydride (3HP)-
modified bovine β-lactoglobulin (3HP-β-LG). This protein was shown to bind to the
L1 positively charged fragment of HPV and block the entry of viral particles into cells
with high efficiency. Potentially in the future, the substance could be used for the topical
treatment of HPV infections [247]. Other in vitro studies of L1 HPV 16 virus-like particles
have shown that non-functionalized gold nanoparticles (nfGNPs) strongly inhibit viral
entry into cells [248].
Int. J. Mol. Sci. 2024, 25, 7616 22 of 33

Other promising in vitro studies have looked at the action of a 29-amino-acid peptide
designated P16/16, containing the CPP (cell-penetrating peptide) and the RBS (retromer-
binding site) from HPV16 L2. The first sequence allows penetration into cells, and the
second binds to a cytoplasmic retromer protein that allows HPV transport through the
Golgi apparatus into the cell nucleus. This blocks of the association of L2 HPV with the
retromer and inhibits the transport of the virus [249]. Other preclinical studies in vitro and
in a mouse model have shown that protamine sulfate probably combines with heparan
sulphate to block virus attachment and entry into the cell interior. Clinical trials are likely
to be initiated [250].
In addition to the previously mentioned epigallocatechin derived from Camelia sinen-
sis, numerous other substances of plant origin have been shown to inhibit HPV infection
in vitro or in vivo including propolis, reservatrol, curcumin, silymarin, neem, and berberine.
This could lead to the development of new drugs [251,252].

13. Conclusions
1. In order to make HPV systematics clearer, it would be necessary to merge and unify
the information contained in the various databases;
2. Current treatment is mainly based on:
- Surgical procedures;
- Topical or intralesional application of substances with antiproliferative and cyto-
toxic effects on infected cells (e.g., podophyllotoxin, bleomycin, 5-fluorouracil,
cidofovir) or non-specific stimulation of the immune system to destroy HPV
(e.g., imiquimod, intralesional immunotherapy). Some of the drugs used such
as sinecatechins and vitamin D have both immunostimulating and antiprolifera-
tive effects;
3. A number of therapeutic vaccines (specific immunotherapy) are undergoing clinical
trials, some of which, such as MVA E2 and VGX-3100, have completed phase III
clinical trials and are expected to be available soon;
4. It is encouraging that prevention of infections with the most common mucosal HPV
types is available. The efficacy of vaccines based on virus-like particles from the L1
protein is fully proven. Also noteworthy is the effect of prophylactic vaccines on
reducing recurrence in women treated for CIN. These vaccines are increasingly used
worldwide. However, in order to reduce the number of infections and their impact, it
would be advisable to further increase the availability of vaccines and to disseminate
more effectively information regarding their efficacy and safety;
5. Despite a great deal of research, there are still no drugs available that specifically
inhibit HPV replication. However, an increasing understanding of the HPV replication
cycle and the structure and function of individual viral proteins should, in the future,
allow the development of effective, specific pharmacotherapy. Research on such drugs
is mostly still in the preclinical phase;
6. The treatment of precancerous lesions, cancers and persistent/recurrent benign lesions
caused by HPV is still an incompletely solved problem. The effectiveness of treatment
may be enhanced by the inclusion of methods which are based on the stimulation of
the immune system in the fight against infection.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijms25147616/s1.
Author Contributions: Conceptualization, B.M.-B. and L.R.; data curation, B.M.-B.; writing—original
draft preparation, review and editing B.M.-B. and L.R.; visualization, B.M.-B. All authors have read
and agreed to the published version of the manuscript.
Funding: This research study received no external funding.
Conflicts of Interest: The authors declare no conflicts of interest.
Int. J. Mol. Sci. 2024, 25, 7616 23 of 33

Abbreviations
AIM2 absent in melanoma 2
BCG Bacillus Calmette–Guérin
CIN cervical intraepithelial neoplasia, and penile
CyPB cyclophilin B
Dlg Discs Large
DNMT1 DNA methyltransferase
ds DNA Double-stranded DNA
EGCG epigallocatechin gallate
EGFR epidermal growth factor receptor
EV epidermodysplasia verruciformis
FGFR fibroblast growth factor receptor
GAGs glycosaminoglycans
HSPG heparan sulfate proteoglycans
hTERT human telomerase reverse transcriptase
ICTV International Committee on Taxonomy of Viruses
IRHC International Human Papillomavirus Reference Center
KLK8 kallikrein-8
L or S lineage or sublineage
LCR long control region
LLO Listeria monocytogenes listeriolysin O
MMR Measles, Mumps, and Rubella (vaccine)
NMSC non-melanoma skin cancer
ORF open reading frame
pAE early polyadenylation sites
PaVe The Papilloma Virus Episteme
PDGFR platelet-derived growth factor receptor
PI3K phosphatidylinositol-3-kinase
PIN penile intraepithelial neoplasia
PML NBs promyelocytic leukemia nuclear bodies
PPD (tuberculin) purified protein derivative
PRR pattern recognition receptors
PSD95 Post Synaptic Density 95
PTPN14 Protein Tyrosine Phosphatase Non-Receptor Type 14
PV papillomaviruse
TB Taxonomy Browser
VIN vulvar intraepithelial neoplasia
ZO-1 Zona Occludens 1

References
1. Bruni, L.; Albero, G.; Serrano, B.; Mena, M.; Collado, J.J.; Gómez, D.; Muñoz, J.; Bosch, F.X.; de Sanjosé, S.; ICO/IARC Information
Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in the World. Summary
Report, 10 March 2023.
2. Chesson, H.W.; Dunne, E.F.; Hariri, S.; Markowitz, L.E. The estimated lifetime probability of acquiring human papillomavirus in
the United States. Sex. Transm. Dis. 2014, 41, 660–664. [CrossRef] [PubMed]
3. Kombe, A.J.; Li, B.; Zahid, A.; Mengist, H.M.; Bounda, G.A.; Zhou, Y.; Jin, T. Epidemiology and burden of human papillomavirus
and related diseases, molecular pathogenesis, and vaccine evaluation. Front. Public Health 2021, 8, 552028. [CrossRef] [PubMed]
4. Available online: https://www.who.int/news-room/fact-sheets/detail/human-papilloma-virus-and-cancer (accessed on 19
April 2024).
5. de Sanjosé, S.; Bruni, L.; Alemany, L. HPV in genital cancers (at the exception of cervical cancer) and anal cancers. Presse Med.
2014, 43, e423–e428. [CrossRef] [PubMed]
6. Zhai, L.; Tumban, E. Gardasil-9: A global survey of projected efficacy. Antivir. Res. 2016, 130, 101–109. [CrossRef] [PubMed]
7. Syrjänen, S.; Syrjänen, K. The history of papillomavirus research. Cent. Eur. J. Public Health 2008, 16 (Suppl. S16), S7–S13.
8. zur Hausen, H. Papillomaviruses in the causation of human cancers—A brief historical account. Virology 2009, 384, 260–265.
[CrossRef] [PubMed]
9. Muñoz, N.; Bosch, F.X.; de Sanjosé, S.; Herrero, R.; Castellsagué, X.; Shah, K.V.; Snijders, P.J.; Meijer, C.J.; International Agency
for Research on Cancer Multicenter Cervical Cancer Study Group. Epidemiologic classification of human papillomavirus types
associated with cervical cancer. N. Engl. J. Med. 2003, 348, 518–527. [CrossRef]
Int. J. Mol. Sci. 2024, 25, 7616 24 of 33

10. Nunes, E.M.; Talpe-Nunes, V.; Sichero, L. Epidemiology and biology of cutaneous human papillomavirus. Clinics 2018, 73
(Suppl. S1), e489s. [CrossRef]
11. Arroyo Mühr, L.S.; Eklund, C.; Dillner, J. Misclassifications in human papillomavirus databases. Virology 2021, 558, 57–66.
[CrossRef]
12. International Committee on Taxonomy of Viruses; Book: Papillomaviridae 2024. Available online: https://ictv.global/report/
chapter/papillomaviridae/papillomaviridae (accessed on 29 January 2024).
13. Taxonomy Browser (Human Papillomavirus). Available online: https://www.ncbi.nlm.nih.gov/Taxonomy/Browser/wwwtax.
cgi?mode=Undef&name=Viruses&lvl=3&srchmode=1&keep=1&unlock (accessed on 28 January 2024).
14. International Human Papillomavirus Reference Center. Available online: https://www.hpvcenter.se (accessed on 28 Jan-
uary 2024).
15. The Papillomavirus Episteme PaVE. Available online: https://pave.niaid.nih.gov/ (accessed on 29 January 2024).
16. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2012. Biological agents. Volume 100 B. A review
of human carcinogens. IARC monographs on the evaluation of carcinogenic risks to humans/World Health Organization. Int.
Agency Res. Cancer 2012, 100, 1–441.
17. Siqueira, J.D.; Alves, B.M.; Prellwitz, I.M.; Furtado, C.; Meyrelles, A.R.; Machado, E.S.; Seuanez, H.N.; Soares, M.A.; Soares,
E.A. Identification of novel human papillomavirus lineages and sublineages in HIV/HPVcoinfected pregnant women by
next-generation sequencing. Virology 2016, 493, 202–208. [CrossRef] [PubMed]
18. Delius, H.; Hofmann, B. Primer-directed sequencing of human papillomavirus types. Curr. Top. Microbiol. Immunol. 1994, 186,
13–31. [CrossRef]
19. Philipp, W.; Honoré, N.; Sapp, M.; Cole, S.T.; Streeck, R.E. Human papillomavirus type 42: New sequences, conserved genome
organization. Virology 1992, 186, 331–334. [CrossRef]
20. Delius, H.; Saegling, B.; Bergmann, K.; Shamanin, V.; de Villiers, E.M. The genomes of three of four novel HPV types, defined
by differences of their L1 genes, show high conservation of the E7 gene and the URR. Virology 1998, 240, 359–365. [CrossRef]
[PubMed]
21. de Villiers, E.M.; Lavergne, D.; McLaren, K.; Benton, E.C. Prevailing papillomavirus types in non-melanoma carcinomas of the
skin in renal allograft recipients. Int. J. Cancer 1997, 73, 356–361. [CrossRef]
22. Kohler, A.; Gottschling, M.; Forster, J.; Rowert-Huber, J.; Stockfleth, E.; Nindl, I. Genomic characterization of a novel human
papillomavirus (HPV117) with a high viral load in a persisting wart. Virology 2010, 399, 129–133. [CrossRef] [PubMed]
23. Kovanda, A.; Kocjan, B.J.; Potocnik, M.; Poljak, M. Characterization of a novel cutaneous human papillomavirus genotype
HPV125. PLoS ONE 2011, 6, e22414. [CrossRef]
24. Mitsuishi, T.; Ohsawa, I.; Kato, T.; Egawa, N.; Kiyono, T. Molecular cloning and characterisation of a novel type of human
papillomavirus 160 isolated from a flat wart of an immunocompetent patient. PLoS ONE 2013, 8, e79592, Erratum in PLoS ONE
2013, 8. [CrossRef]
25. Tachezy, R.; Van Ranst, M.A.; Cruz, Y.; Burk, R.D. Analysis of short novel human papillomavirus sequences. Biochem. Biophys. Res.
Commun. 1994, 204, 820–827. [CrossRef]
26. Burk, R.D.; Harari, A.; Chen, Z. Human papillomavirus genome variants. Virology 2013, 445, 232–243. [CrossRef]
27. Fu, L.; Terai, M.; Matsukura, T.; Herrero, R.; Burk, R.D. Codetection of a mixed population of candHPV62 containing wild-type
and disrupted E1 open-reading frame in a 45-year-old woman with normal cytology. J. Infect. Dis. 2004, 190, 1303–1309. [CrossRef]
[PubMed]
28. Terai, M.; Burk, R.D. Complete nucleotide sequence and analysis of a novel human papillomavirus (HPV 84) genome cloned by
an overlapping PCR method. Virology 2001, 279, 109–115. [CrossRef] [PubMed]
29. Terai, M.; Burk, R.D. Identification and characterization of 3 novel genital human papillomaviruses by overlapping polymerase
chain reaction: candHPV89, candHPV90, and candHPV91. J. Infect. Dis. 2002, 185, 1794–1797. [CrossRef] [PubMed]
30. Matsukura, T.; Sugase, M. Relationships between 80 human papillomavirus genotypes and different grades of cervical intraep-
ithelial neoplasia: Association and causality. Virology 2001, 283, 139–147. [CrossRef] [PubMed]
31. Menzo, S.; Monachetti, A.; Trozzi, C.; Ciavattini, A.; Carloni, G.; Varaldo, P.E.; Clementi, M. Identification of six putative novel
human papillomaviruses (HPV) and characterization of candidate HPV type 87. J. Virol. 2001, 75, 11913–11919. [CrossRef]
[PubMed]
32. Brown, D.R.; McClowry, T.L.; Woods, K.; Fife, K.H. Nucleotide sequence and characterization of human papillomavirus type 83, a
novel genital papillomavirus. Virology 1999, 260, 165–172. [CrossRef] [PubMed]
33. Ekstrom, J.; Forslund, O.; Dillner, J. Three novel papillomaviruses (HPV109, HPV112 and HPV114) and their presence in cutaneous
and mucosal samples. Virology 2010, 397, 331–336. [CrossRef] [PubMed]
34. Hirsch-Behnam, A.; Delius, H.; de Villiers, E.M. A comparative sequence analysis of two human papillomavirus (HPV) types 2a
and 57. Virus Res. 1990, 18, 81–97. [CrossRef] [PubMed]
35. Chan, S.Y.; Tan, C.H.; Delius, H.; Bernard, H.U. Human papillomavirus type 2c is identical to human papillomavirus type 27.
Virology 1994, 201, 397–398. [CrossRef]
36. Yamaguchi, T.; Miwa, Y.; Eizuru, Y. Candidate human papillomavirus (HPV) type 27b: Nucleotide sequence and heterogeneity
with HPV 27. J. Med. Virol. 2005, 77, 113–115. [CrossRef]
Int. J. Mol. Sci. 2024, 25, 7616 25 of 33

37. Lungu, O.; Crum, C.P.; Silverstein, S. Biologic properties and nucleotide sequence analysis of human papillomavirus type 51. J.
Virol. 1991, 65, 4216–4225. [CrossRef]
38. Kino, N.; Sata, T.; Sato, Y.; Sugase, M.; Matsukura, T. Molecular cloning and nucleotide sequence analysis of a novel human
papillomavirus (type 82) associated with vaginal intraepithelial neoplasia. Clin. Diagn. Lab. Immunol. 2000, 7, 91–95. [CrossRef]
[PubMed]
39. Narechania, A.; Chen, Z.; DeSalle, R.; Burk, R.D. Phylogenetic incongruence among oncogenic genital alpha human papillo-
maviruses. J. Virol. 2005, 79, 15503–15510. [CrossRef] [PubMed]
40. Wu, X.L.; Zhang, C.T.; Zhu, X.K.; Wang, Y.C. Detection of HPV types and neutralizing antibodies in women with genital warts in
Tianjin City, China. Virol. Sin. 2010, 25, 8–17. [CrossRef] [PubMed]
41. Tawheed, A.R.; Beaudenon, S.; Favre, M.; Orth, G. Characterization of human papillomavirus type 66 from an invasive carcinoma
of the uterine cervix. J. Clin. Microbiol. 1991, 29, 2656–2660. [CrossRef] [PubMed]
42. Cole, S.T.; Danos, O. Nucleotide sequence and comparative analysis of the human papillomavirus type 18 genome. Phylogeny of
papillomaviruses and repeated structure of the E6 and E7 gene products. J. Mol. Biol. 1987, 193, 599–608. [CrossRef]
43. Muñoz-Bello, J.O.; Carrillo-García, A.; Lizano, M. Epidemiology and molecular biology of HPV variants in cervical cancer: The
state of the art in Mexico. Int. J. Mol. Sci. 2022, 23, 8566. [CrossRef]
44. Chen, Z.; DeSalle, R.; Schiffman, M.; Herrero, R.; Burk, R.D. Evolutionary dynamics of variant genomes of human papillomavirus
types 18, 45, and 97. J. Virol. 2009, 83, 1443–1455. [CrossRef]
45. Chen, Z.; Fu, L.; Herrero, R.; Schiffman, M.; Burk, R.D. Identification of a novel human papillomavirus (HPV97) related to HPV18
and HPV45. Int. J. Cancer 2007, 121, 193–198. [CrossRef]
46. Chen, Z.; Schiffman, M.; Herrero, R.; Desalle, R.; Anastos, K.; Segondy, M.; Sahasrabuddhe, V.V.; Gravitt, P.E.; Hsing, A.W.; Burk,
R.D. Evolution and taxonomic classification of Alphapapillomavirus 7 complete genomes: HPV18, HPV39, HPV45, HPV59,
HPV68 and HPV70. PLoS ONE 2013, 8, e72565. [CrossRef]
47. Lurchachaiwong, W.; Junyangdikul, P.; Termrungruanglert, W.; Payungporn, S.; Sampatanukul, P.; Tresukosol, D.; Niruthisard,
S.; Trivijitsilp, P.; Karalak, A.; Swangvaree, S.; et al. Whole-genome sequence analysis of human papillomavirus type 18 from
infected thai women. Intervirology 2010, 53, 161–166. [CrossRef] [PubMed]
48. Volpers, C.; Streeck, R.E. Genome organization and nucleotide sequence of human papillomavirus type 39. Virology 1991, 181,
419–423. [CrossRef]
49. Rho, J.; Roy-Burman, A.; Kim, H.; de Villiers, E.M.; Matsukura, T.; Choe, J. Nucleotide sequence and phylogenetic classification of
human papillomavirus type 59. Virology 1994, 203, 158–161. [CrossRef]
50. Longuet, M.; Beaudenon, S.; Orth, G. Two novel genital human papillomavirus (HPV) types, HPV68 and HPV70, related to the
potentially oncogenic HPV39. J. Clin. Microbiol. 1996, 34, 738–744. [CrossRef] [PubMed]
51. Forslund, O.; Hansson, B.G. Human papillomavirus type 70 genome cloned from overlapping PCR products: Complete nucleotide
sequence and genomic organization. J. Clin. Microbiol. 1996, 34, 802–809. [CrossRef]
52. Chow, V.T.; Leong, P.W. Complete nucleotide sequence, genomic organization and phylogenetic analysis of a novel genital human
papillomavirus type, HLT7474-S. J. Gen. Virol. 1999, 80, 2923–2929. [CrossRef]
53. Burk, R.D.; Mirabello, L.; DeSalle, R. Distinguishing genetic drift from selection in papillomavirus evolution. Viruses 2023, 15, 1631.
[CrossRef] [PubMed]
54. Guerendiain, D.; Mühr, L.S.A.; Grigorescu, R.; Holden, M.T.G.; Cuschieri, K. Mapping HPV 16 sub-lineages in anal cancer and
implications for disease outcomes. Diagnostics 2022, 12, 3222. [CrossRef]
55. Mirabello, L.; Clarke, M.A.; Nelson, C.W.; Dean, M.; Wentzensen, N.; Yeager, M.; Cullen, M.; Boland, J.F.; NCI HPV Workshop;
Schiffman, M.; et al. The intersection of HPV epidemiology, genomics and mechanistic studies of HPV mediated carcinogenesis.
Viruses 2018, 10, 80. [CrossRef]
56. Clifford, G.M.; Tenet, V.; Georges, D.; Alemany, L.; Pavón, M.A.; Chen, Z.; Yeager, M.; Cullen, M.; Boland, J.F.; Bass, S.; et al.
Human papillomavirus 16 sub-lineage dispersal and cervical cancer risk worldwide: Whole viral genome sequences from 7116
HPV16-positive women. Papillomavirus Res. 2019, 7, 67–74. [CrossRef]
57. Farhadi, A.; Abuei, H.; Okhovat, M.A.; Geramizadeh, B.; Behzad-Behbahani, A.; Chong, P.P.; Nikouyan, N.; Namdari, S. Type
distribution of human papillomaviruses in ThinPrep cytology samples and HPV16/18 E6 gene variations in FFPE cervical cancer
specimens in Fars province, Iran. Cancer Cell Int. 2023, 23, 166. [CrossRef] [PubMed]
58. Seedorf, K.; Krammer, G.; Durst, M.; Suhai, S.; Rowekamp, W.G. Human papillomavirus type 16 DNA sequence. Virology 1985,
145, 181–185. [CrossRef] [PubMed]
59. Kennedy, I.M.; Haddow, J.K.; Clements, J.B. A negative regulatory element in the human papillomavirus type 16 genome acts at
the level of late mRNA stability. J. Virol. 1991, 65, 2093–2097. [CrossRef] [PubMed]
60. Smith, B.; Chen, Z.; Reimers, L.; van Doorslaer, K.; Schiffman, M.; Desalle, R.; Herrero, R.; Yu, K.; Wacholder, S.; Wang, T.; et al.
Sequence imputation of HPV16 genomes for genetic association studies. PLoS ONE 2011, 6, e21375. [CrossRef] [PubMed]
61. Chen, Z.; Terai, M.; Fu, L.; Herrero, R.; DeSalle, R.; Burk, R.D. Diversifying selection in human papillomavirus type 16 lineages
based on complete genome analyses. J. Virol. 2005, 79, 7014–7023. [CrossRef]
62. Chen, Z.; Schiffman, M.; Herrero, R.; Desalle, R.; Anastos, K.; Segondy, M.; Sahasrabuddhe, V.V.; Gravitt, P.E.; Hsing, A.W.; Burk,
R.D. Evolution and taxonomic classification of human papillomavirus 16 (HPV16)-related variant genomes: HPV31, HPV33,
HPV35, HPV52, HPV58 and HPV67. PLoS ONE 2011, 6, e20183. [CrossRef] [PubMed]
Int. J. Mol. Sci. 2024, 25, 7616 26 of 33

63. Pinheiro, M.; Harari, A.; Schiffman, M.; Clifford, G.M.; Chen, Z.; Yeager, M.; Cullen, M.; Boland, J.F.; Raine-Bennett, T.; Steinberg,
M.; et al. Phylogenomic analysis of human Papillomavirus type 31 and cervical carcinogenesis: A study of 2093 viral genomes.
Viruses 2021, 13, 1948. [CrossRef] [PubMed]
64. Goldsborough, M.D.; DiSilvestre, D.; Temple, G.F.; Lorincz, A.T. Nucleotide sequence of human papillomavirus type 31: A
cervical neoplasia-associated virus. Virology 1989, 171, 306–311. [CrossRef]
65. Cole, S.T.; Streeck, R.E. Genome organization and nucleotide sequence of human papillomavirus type 33, which is associated
with cervical cancer. J. Virol. 1986, 58, 991–995. [CrossRef]
66. Wu, X.; Zhang, C.; Feng, S.; Liu, C.; Li, Y.; Yang, Y.; Gao, J.; Li, H.; Meng, S.; Li, L.; et al. Detection of HPV types and neutralizing
antibodies in Gansu province, China. J. Med. Virol. 2009, 81, 693–702. [CrossRef]
67. Kirii, Y.; Iwamoto, S.; Matsukura, T. Human papillomavirus type 58 DNA sequence. Virology 1991, 185, 424–427. [CrossRef]
68. Kirii, Y.; Matsukura, T. Nucleotide sequence and phylogenetic classification of human papillomavirus type 67. Virus Genes 1998,
17, 117–121. [CrossRef]
69. Bee, K.J.; Gradissimo, A.; Chen, Z.; Harari, A.; Schiffman, M.; Raine-Bennett, T.; Castle, P.E.; Clarke, M.; Wentzensen, N.; Burk,
R.D. Genetic and epigenetic variations of HPV52 in cervical precancer. Int. J. Mol. Sci. 2021, 22, 6463. [CrossRef] [PubMed]
70. Danielewski, J.A.; Garland, S.M.; McCloskey, J.; Hillman, R.J.; Tabrizi, S.N. Human papillomavirus type 6 and 11 genetic variants
found in 71 oral and anogenital epithelial samples from Australia. PLoS ONE 2013, 8, e63892, Erratum in: PLoS ONE 2015,
10, e0117962. [CrossRef]
71. Schwarz, E.; Durst, M.; Demankowski, C.; Lattermann, O.; Zech, R.; Wolfsperger, E.; Suhai, S.; zur Hausen, H. DNA sequence and
genome organization of genital human papillomavirus type 6b. EMBO J. 1983, 2, 2341–2348. [CrossRef] [PubMed]
72. Seedat, R.Y.; Combrinck, C.E.; Bester, P.A.; Lee, J.Y.; Burt, F.J. Determination of the complete genome and functional analysis
of HPV6 isolate VBD19/10 from a patient with aggressive recurrent respiratory papillomatosis. Epidemiol. Infect. 2016, 144,
2128–2135. [CrossRef] [PubMed]
73. Jelen, M.M.; Chen, Z.; Kocjan, B.J.; Burt, F.J.; Chan, P.K.; Chouhy, D.; Combrinck, C.E.; Coutlée, F.; Estrade, C.; Ferenczy, A.; et al.
Global genomic diversity of human papillomavirus 6 based on 724 isolates and 190 complete genome sequences. J. Virol. 2014, 88,
7307–7316. [CrossRef]
74. Jelen, M.M.; Chen, Z.; Kocjan, B.J.; Hošnjak, L.; Burt, F.J.; Chan, P.K.S.; Chouhy, D.; Combrinck, C.E.; Estrade, C.; Fiander, A.; et al.
Global genomic diversity of human papillomavirus 11 based on 433 isolates and 78 complete genome sequences. J. Virol. 2016, 90,
5503–5513. [CrossRef]
75. Kovelman, R.; Bilter, G.K.; Roman, A.; Brown, D.R.; Barbosa, M.S. Human papillomavirus type 6: Classification of clinical isolates
and functional analysis of E2 proteins. J. Gen. Virol. 1999, 80, 2445–2451. [CrossRef]
76. Burk, R.D.; Chen, Z.; Harari, A.; Smith, B.C.; Kocjan, B.J.; Maver, P.J.; Poljak, M. Classification and nomenclature system for
human Alphapapillomavirus variants: General features, nucleotide landmarks and assignment of HPV6 and HPV11 isolates to
variant lineages. Acta Dermatovenerol. Alp. Pannonica Adriat. 2011, 20, 113–123.
77. Kocjan, B.J.; Jelen, M.M.; Maver, P.J.; Seme, K.; Poljak, M. Pre-vaccination genomic diversity of human papillomavirus genotype
6 (HPV 6): A comparative analysis of 21 full-length genome sequences. Infect. Genet. Evol. 2011, 11, 1805–1810. [CrossRef]
[PubMed]
78. Hofmann, K.J.; Cook, J.C.; Joyce, J.G.; Brown, D.R.; Schultz, L.D.; George, H.A.; Rosolowsky, M.; Fife, K.H.; Jansen, K.U. Sequence
determination of human papillomavirus type 6a and assembly of virus-like particles in Saccharomyces cerevisiae. Virology 1995,
209, 506–518. [CrossRef] [PubMed]
79. Kahn, T.; Turazza, E.; Ojeda, R.; Bercovich, A.; Stremlau, A.; Lichter, P.; Poustka, A.; Grinstein, S.; zur Hausen, H. Integration of
human papillomavirus type 6a DNA in a tonsillar carcinoma: Chromosomal localization and nucleotide sequence of the genomic
target region. Cancer Res. 1994, 54, 1305–1312. [PubMed]
80. Metcalfe, L.; Chen, S.L.; Mounts, P. Structural analysis of human papillomavirus type 6c isolates from condyloma acuminatum
and juvenile-onset and adult-onset laryngeal papillomata. Virus Genes 1989, 3, 11–27. [CrossRef] [PubMed]
81. Dartmann, K.; Schwarz, E.; Gissmann, L.; zur Hausen, H. The nucleotide sequence and genome organization of human papilloma
virus type 11. Virology 1986, 151, 124–130. [CrossRef] [PubMed]
82. Maver, P.J.; Kocjan, B.J.; Seme, K.; Potocnik, M.; Gale, N.; Poljak, M. Prevaccination genomic diversity of human papillomavirus
genotype 11: A study on 63 clinical isolates and 10 full-length genome sequences. J. Med. Virol. 2011, 83, 461–470. [CrossRef]
[PubMed]
83. Conde-Ferráez, L.; Ek-Hernández, G.E.; Canché-Pech, J.R.; Gómez-Carballo, J.G.; Kantún-Moreno, N.E.; González-Losa, M.D.R.
Genomic characterization of human papillomavirus type 13, associated to multifocal epithelial hyperplasia, in a Mayan community.
Infect. Genet. Evol. 2021, 91, 104595. [CrossRef] [PubMed]
84. Van Ranst, M.; Fuse, A.; Fiten, P.; Beuken, E.; Pfister, H.; Burk, R.D.; Opdenakker, G. Human papillomavirus type 13 and pygmy
chimpanzee papillomavirus type 1: Comparison of the genome organizations. Virology 1992, 190, 587–596. [CrossRef] [PubMed]
85. Schoch, C.L.; Ciufo, S.; Domrachev, M.; Hotton, C.L.; Kannan, S.; Khovanskaya, R.; Leipe, D.; Mcveigh, R.; O’Neill, K.; Robbertse,
B.; et al. NCBI Taxonomy: A comprehensive update on curation, resources and tools. Database 2020, 2020, baaa062. [CrossRef]
86. Volter, C.; He, Y.; Delius, H.; Roy-Burman, A.; Greenspan, J.S.; Greenspan, D.; de Villiers, E.M. Novel HPV types present in oral
papillomatous lesions from patients with HIV infection. Int. J. Cancer 1996, 66, 453–456. [CrossRef]
Int. J. Mol. Sci. 2024, 25, 7616 27 of 33

87. Zachow, K.R.; Ostrow, R.S.; Faras, A.J. Nucleotide sequence and genome organization of human papillomavirus type 5. Virology
1987, 158, 251–254. [CrossRef] [PubMed]
88. Yabe, Y.; Sakai, A.; Hitsumoto, T.; Kato, H.; Ogura, H. A subtype of human papillomavirus 5 (HPV5b) and its subgenomic
segment amplified in a carcinoma: Nucleotide sequences and genomic organizations. Virology 1991, 183, 793–798. [CrossRef]
[PubMed]
89. Fuchs, P.G.; Iftner, T.; Weninger, J.; Pfister, H. Epidermodysplasia verruciformis-associated human papillomavirus 8: Genomic
sequence and comparative analysis. J. Virol. 1986, 58, 626–634. [CrossRef] [PubMed]
90. Kremsdorf, D.; Favre, M.; Jablonska, S.; Obalek, S.; Rueda, L.A.; Lutzner, M.A.; Blanchet-Bardon, C.; Van Voorst Vader, P.C.; Orth,
G. Molecular cloning and characterization of the genomes of nine newly recognized human papillomavirus types associated with
epidermodysplasia verruciformis. J. Virol. 1984, 52, 1013–1018. [CrossRef] [PubMed]
91. Kawashima, M.; Favre, M.; Jablonska, S.; Obalek, S.; Orth, G. Characterization of a new type of human papillomavirus (HPV)
related to HPV5 from a case of actinic keratosis. Virology 1986, 154, 389–394. [CrossRef] [PubMed]
92. Kiyono, T.; Adachi, A.; Ishibashi, M. Genome organization and taxonomic position of human papillomavirus type 47 inferred
from its DNA sequence. Virology 1990, 177, 401–405. [CrossRef]
93. Vasiljevic, N.; Hazard, K.; Eliasson, L.; Ly, H.; Hunziker, A.; de Villiers, E.M.; Norrild, B.; Dillner, J.; Forslund, O. Characterization
of two novel cutaneous human papillomaviruses, HPV93 and HPV96. J. Gen. Virol. 2007, 88, 1479–1483. [CrossRef]
94. de Villiers, E.M.; Gunst, K. Characterization of seven novel human papillomavirus types isolated from cutaneous tissue, but also
present in mucosal lesions. J. Gen. Virol. 2009, 90, 1999–2004. [CrossRef] [PubMed]
95. Bernard, H.U.; Burk, R.D.; Chen, Z.; van Doorslaer, K.; Hausen, H.; de Villiers, E.M. Classification of papillomaviruses (PVs)
based on 189 PV types and proposal of taxonomic amendments. Virology 2010, 401, 70–79. [CrossRef]
96. Bottalico, D.; Chen, Z.; Dunne, A.; Ostoloza, J.; McKinney, S.; Sun, C.; Schlecht, N.F.; Fatahzadeh, M.; Herrero, R.; Schiffman,
M.; et al. The oral cavity contains abundant known and novel human papillomaviruses from the Betapapillomavirus and
Gammapapillomavirus genera. J. Infect. Dis. 2011, 204, 787–792. [CrossRef]
97. Hopfl, R.; Bens, G.; Wieland, U.; Petter, A.; Zelger, B.; Fritsch, P.; Pfister, H. Human papillomavirus DNA in non-melanoma skin
cancers of a renal transplant recipient: Detection of a new sequence related to epidermodysplasia verruciformis associated types.
J. Investig. Dermatol. 1997, 108, 53–56. [CrossRef] [PubMed]
98. Scheurlen, W.; Gissmann, L.; Gross, G.; zur Hausen, H. Molecular cloning of two new HPV types (HPV 37 and HPV 38) from a
keratoacanthoma and a alignant melanoma. Int. J. Cancer 1986, 37, 505–510. [CrossRef] [PubMed]
99. Oliveira, L.; Santos, L.; Neves, F. Characterization of a new genotype of Betapapillomavirus HPV 17 through L1, E7, E7 and LCR
sequences. Acta Virol. 2018, 62, 172–178. [CrossRef] [PubMed]
100. Vasiljevic, N.; Hazard, K.; Dillner, J.; Forslund, O. Four novel human betapapillomaviruses of species 2 preferentially found in
actinic keratosis. J. Gen. Virol. 2008, 89, 2467–2474. [CrossRef]
101. Bottalico, D.; Chen, Z.; Kocjan, B.J.; Seme, K.; Poljak, M.; Burk, R.D. Characterization of human papillomavirus type 120: A novel
betapapillomavirus with tropism for multiple anatomical niches. J. Gen. Virol. 2012, 93, 1774–1779. [CrossRef] [PubMed]
102. Kocjan, B.J.; Poljak, M.; Seme, K.; Potocnik, M.; Fujs, K.; Babic, D.Z. Distribution of human papillomavirus genotypes in plucked
eyebrow hairs from Slovenian males with genital warts Infect. Genet. Evol. 2005, 5, 255–259. [CrossRef]
103. Kovanda, A.; Kocjan, B.J.; Luzar, B.; Bravo, I.G.; Poljak, M. Characterization of novel cutaneous human papillomavirus genotypes
HPV150 and HPV151. PLoS ONE 2011, 6, e22529. [CrossRef]
104. Kocjan, B.J.; Hosnjak, L.; Seme, K.; Poljak, M. Complete genome sequence of a novel human Betapapillomavirus, HPV159. Genome
Announc. 2013, 1, e00298-13. [CrossRef] [PubMed]
105. Kocjan, B.J.; Steyer, A.; Sagadin, M.; Hosnjak, L.; Poljak, M. Novel human papillomavirus type 174 from a cutaneous squamous
cell carcinoma. Genome Announc. 2013, 1, e00445-13. [CrossRef]
106. Marković, I.; Hosnjak, L.; Seme, K.; Poljak, M. Molecular characterization of human papillomavirus type 159 (HPV159). Viruses
2021, 13, 1668. [CrossRef]
107. Dutta, S.; Robitaille, A.; Rollison, D.E.; Tommasino, M.; Gheit, T. Complete genome sequence of a novel human Betapapillomavirus
isolated from a skin sample. Genome Announc. 2017, 5, e01642-16. [CrossRef] [PubMed]
108. Bolatti, E.M.; Chouhy, D.; Hošnjak, L.; Casal, P.E.; Kocjan, B.J.; Bottai, H.; Stella, E.J.; Sanchez, A.; Bussy, R.F.; Poljak, M.; et al.
Natural history of human papillomavirus infection of sun-exposed healthy skin of immunocompetent individuals over three
climatic seasons and identification of HPV209, a novel betapapillomavirus. J. Gen. Virol. 2017, 98, 1334–1348, Erratum in: J. Gen.
Virol. 2017, 98, 2205–2206. [CrossRef] [PubMed]
109. Brancaccio, R.N.; Robitaille, A.; Dutta, S.; Rollison, D.E.; Tommasino, M.; Gheit, T. Isolation of a novel beta-2 human papillo-
mavirus from skin. Microbiol. Resour. Announc. 2019, 8, e01628-18. [CrossRef] [PubMed]
110. Chouhy, D.; Gorosito, M.; Sanchez, A.; Serra, E.C.; Bergero, A.; Fernandez Bussy, R.; Giri, A.A. New generic primer system target-
ing mucosal/genital and cutaneous human papillomaviruses leads to the characterization of HPV 115, a novel Betapapillomavirus
species 3. Virology 2010, 397, 205–216. [CrossRef] [PubMed]
111. Forslund, O.; Antonsson, A.; Higgins, G.; Ly, H.; Delius, H.; Hunziker, A.; de Villiers, E.M. Nucleotide sequence and phylogenetic
classification of candidate human papilloma virus type 92. Virology 2003, 312, 255–260. [CrossRef] [PubMed]
112. Winer, R.L.; Gheit, T.; Feng, Q.; Stern, J.E.; Lin, J.; Cherne, S.; Tommasino, M. Prevalence and correlates of β- and γ-human
papillomavirus detection in oral samples from mid-adult women. J. Infect. Dis. 2019, 219, 1067–1075. [CrossRef]
Int. J. Mol. Sci. 2024, 25, 7616 28 of 33

113. Egawa, K.; Delius, H.; Matsukura, T.; Kawashima, M.; de Villiers, E.M. Two novel types of human papillomavirus, HPV 63
and HPV 65:comparisons of their clinical and histological features and DNA sequences to other HPV types. Virology 1993, 194,
789–799. [CrossRef] [PubMed]
114. Martin, E.; Dang, J.; Bzhalava, D.; Stern, J.; Edelstein, Z.R.; Koutsky, L.A.; Kiviat, N.B.; Feng, Q. Characterization of three novel
human papillomavirus types isolated from oral rinse samples of healthy individuals. J. Clin. Virol. 2014, 59, 30–37. [CrossRef]
[PubMed]
115. Bolatti, E.M.; Chouhy, D.; Casal, P.E.; Perez, G.R.; Stella, E.J.; Sanchez, A.; Gorosito, M.; Bussy, R.F.; Giri, A.A. Characteriza-
tion of novel human papillomavirus types 157, 158 and 205 from healthy skin and recombination analysis in genus gamma-
Papillomavirus. Infect. Genet. Evol. 2016, 42, 20–29. [CrossRef]
116. Muller, M.; Kelly, G.; Fiedler, M.; Gissmann, L. Human papillomavirus type 48. J. Virol. 1989, 63, 4907–4908. [CrossRef]
117. Arroyo Muhr, L.S.; Bzhalava, D.; Lagheden, C.; Eklund, C.; Johansson, H.; Forslund, O.; Dillner, J.; Hultin, E. Does human
papillomavirus-negative condylomata exist? Virology 2015, 485, 283–288. [CrossRef] [PubMed]
118. Favre, M.; Obalek, S.; Jablonska, S.; Orth, G. Human papillomavirus (HPV) type 50, a type associated with epidermodysplasia
verruciformis (EV) and only weakly related to other EV-specific HPVs. J. Virol. 1989, 63, 4910. [CrossRef] [PubMed]
119. Matsukura, T.; Iwasaki, T.; Kawashima, M. Molecular cloning of a novel human papillomavirus (type 60) from a plantar cyst with
characteristic pathological changes. Virology 1992, 190, 561–564. [CrossRef] [PubMed]
120. Kullander, J.; Handisurya, A.; Forslund, O.; Geusau, A.; Kirnbauer, R.; Dillner, J. Cutaneous human papillomavirus 88: Remarkable
differences in viral load. Int. J. Cancer 2008, 122, 477–480. [CrossRef] [PubMed]
121. Nobre, R.J.; Herraez-Hernandez, E.; Fei, J.W.; Langbein, L.; Kaden, S.; Grone, H.J.; de Villiers, E.M. E7 oncoprotein of novel
human papillomavirus type 108 lacking the E6 gene induces dysplasia in organotypic keratinocyte cultures. J. Virol. 2009, 83,
2907–2916. [CrossRef] [PubMed]
122. Chen, Z.; Schiffman, M.; Herrero, R.; Desalle, R.; Burk, R.D. Human papillomavirus (HPV) types 101 and 103 isolated from
cervicovaginal cells lack an E6 open reading frame (ORF) and are related to gamma-papillomaviruses. Virology 2007, 360, 447–453.
[CrossRef] [PubMed]
123. Murahwa, A.T.; Meiring, T.L.; Mbulawa, Z.Z.A.; Williamson, A.L. Discovery, characterisation and genomic variation of six novel
Gammapapillomavirus types from penile swabs in South Africa. Papillomavirus Res. 2019, 7, 102–111. [CrossRef] [PubMed]
124. Latsuzbaia, A.; Arbyn, M.; Dutta, S.; Fischer, M.; Gheit, T.; Tapp, J.; Tommasino, M.; Weyers, S.; Mossong, J. Complete genome
sequence of a novel human Gammapapillomavirus isolated from a cervical swab in Luxembourg. Genome Announc. 2018,
6, e00114-18. [CrossRef] [PubMed]
125. Ekström, J.; Bzhalava, D.; Svenback, D.; Forslund, O.; Dillner, J. High throughput sequencing reveals diversity of Human
Papillomaviruses in cutaneous lesions. Int. J. Cancer 2011, 129, 2643–2650. [CrossRef]
126. Kohler, A.; Gottschling, M.; Manning, K.; Lehmann, M.D.; Schulz, E.; Kruger-Corcoran, D.; Stockfleth, E.; Nindl, I. Genomic
characterization of ten novel cutaneous human papillomaviruses from keratotic lesions of immunosuppressed patients. J. Gen.
Virol. 2011, 92, 1585–1594. [CrossRef]
127. Li, J.; Cai, H.; Xu, Z.; Wang, Q.; Hang, D.; Shen, N.; Liu, M.; Zhang, C.; Abliz, A.; Ke, Y. Nine complete genome sequences of
cutaneous human papillomavirus genotypes isolated from healthy skin of individuals living in rural he nan province, China. J.
Virol. 2012, 86, 11936. [CrossRef] [PubMed]
128. Chatterjee, N.; Sultana, F.; Roy, R.; Dey, S.; Naskar, S.; Dam, A.; Bhowmick, A.K.; Begum, R.; Mandal, S.S.; Mandal, R.K.; et al.
Prevalence of novel gamma HPV types 223 and 225 in oral cavity and skin of Indian normal and neoplastic participants. J. Med.
Virol. 2023, 95, e29019. [CrossRef] [PubMed]
129. Li, J.; Pan, Y.; Deng, Q.; Cai, H.; Ke, Y. Identification and characterization of eleven novel human gamma-papillomavirus isolates
from healthy skin, found at low frequency in a normal population. PLoS ONE 2013, 8, e77116. [CrossRef]
130. Li, L.; Barry, P.; Yeh, E.; Glaser, C.; Schnurr, D.; Delwart, E. Identification of a novel human gammapapillomavirus species. J. Gen.
Virol. 2009, 90, 2413–2417. [CrossRef] [PubMed]
131. Johansson, H.; Bzhalava, D.; Ekstrom, J.; Hultin, E.; Dillner, J.; Forslund, O. Metagenomic sequencing of ‘HPVnegative’ condylo-
mas detects novel putative HPV types. Virology 2013, 440, 1–7. [CrossRef]
132. Murahwa, A.T.; Meiring, T.L.; Mbulawa, Z.Z.A.; Williamson, A.L. Complete genome sequences of four novel human Gammapa-
pillomavirus types, HPV219, HPV220, HPV221, and HPV222, isolated from penile skin swabs from South African men. Genome
Announc. 2018, 6, e00584-18. [CrossRef]
133. Egawa, N.; Kawai, K.; Egawa, K.; Honda, Y.; Kanekura, T.; Kiyono, T. Molecular cloning and characterization of a novel human
papillomavirus, HPV 126, isolated from a flat wart-like lesion with intracytoplasmic inclusion bodies and a peculiar distribution
of Ki-67 and p53. Virology 2012, 422, 99–104. [CrossRef]
134. Ure, A.E.; Forslund, O. Characterization of human papillomavirus type 154 and tissue tropism of Gammapapillomaviruses. PLoS
ONE 2014, 9, e89342. [CrossRef]
135. Schowalter, R.M.; Pastrana, D.V.; Pumphrey, K.A.; Moyer, A.L.; Buck, C.B. Merkel cell polyomavirus and two previously unknown
polyomaviruses are chronically shed from human skin. Cell Host Microbe 2010, 7, 509–515. [CrossRef]
136. Ostrbenk, A.; Kocjan, B.J.; Hosnjak, L.; Li, J.; Deng, Q.; Sterbenc, A.; Poljak, M. Identification of a novel human papillomavirus,
type HPV199, isolated from a nasopharynx and anal canal, and complete genomic characterization of papillomavirus species
Gamma-12. PLoS ONE 2015, 10, e0138628. [CrossRef]
Int. J. Mol. Sci. 2024, 25, 7616 29 of 33

137. Bolatti, E.M.; Hosnjak, L.; Chouhy, D.; Re-Louhau, M.F.; Casal, P.E.; Bottai, H.; Kocjan, B.J.; Stella, E.J.; Gorosito, M.D.; Sanchez,
A.; et al. High prevalence of Gammapapillomaviruses (Gamma-PVs) in pre-malignant cutaneous lesions of immunocompetent
individuals using a new broad-spectrum primer system, and identification of HPV210, a novel Gamma-PV type. Virology 2018,
525, 182–191. [CrossRef] [PubMed]
138. Sturegård, E.; Johansson, H.; Ekström, J.; Hansson, B.G.; Johnsson, A.; Gustafsson, E.; Dillner, J.; Forslund, O. Human papil-
lomavirus typing in reporting of condyloma. Sex. Transm. Dis. 2013, 40, 123–129, Erratum in Sex. Transm. Dis. 2013, 40, 760.
[CrossRef] [PubMed]
139. Hosnjak, L.; Kocjan, B.J.; Pirš, B.; Seme, K.; Poljak, M. Characterization of two novel Gammapapillomaviruses, HPV179 and
HPV184, isolated from common warts of a renal-transplant recipient. PLoS ONE 2015, 10, e0119154. [CrossRef] [PubMed]
140. Hosnjak, L.; Kocjan, B.J.; Pirš, B.; Seme, K.; Poljak, M. The genetic diversity of human papillomavirus types from the species
Gammapapillomavirus 15: HPV135, HPV146, and HPV179. PLoS ONE 2021, 16, e0249829. [CrossRef] [PubMed]
141. Chouhy, D.; Bolatti, E.M.; Piccirilli, G.; Sanchez, A.; Fernandez Bussy, R.; Giri, A.A. Identification of human papillomavirus type
156, the prototype of a new human gammapapillomavirus species, by a generic and highly sensitive PCR strategy for long DNA
fragments. J. Gen. Virol. 2013, 94, 524–533. [CrossRef] [PubMed]
142. Johansson, H.; Forslund, O. Complete genome sequences of three novel human papillomavirus types, 175, 178, and 180. Genome
Announc. 2014, 2, e00443-14. [CrossRef] [PubMed]
143. Arroyo Mühr, L.S.; Hultin, E.; Bzhalava, D.; Eklund, C.; Lagheden, C.; Ekström, J.; Johansson, H.; Forslund, O.; Dillner, J. Human
papillomavirus type 197 is commonly present in skin tumors. Int. J. Cancer 2015, 136, 2546–2555. [CrossRef] [PubMed]
144. Danos, O.; Katinka, M.; Yaniv, M. Human papillomavirus 1a complete DNA sequence: A novel type of genome organization
among papovaviridae. EMBO J. 1982, 1, 231–236. [CrossRef]
145. Sterbenc, A.; Hosnjak, L.; Chouhy, D.; Bolatti, E.M.; Oštrbenk, A.; Seme, K.; Kocjan, B.J.; Luzar, B.; Giri, A.A.; Poljak, M. Molecular
characterization, tissue tropism, and genetic variability of the novel Mupapillomavirus type HPV204 and phylogenetically related
types HPV1 and HPV63. PLoS ONE 2017, 12, e0175892. [CrossRef]
146. Kocjan, B.J.; Šterbenc, A.; Hošnjak, L.; Chouhy, D.; Bolatti, E.; Giri, A.A.; Poljak, M. Genome announcement: Complete genome
sequence of a novel Mupapillomavirus, HPV204. Acta Dermatovenerol. Alp. Pannonica Adriat. 2015, 24, 21–23. [CrossRef]
147. Hirt, L.; Hirsch-Behnam, A.; de Villiers, E.M. Nucleotide sequence of human papillomavirus (HPV) type 41: An unusual HPV
type without a typical E2 binding site consensus sequence. Virus Res. 1991, 18, 179–189. [CrossRef]
148. Buck, C.B.; Cheng, N.; Thompson, C.D.; Lowy, D.R.; Steven, A.C.; Schiller, J.T.; Trus, B.L. Arrangement of L2 within the
papillomavirus capsid. J. Virol. 2008, 82, 5190–5197. [CrossRef]
149. Wang, J.W.; Roden, R.B. L2, the minor capsid protein of papillomavirus. Virology 2013, 445, 175–186. [CrossRef]
150. Finnen, R.L.; Erickson, K.D.; Chen, X.S.; Garcea, R.L. Interactions between papillomavirus L1 and L2 capsid proteins. J. Virol.
2003, 77, 4818–4826. [CrossRef]
151. Zhang, J.; Fan, J.; Skwarczynski, M.; Stephenson, R.J.; Toth, I.; Hussein, W.M. Peptide-based nanovaccines in the treatment of
cervical cancer: A review of recent advances. Int. J. Nanomed. 2022, 17, 869–900. [CrossRef]
152. Burd, E.M. Human papillomavirus and cervical cancer. Clin. Microbiol. Rev. 2003, 16, 1–17. [CrossRef]
153. Xue, J.; Vesper, B.J.; Radosevich, J.A. Proteins encoded by the human papillomavirus genome and their functions. In HPV and
Cancer; Radosevich, J.A., Ed.; Springer: Dordrecht, The Netherlands, 2012. [CrossRef]
154. Egawa, N.; Shiraz, A.; Crawford, R.; Saunders-Wood, T.; Yarwood, J.; Rogers, M.; Sharma, A.; Eichenbaum, G.; Doorbar, J.
Dynamics of papillomavirus in vivo disease formation & susceptibility to high-level disinfection-implications for transmission in
clinical settings. EBioMedicine 2021, 63, 103177. [CrossRef]
155. Meyers, C.; Milici, J.; Robison, R. UVC radiation as an effective disinfectant method to inactivate human papillomaviruses. PLoS
ONE 2017, 12, e0187377. [CrossRef]
156. Petca, A.; Borislavschi, A.; Zvanca, M.E.; Petca, R.C.; Sandru, F.; Dumitrascu, M.C. Non-sexual HPV transmission and role of
vaccination for a better future (review). Exp. Ther. Med. 2020, 20, 186. [CrossRef]
157. Yu, L.; Majerciak, V.; Zheng, Z.M. HPV16 and HPV18 genome structure, expression, and post-transcriptional regulation. Int. J.
Mol. Sci. 2022, 23, 4943. [CrossRef]
158. Graham, S.V. The human papillomavirus replication cycle, and its links to cancer progression: A comprehensive review. Clin. Sci.
2017, 131, 2201–2221. [CrossRef]
159. Doorbar, J.; Egawa, N.; Griffin, H.; Kranjec, C.; Murakami, I. Human papillomavirus molecular biology and disease association.
Rev. Med. Virol. 2015, 25 (Suppl. S1), 2–23. [CrossRef]
160. Aksoy, P.; Gottschalk, E.Y.; Meneses, P.I. HPV entry into cells. Mutat. Res. Rev. Mutat. Res. 2017, 772, 13–22. [CrossRef]
161. Aranda-Rivera, A.K.; Cruz-Gregorio, A.; Briones-Herrera, A.; Pedraza-Chaverri, J. Regulation of autophagy by high- and low-risk
human papillomaviruses. Rev. Med. Virol. 2021, 31, e2169. [CrossRef]
162. Cruz, L.; Meyers, C. Differential dependence on host cell glycosaminoglycans for infection of epithelial cells by high-risk HPV
types. PLoS ONE 2013, 8, e68379. [CrossRef]
163. Mikuličić, S.; Strunk, J.; Florin, L. HPV16 entry into epithelial cells: Running a gauntlet. Viruses 2021, 13, 2460. [CrossRef]
164. Scarth, J.A.; Patterson, M.R.; Morgan, E.L.; Macdonald, A. The human papillomavirus oncoproteins: A review of the host
pathways targeted on the road to transformation. J. Gen. Virol. 2021, 102, 001540. [CrossRef]
165. Graham, S.V. Keratinocyte differentiation-dependent human papillomavirus gene regulation. Viruses 2017, 9, 245. [CrossRef]
Int. J. Mol. Sci. 2024, 25, 7616 30 of 33

166. Moody, C. Mechanisms by which HPV induces a replication competent environment in differentiating keratinocytes. Viruses
2017, 9, 261. [CrossRef]
167. Della Fera, A.N.; Warburton, A.; Coursey, T.L.; Khurana, S.; McBride, A.A. Persistent human papillomavirus infection. Viruses
2021, 13, 321. [CrossRef]
168. Campo, M.S.; Graham, S.V.; Cortese, M.S.; Ashrafi, G.H.; Araibi, E.H.; Dornan, E.S.; Miners, K.; Nunes, C.; Man, S. HPV-16 E5
down-regulates expression of surface HLA class I and reduces recognition by CD8 T cells. Virology 2010, 407, 137–142. [CrossRef]
169. Chen, B.; Zhao, L.; Yang, R.; Xu, T. Advances in molecular mechanism of HPV16 E5 oncoprotein carcinogenesis. Arch. Biochem.
Biophys. 2023, 745, 109716. [CrossRef]
170. Graham, S.V. Human papillomavirus: Gene expression, regulation and prospects for novel diagnostic methods and antiviral
therapies. Future Microbiol. 2010, 5, 1493–1506. [CrossRef]
171. Martinez-Zapien, D.; Ruiz, F.X.; Poirson, J.; Mitschler, A.; Ramirez, J.; Forster, A.; Cousido-Siah, A.; Masson, M.; Vande Pol, S.;
Podjarny, A.; et al. Structure of the E6/E6AP/p53 complex required for HPV-mediated degradation of p53. Nature 2016, 529,
541–545. [CrossRef]
172. Moody, C.A.; Laimins, L.A. Human papillomavirus oncoproteins: Pathways to transformation. Nat. Rev. Cancer. 2010, 10, 550–560.
[CrossRef]
173. Fu, L.; Van Doorslaer, K.; Chen, Z.; Ristriani, T.; Masson, M.; Travé, G.; Burk, R.D. Degradation of p53 by human Alphapapillo-
mavirus E6 proteins shows a stronger correlation with phylogeny than oncogenicity. PLoS ONE 2010, 5, e12816. [CrossRef]
174. Hatterschide, J.; Bohidar, A.E.; Grace, M.; Nulton, T.J.; Kim, H.W.; Windle, B.; Morgan, I.M.; Munger, K.; White, E.A. PTPN14
degradation by high-risk human papillomavirus E7 limits keratinocyte differentiation and contributes to HPV-mediated oncogen-
esis. Proc. Natl. Acad. Sci. USA 2019, 116, 7033–7042. [CrossRef]
175. Ibeanu, O.A. Molecular pathogenesis of cervical cancer. Cancer Biol. Ther. 2011, 11, 295–306. [CrossRef]
176. Katzenellenbogen, R. Telomerase induction in HPV infection and oncogenesis. Viruses 2017, 9, 180. [CrossRef]
177. Ganti, K.; Broniarczyk, J.; Manoubi, W.; Massimi, P.; Mittal, S.; Pim, D.; Szalmas, A.; Thatte, J.; Thomas, M.; Tomaić, V.; et al. The
human papillomavirus E6 PDZ binding motif: From life cycle to malignancy. Viruses 2015, 7, 3530–3551. [CrossRef]
178. Gupta, S.; Kumar, P.; Das, B.C. HPV: Molecular pathways and targets. Curr. Probl. Cancer. 2018, 42, 161–174. [CrossRef]
179. Gheit, T. Mucosal and cutaneous human papillomavirus Infections and cancer biology. Front. Oncol. 2019, 9, 355. [CrossRef]
[PubMed]
180. Ren, S.; Gaykalova, D.A.; Guo, T.; Favorov, A.V.; Fertig, E.J.; Tamayo, P.; Callejas-Valera, J.L.; Allevato, M.; Gilardi, M.; Santos, J.;
et al. HPV E2, E4, E5 drive alternative carcinogenic pathways in HPV positive cancers. Oncogene 2020, 39, 6327–6339. [CrossRef]
181. Westrich, J.A.; Warren, C.J.; Pyeon, D. Evasion of host immune defenses by human papillomavirus. Virus Res. 2017, 231, 21–33.
[CrossRef]
182. Beachler, D.C.; Jenkins, G.; Safaeian, M.; Kreimer, A.R.; Wentzensen, N. Natural acquired immunity against subsequent genital
human papillomavirus infection: A systematic review and meta-analysis. J. Infect. Dis. 2016, 213, 1444–1454. [CrossRef] [PubMed]
183. Zhou, C.; Tuong, Z.K.; Frazer, I.H. Papillomavirus immune evasion strategies target the infected cell and the local immune system.
Front. Oncol. 2019, 9, 682. [CrossRef]
184. Tang, J.; Li, M.; Zhao, C.; Shen, D.; Liu, L.; Zhang, X.; Wei, L. Therapeutic DNA vaccines against HPV-related malignancies:
Promising leads from clinical trials. Viruses 2022, 14, 239. [CrossRef] [PubMed]
185. Franciosi, J.R.; Gelmini, G.F.; Roxo, V.S.; de Carvalho, N.S.; Bicalho, M.D.G. Is there a role played by HLA-E, if any, in HPV
immune evasion? Scand. J. Immunol. 2020, 91, 12850. [CrossRef]
186. Hancock, G.; Hellner, K.; Dorrell, L. Therapeutic HPV vaccines. Best. Pract. Res. Clin. Obstet. Gynaecol. 2018, 47, 59–72. [CrossRef]
187. Kamolratanakul, S.; Pitisuttithum, P. Human papillomavirus vaccine efficacy and effectiveness against cancer. Vaccines 2021,
9, 1413. [CrossRef]
188. Rochefort, J.; Karagiannidis, I.; Baillou, C.; Belin, L.; Guillot-Delost, M.; Macedo, R.; Le Moignic, A.; Mateo, V.; Soussan, P.;
Brocheriou, I.; et al. Defining biomarkers in oral cancer according to smoking and drinking status. Front. Oncol. 2023, 12, 1068979.
[CrossRef] [PubMed]
189. Westrich, J.A.; Vermeer, D.W.; Colbert, P.L.; Spanos, W.C.; Pyeon, D. The multifarious roles of the chemokine CXCL14 in cancer
progression and immune responses. Mol. Carcinog. 2020, 59, 794–806. [CrossRef]
190. Winer, R.L.; Kiviat, N.B.; Hughes, J.P.; Adam, D.E.; Lee, S.K.; Kuypers, J.M.; Koutsky, L.A. Development and duration of human
papillomavirus lesions, after initial infection. J. Infect. Dis. 2005, 191, 731–738. [CrossRef]
191. Harper, A.; Vijayakumar, V.; Ouwehand, A.C.; Ter Haar, J.; Obis, D.; Espadaler, J.; Binda, S.; Desiraju, S.; Day, R. Viral infections,
the microbiome, and probiotics. Front. Cell Infect. Microbiol. 2021, 10, 596166. [CrossRef]
192. Bukowska, E.; Mlynarczyk-Bonikowska, B.; Malejczyk, M.; Przedpełska, G.; Walter De Walthoffen, S.; Mlynarczyk, G.; Majewski, S.
Human papillomavirus (HPV) coinfection with other sexually transmitted infections in patients of the Department of Dermatology
and Venereology at the Medical University of Warsaw. Dermatol. Rev. 2020, 107, 138–147. [CrossRef]
193. Norenhag, J.; Du, J.; Olovsson, M.; Verstraelen, H.; Engstrand, L.; Brusselaers, N. The vaginal microbiota, human papillomavirus
and cervical dysplasia: A systematic review and network meta-analysis. BJOG 2020, 127, 171–180. [CrossRef] [PubMed]
194. Mlynarczyk, B.; Malejczyk, M.; Muszyński, J.; Majewski, S. The occurrence of human papillomavirus--HPV in the biopsies from
colon polyps and cancer. Med. Dosw. Mikrobiol. 2009, 61, 191–196.
195. Bristow, I. Paediatric cutaneous warts and verrucae: An update. Int. J. Environ. Res. Public Health 2022, 19, 16400. [CrossRef]
Int. J. Mol. Sci. 2024, 25, 7616 31 of 33

196. Skubic, L.; Breznik, V.; Poljak, M. Different skin wart types, different human papillomavirus types? A narrative review. Acta
Dermatovenerol. Alp. Pannonica Adriat. 2023, 32, 165–171. [CrossRef]
197. Yuan, H.; Li, R.; Lv, J.; Yi, G.; Sun, X.; Zhao, N.; Zhao, F.; Xu, A.; Kou, Z.; Wen, H. Epidemiology of human papillomavirus on
condyloma acuminatum in Shandong Province, China. Hum. Vaccines Immunother. 2023, 19, 2170662. [CrossRef]
198. Wang, Q.; Xu, L.; Li, X.; Yu, M.; Chen, Q. Multifocal epithelial hyperplasia confined to the interdental papilla of an adult Chinese
man: A rare case report and literature review. BMC Oral Health 2023, 23, 699. [CrossRef] [PubMed]
199. Becerril, S.; Corchado-Cobos, R.; García-Sancha, N.; Revelles, L.; Revilla, D.; Ugalde, T.; Román-Curto, C.; Pérez-Losada, J.;
Cañueto, J. Viruses and skin cancer. Int. J. Mol. Sci. 2021, 22, 5399. [CrossRef] [PubMed]
200. Shimizu, A.; Yamaguchi, R.; Kuriyama, Y. Recent advances in cutaneous HPV infection. J. Dermatol. 2023, 50, 290–298. [CrossRef]
[PubMed]
201. Malagón, T.; Drolet, M.; Boily, M.C.; Franco, E.L.; Jit, M.; Brisson, J.; Brisson, M. Cross-protective efficacy of two human
papillomavirus vaccines: A systematic review and meta-analysis. Lancet Infect. Dis. 2012, 12, 781–789. [CrossRef] [PubMed]
202. Markowitz, L.E.; Schiller, J.T. Human papillomavirus vaccines. J. Infect. Dis. 2021, 224 (Suppl. S2), S367–S378. [CrossRef]
[PubMed]
203. Bednarczyk, R.A. Addressing HPV vaccine myths: Practical information for healthcare providers. Hum. Vaccines Immunother.
2019, 15, 1628–1638. [CrossRef] [PubMed]
204. Stefanos, R.; Lewis, R.M.; Querec, T.D.; Gargano, J.W.; Unger, E.R.; Markowitz, L.E. High impact of quadrivalent human
papillomavirus vaccine across racial/ethnic groups: National Health and Nutrition Examination Survey, 2003-2006 and 2015-2018.
Hum. Vaccines Immunother. 2024, 20, 2308378. [CrossRef] [PubMed]
205. Williamson, A.L. Recent developments in human papillomavirus (HPV) vaccinology. Viruses 2023, 15, 1440. [CrossRef] [PubMed]
206. Li, M.; Zhao, C.; Zhao, Y.; Li, J.; Wei, L. Immunogenicity, efficacy, and safety of human papillomavirus vaccine: Data from China.
Front. Immunol. 2023, 14, 1112750. [CrossRef]
207. Mo, Y.; Ma, J.; Zhang, H.; Shen, J.; Chen, J.; Hong, J.; Xu, Y.; Qian, C. Prophylactic and therapeutic HPV vaccines: Current scenario
and perspectives. Front. Cell Infect. Microbiol. 2022, 12, 909223. [CrossRef]
208. Huber, B.; Wang, J.W.; Roden, R.B.S.; Kirnbauer, R. RG1-VLP and other L2-based, broad-spectrum HPV vaccine candidates. J.
Clin. Med. 2021, 10, 1044. [CrossRef]
209. Goldstone, S.E. Human papillomavirus (HPV) vaccines in adults: Learnings from long-term follow-up of quadrivalent HPV
vaccine clinical trials. Hum. Vaccines Immunother. 2023, 19, 2184760. [CrossRef] [PubMed]
210. Han, L.; Zhang, B. Can prophylactic HPV vaccination reduce the recurrence of cervical lesions after surgery? review and prospect.
Infect. Agent Cancer 2023, 18, 66. [CrossRef]
211. Karimi-Zarchi, M.; Allahqoli, L.; Nehmati, A.; Kashi, A.M.; Taghipour-Zahir, S.; Alkatout, I. Can the prophylactic quadrivalent
HPV vaccine be used as a therapeutic agent in women with CIN? A randomized trial. BMC Public Health 2020, 20, 274. [CrossRef]
[PubMed]
212. Kechagias, K.S.; Kalliala, I.; Bowden, S.J.; Athanasiou, A.; Paraskevaidi, M.; Paraskevaidis, E.; Dillner, J.; Nieminen, P.; Strander,
B.; Sasieni, P.; et al. Role of human papillomavirus (HPV) vaccination on HPV infection and recurrence of HPV related disease
after local surgical treatment: Systematic review and meta-analysis. BMJ 2022, 378, e070135. [CrossRef] [PubMed]
213. Skolnik, J.M.; Morrow, M.P. Vaccines for HPV-associated diseases. Mol. Asp. Med. 2023, 94, 101224. [CrossRef]
214. Yan, F.; Cowell, L.G.; Tomkies, A.; Day, A.T. Therapeutic vaccination for HPV-mediated cancers. Curr. Otorhinolaryngol. Rep. 2023,
11, 44–61. [CrossRef]
215. Harper, D.M.; Nieminen, P.; Donders, G.; Einstein, M.H.; Garcia, F.; Huh, W.K.; Stoler, M.H.; Glavini, K.; Attley, G.; Limacher, J.M.;
et al. The efficacy and safety of Tipapkinogen Sovacivec therapeutic HPV vaccine in cervical intraepithelial neoplasia grades 2
and 3: Randomized controlled phase II trial with 2.5 years of follow-up. Gynecol. Oncol. 2019, 153, 521–529. [CrossRef]
216. Rosales, R.; Rosales, C. Immune therapy for human papillomaviruses-related cancers. World J. Clin. Oncol. 2014, 5, 1002–1019.
[CrossRef]
217. Cabo Beltran, O.R.; Rosales Ledezma, R. MVA E2 therapeutic vaccine for marked reduction in likelihood of recurrence of
respiratory papillomatosis. Head Neck 2019, 41, 657–665. [CrossRef]
218. Trimble, C.L.; Morrow, M.P.; Kraynyak, K.A.; Shen, X.; Dallas, M.; Yan, J.; Edwards, L.; Parker, R.L.; Denny, L.; Giffear, M.; et al.
Safety, efficacy, and immunogenicity of VGX-3100, a therapeutic synthetic DNA vaccine targeting human papillomavirus 16 and
18 E6 and E7 proteins for cervical intraepithelial neoplasia 2/3: A randomised, double-blind, placebo-controlled phase 2b trial.
Lancet 2015, 386, 2078–2088. [CrossRef] [PubMed]
219. Choi, Y.J.; Hur, S.Y.; Kim, T.J.; Hong, S.R.; Lee, J.K.; Cho, C.H.; Park, K.S.; Woo, J.W.; Sung, Y.C.; Suh, Y.S.; et al. A phase II,
prospective, randomized, multicenter, open-label study of GX-188E, an HPV DNA vaccine, in patients with cervical intraepithelial
neoplasia 3. Clin. Cancer Res. 2020, 26, 1616–1623. [CrossRef] [PubMed]
220. Einstein, M.H.; Roden, R.B.S.; Ferrall, L.; Akin, M.; Blomer, A.; Wu, T.C.; Chang, Y.N. Safety run-in of intramuscular pNGVL4a-
Sig/E7(detox)/HSP70 DNA and TA-CIN protein vaccination as treatment for HPV16+ ASC-US, ASC-H, or LSIL/CIN1. Cancer
Prev. Res. 2023, 16, 219–227. [CrossRef] [PubMed]
Int. J. Mol. Sci. 2024, 25, 7616 32 of 33

221. Ikeda, Y.; Adachi, K.; Tomio, K.; Eguchi-Kojima, S.; Tsuruga, T.; Uchino-Mori, M.; Taguchi, A.; Komatsu, A.; Nagamatsu, T.;
Oda, K.; et al. A placebo-controlled, double-blind randomized (phase IIB) trial of oral administration with HPV16 E7-expressing
Lactobacillus, GLBL101c, for the treatment of cervical intraepithelial neoplasia grade 2 (CIN2). Vaccines 2021, 9, 329. [CrossRef]
[PubMed]
222. Kawana, K.; Kobayashi, O.; Ikeda, Y.; Yahata, H.; Iwata, T.; Satoh, T.; Akiyama, A.; Maeda, D.; Hori-Hirose, Y.; Uemura, Y.; et al.
Phase I and II randomized clinical trial of an oral therapeutic vaccine targeting human papillomavirus for treatment of cervical
intraepithelial neoplasia 2 and 3. JNCI Cancer Spectr. 2023, 7, pkad101. [CrossRef] [PubMed]
223. Park, Y.C.; Ouh, Y.T.; Sung, M.H.; Park, H.G.; Kim, T.J.; Cho, C.H.; Park, J.S.; Lee, J.K. A phase 1/2a, dose-escalation, safety and
preliminary efficacy study of oral therapeutic vaccine in subjects with cervical intraepithelial neoplasia 3. J. Gynecol. Oncol. 2019,
30, e88. [CrossRef]
224. Speetjens, F.M.; Welters, M.J.P.; Slingerland, M.; van Poelgeest, M.I.E.; de Vos van Steenwijk, P.J.; Roozen, I.; Boekestijn, S.; Loof,
N.M.; Zom, G.G.; Valentijn, A.R.P.M.; et al. Intradermal vaccination of HPV-16 E6 synthetic peptides conjugated to an optimized
Toll-like receptor 2 ligand shows safety and potent T cell immunogenicity in patients with HPV-16 positive (pre-) malignant
lesions. J. Immunother. Cancer. 2022, 10, e005016. [CrossRef] [PubMed]
225. Kenter, G.G.; Welters, M.J.; Valentijn, A.R.; Lowik, M.J.; Berends-van der Meer, D.M.; Vloon, A.P.; Essahsah, F.; Fathers, L.M.;
Offringa, R.; Drijfhout, J.W.; et al. Vaccination against HPV-16 oncoproteins for vulvar intraepithelial neoplasia. N. Engl. J. Med.
2009, 361, 1838–1847. [CrossRef]
226. Akhatova, A.; Chan, C.K.; Azizan, A.; Aimagambetova, G. The efficacy of therapeutic DNA vaccines expressing the human
papillomavirus E6 and E7 oncoproteins for treatment of cervical cancer: Systematic review. Vaccines 2021, 10, 53. [CrossRef]
227. Aggarwal, C.; Saba, N.F.; Algazi, A.; Sukari, A.; Seiwert, T.Y.; Haigentz, M.; Porosnicu, M.; Bonomi, M.; Boyer, J.; Esser, M.T.; et al.
Safety and efficacy of MEDI0457 plus Durvalumab in patients with human papillomavirus-associated recurrent/metastatic head
and neck squamous cell carcinoma. Clin. Cancer Res. 2023, 29, 560–570. [CrossRef]
228. Morris, V.K.; Jazaeri, A.; Westin, S.N.; Pettaway, C.; George, S.; Huey, R.W.; Grinsfelder, M.; Shafer, A.; Johnson, B.; Vining, D.;
et al. Phase II trial of MEDI0457 and Durvalumab for patients with recurrent/metastatic human papillomavirus-associated
cancers. Oncologist 2023, 28, 618–623. [CrossRef] [PubMed]
229. Galicia-Carmona, T.; Arango-Bravo, E.; Serrano-Olvera, J.A.; Flores-de La Torre, C.; Cruz-Esquivel, I.; Villalobos-Valencia, R.;
Morán-Mendoza, A.; Castro-Eguiluz, D.; Cetina-Pérez, L. ADXS11-001 LM-LLO as specific immunotherapy in cervical cancer.
Hum. Vaccines Immunother. 2021, 17, 2617–2625. [CrossRef]
230. Ramos da Silva, J.; Bitencourt Rodrigues, K.; Formoso Pelegrin, G.; Silva Sales, N.; Muramatsu, H.; de Oliveira Silva, M.;
Porchia, B.F.M.M.; Moreno, A.C.R.; Aps, L.R.M.M.; Venceslau-Carvalho, A.A.; et al. Single immunizations of self-amplifying or
non-replicating mRNA-LNP vaccines control HPV-associated tumors in mice. Sci. Transl. Med. 2023, 15, eabn3464. [CrossRef]
[PubMed]
231. Kollipara, R.; Ekhlassi, E.; Downing, C.; Guidry, J.; Lee, M.; Tyring, S.K. Advancements in pharmacotherapy for noncancerous
manifestations of HPV. J. Clin. Med. 2015, 4, 832–846. [CrossRef] [PubMed]
232. Stern, P.L.; van der Burg, S.H.; Hampson, I.N.; Broker, T.R.; Fiander, A.; Lacey, C.J.; Kitchener, H.C.; Einstein, M.H. Therapy of
human papillomavirus-related disease. Vaccine 2012, 30 (Suppl. S5), F71–F82. [CrossRef] [PubMed]
233. García-Oreja, S.; Álvaro-Afonso, F.J.; García-Álvarez, Y.; García-Morales, E.; Sanz-Corbalán, I.; Lázaro Martínez, J.L. Topical
treatment for plantar warts: A systematic review. Dermatol. Ther. 2021, 34, e14621. [CrossRef] [PubMed]
234. Majewski, S.; Marczak, M.; Mlynarczyk, B.; Benninghoff, B.; Jablonska, S. Imiquimod is a strong inhibitor of tumor cell-induced
angiogenesis. Int. J. Dermatol. 2005, 44, 14–19. [CrossRef] [PubMed]
235. Yuan, J.; Ni, G.; Wang, T.; Mounsey, K.; Cavezza, S.; Pan, X.; Liu, X. Genital warts treatment: Beyond imiquimod. Hum. Vaccines
Immunother. 2018, 14, 1815–1819. [CrossRef] [PubMed]
236. Herzum, A.; Ciccarese, G.; Occella, C.; Gariazzo, L.; Pastorino, C.; Trave, I.; Viglizzo, G. Treatment of pediatric anogenital warts in
the era of HPV-vaccine: A literature review. J. Clin. Med. 2023, 12, 4230. [CrossRef]
237. Miyoshi, N.; Tanabe, H.; Suzuki, T.; Saeki, K.; Hara, Y. Applications of a standardized green tea catechin preparation for viral
warts and human papilloma virus-related and unrelated cancers. Molecules 2020, 25, 2588. [CrossRef]
238. Lau, W.C.; Lau, C.B.; Frangos, J.E.; Nambudiri, V.E. Intralesional cidofovir for the management of refractory cutaneous verrucae:
A review of applications and opportunities. Ther. Adv. Infect. Dis. 2023, 10, 20499361231165862. [CrossRef] [PubMed]
239. Eldahshan, R.M.; Ashry, W.M.O.; Elsaie, M.L. Comparative study between intralesional injection of MMR, BCG, and candida
albicans antigen in treatment of multiple recalcitrant warts. J. Cosmet. Dermatol. 2022, 21, 1120–1126. [CrossRef] [PubMed]
240. Elsayed Ghaly, N.; El-Ashmawy, A.A.; Abou Zeid, M.; E Shaker, E.S. Efficacy and safety of intralesional injection of vitamin D3
versus tuberculin PPD in the treatment of plantar warts: A comparative controlled study. J. Cosmet. Dermatol. 2021, 20, 1231–1240.
[CrossRef] [PubMed]
241. Gunasinghe, J.; Hwang, S.S.; Yam, W.K.; Rahman, T.; Wezen, X.C. In-silico discovery of inhibitors against human papillomavirus
E1 protein. J. Biomol. Struct. Dyn. 2023, 41, 5583–5596. [CrossRef] [PubMed]
242. Bhattacharjee, R.; Das, S.S.; Biswal, S.S.; Nath, A.; Das, D.; Basu, A.; Malik, S.; Kumar, L.; Kar, S.; Singh, S.K.; et al. Mechanistic
role of HPV-associated early proteins in cervical cancer: Molecular pathways and targeted therapeutic strategies. Crit. Rev. Oncol.
Hematol. 2022, 174, 103675. [CrossRef] [PubMed]
Int. J. Mol. Sci. 2024, 25, 7616 33 of 33

243. Toots, M.; Ustav, M., Jr.; Männik, A.; Mumm, K.; Tämm, K.; Tamm, T.; Ustav, E.; Ustav, M. Identification of several high-risk HPV
inhibitors and drug targets with a novel high-throughput screening assay. PLoS Pathog. 2017, 13, e1006168. [CrossRef] [PubMed]
244. Zheng, K.; Egawa, N.; Shiraz, A.; Katakuse, M.; Okamura, M.; Griffin, H.M.; Doorbar, J. The reservoir of persistent human
papillomavirus infection; strategies for elimination using anti-viral therapies. Viruses 2022, 14, 214. [CrossRef] [PubMed]
245. Wetherill, L.F.; Wasson, C.W.; Swinscoe, G.; Kealy, D.; Foster, R.; Griffin, S.; Macdonald, A. Alkyl-imino sugars inhibit the
pro-oncogenic ion channel function of human papillomavirus (HPV) E5. Antivir. Res. 2018, 158, 113–121. [CrossRef] [PubMed]
246. Bertagnin, C.; Messa, L.; Pavan, M.; Celegato, M.; Sturlese, M.; Mercorelli, B.; Moro, S.; Loregian, A. A small molecule targeting
the interaction between human papillomavirus E7 oncoprotein and cellular phosphatase PTPN14 exerts antitumoral activity in
cervical cancer cells. Cancer Lett. 2023, 571, 216331. [CrossRef]
247. Hua, C.; Zhu, Y.; Wu, C.; Si, L.; Wang, Q.; Sui, L.; Jiang, S. The underlying mechanism of 3-hydroxyphthalic anhydride-modified
bovine beta-lactoglobulin to block human papillomavirus entry into the host cell. Front. Microbiol. 2019, 10, 2188. [CrossRef]
248. Valencia-Reséndiz, D.G.; Villegas, A.; Bahena, D.; Palomino, K.; Cornejo-Bravo, J.M.; Quintanar, L.; Palomino-Vizcaino, G.;
Alvarez-Salas, L.M. Non-functionalized gold nanoparticles inhibit human papillomavirus (HPV) infection. Int. J. Mol. Sci. 2022,
23, 7552. [CrossRef] [PubMed]
249. Zhang, P.; Moreno, R.; Lambert, P.F.; DiMaio, D. Cell-penetrating peptide inhibits retromer-mediated human papillomavirus
trafficking during virus entry. Proc. Natl. Acad. Sci. USA 2020, 117, 6121–6128. [CrossRef] [PubMed]
250. Young, J.M.; Zine El Abidine, A.; Gómez-Martinez, R.A.; Bondu, V.; Sterk, R.T.; Surviladze, Z.; Ozbun, M.A. Protamine sulfate
is a potent inhibitor of human papillomavirus infection in vitro and in vivo. Antimicrob. Agents Chemother. 2022, 66, e0151321.
[CrossRef] [PubMed]
251. Khamjan, N.A.; Beigh, S.; Algaissi, A.; Megha, K.; Lohani, M.; Darraj, M.; Kamli, N.; Madkhali, F.; Dar, S.A. Natural and synthetic
drugs and formulations for intravaginal HPV clearance. J. Infect. Public Health 2023, 16, 1471–1480. [CrossRef]
252. Nadile, M.; Retsidou, M.I.; Gioti, K.; Beloukas, A.; Tsiani, E. Resveratrol against cervical cancer: Evidence from in vitro and
in vivo studies. Nutrients 2022, 14, 5273. [CrossRef]

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