By Gary M. White, MD
Condyloma acuminata (COA) or genital warts is the most common sexually transmitted disease and represents infection by the human papillomavirus (HPV).
In one study, about 1/4 of prepubertal girls carried genital HPV.
Smooth or papillomatous papules or nodules occur on the penis, scrotum, perianal region, and on the skin of the groin in men. In women, lesions may occur on the vulva, labia, cervix or intravaginally. Lesions may be flesh-colored, tan, or brown.
The moist-occluded inguinal folds may give rise to larger cauliflower-like growths that are often foul-smelling.
All patients with genital lesions should have a perianal exam to exclude perianal involvement. Those with perianal condyloma and a history of receptive anal sex should have anoscopy to exclude intra-anal warts.
Most classic appearing condyloma are caused by the "benign" HPV types 6 and 11. The "high-risk" HPV types 16 and 18 often produce a flattish, hyperpigmented papule which in the past was called "Bowenoid papulosis." Now this lesion is termed "high-grade squamous intraepithelial lesion" (HGSIL). Histologically, these lesions show hyperpigmentation and numerous mitoses. Female sexual partners of men with HGSIL are at increased risk for cervical cancer.
HIV-positive patients with anogenital warts are much more likely to harbor high-grade dysplasia or even cancer, despite classic morphology, than HIV-negative patients [JAMA Derm 2016;152;1225]. Thus, histologic examination of AGW in HIV-positive patients is recommended.
Patients with COA are at increased risk for other STDs. Both sexes should have a complete genital and perianal exam. Women should also have a pelvic exam with cervical cytology screening. An HIV test may be ordered and RPR if indicated. Trying to type the HPV is generally not useful due to 1) the high background rate of latent infection (up to 50%), 2) multiple HPV types in the same patient, and 3) differing results depending upon whether the surface or deeper epidermis is sampled.
See perianal condyloma as well.
The patient should first be educated about the contagious nature of this condition. For men, a condom should be used during sex until the skin is clear of lesions for three months. Even after that however, recurrence and transmission may occur. Furthermore, wearing a condom does not prevent transmission of HPV from the base of the penis and scrotum to the vulva and vice versa. Sexual partners should be examined and women should have a pap smear because of the risk of cervical dysplasia/cancer.
Because clearance of visible lesions does not rule out latent infection and recurrence, treatment is not mandatory. Pain, discomfort, social embarrassment, foul-odor, and the theoretical, but not proven, decreased risk of transmission may all be taken into account when deciding upon treatment vs. observation. This does not apply, however, to Bowenoid papulosis/high-grade squamous intraepithelial lesions which should be eradicated if possible.
Cryotherapy every 1-3 weeks is perhaps the most common treatment. Waiting longer between treatments allows the lesions to grow back. In one study, freezing every 7-8 days cleared the lesions in fewer sessions than freezing every 14-21 days [Dermatologica Sinica September 2014; 32, Issue 3, Pages 154–156]. Cryotherapy for warts may be done as follows: Freeze until white with 1 mm margin. Let thaw, repeat.
Local anesthesia followed by light cautery, curettage, or both is often more effective than freezing. There is a higher risk of scarring however. Patients are often seen monthly until the area stays clear.
Several condyloma may be injected every 3-4 weeks for 3-5 treatments.
Podofilox is applied to each wart BID for three consecutive days a week. Significant inflammation should be expected.
For external genital/perianal warts, imiquimod 5% cream (Aldara) is to be applied three days a week (e.g., Monday, Wednesday, and Friday) for up to 16 weeks. Patients should be warned about the potential for significant inflammation and rarely the development of permanent white spots.
Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) may be applied in the office with repeat treatments every 2-3 weeks until clearing is achieved.
The application of 5% KOH daily for 12 weeks resulted in 70% of patients clear or almost clear [Int J Dermatol 2014;53:1145-50].
Ingenol mebutate appears highly effective in the treatment of anogenital warts with just one application. In one report of 10 patients using either 0.015% or 0.05% ingenol mebutate (IM) or placebo, all warts cleared within 3-7 days. No sites treated with vehicle cleared. There were no recurrences in three months at sites which cleared. There was mild to moderate burning x 1-2 days. [J Invest Dermatol 2014;134:S90-107]. In a similar study [JEADV 2016;30;1041], a single application of either 0.015% or 0.05% gel cleared 13/17 patients with anogenital warts. Up to three applications cleared 16/17.
Ever-smokers have significant increased risk of external genital warts compared to never-smokers even when corrected for sexual behavior (age at onset of sex, number of partners, use of condoms). The study found 0.6% increased risk per each extra cigarette/day [Sex Transm Infect 2010;86:258].
Condyloma of the urethral meatus may be treated with any of the destructive methods above. In addition, 5% fluorouracil (5-FU) may be applied after voiding BID-TID for 2-3 weeks. The urethra may be dried with one end of a cotton-tipped applicator and then the 5-FU applied with the other end. The opening is then pressed closed and the excess wiped off. Painful urination and discharge may occur with this therapy.
Condyloma in children always brings up the issue of sexual abuse. That risk is highest in those over three years of age. Infants < 1 year of age probably acquired the HPV through vertical transmission. Children 1-3 years of age may be referred to child protective services on a case-by-case basis.
For infants and children with genital (including perianal) warts, imiquimod three times per week and/or podofilox BID for three days with a four day break are useful [PD 2001;18;448 and 50].
Seborrheic keratosis-like lesion induced by HPV on the abdomen.
In a 6-year-old.
A 23-year-old woman with Bowenoid papulosis (high-grade squamous intraepithelial lesions) of the vulva and subsequent periungual Bowen's disease. Ann Dermatol. 2011 Nov; 23(4): 493–496
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