Overview
Epidemiology
- HPV:
- Most common sexually transmitted infection (STI) globally
- Affects 75% of sexually active adults in the United States at some point in their life
- Prevalence: 10%–20% in the United States
- Condylomata acuminata (CA):
- Incidence: 200 in 100,000 individuals in the United States
- Prevalence: 1% in the United States
- 80% of infected patients are between 17 and 33 years of age.
- Peak age at presentation: 22–24 years
Etiology
Condylomata acuminata are specifically lesions created by HPV.
- HPV:
- 100 strains described, 40 cause anogenital lesions
- Types 6 and 11 cause approximately 90% of cases.
- 90% of patients present with clinical symptoms.
- Transmission:
- ⅔ of patients who have intercourse with someone with CA develop CA.
- Skin-to-skin (an STD)
- Autoinoculation
- Risk factors for development of warts:
- Immunosuppression:
- Diabetes
- HIV
- Immunosuppressive therapy
- Multiple partners
- History of STI (especially chlamydia and gonorrhea)
- Young coital age
- Smoking increases risk of malignant transformation.
- Immunosuppression:
Pathophysiology
Infection to resolution:
- HPV enters through break in epithelium.
- HPV infects nucleus of differentiated squamous epithelial cells.
- Long latent phase (1 month to 2 years)
- Basal cells replicate and rise to epidermal surface (3–4 months to form wart).
- Skin cells shed, with viral particles becoming transmissible.
- Healthy individuals can clear infection over months to years.
Histopathology
- Proliferation in all epithelial layers:
- Hyperkeratosis
- Acanthosis
- Paraketosis
- Perinuclear cytoplasmic vacuolization and nuclear enlargement
Clinical Manifestation and Diagnosis
Clinical manifestation
Patients are often asymptomatic, presenting only for the appearance of lesions. The diagnosis of HPV may cause significant psychosocial distress, given the associated stigma.
- Lesion characteristics:
- Exophytic (cauliflower-like)
- Sessile: attached by short, broad peduncle (stalk)
- Flesh-colored or darker
- < 5 mm; may appears larger when grouped together
- Often asymptomatic
- If symptomatic:
- Pruritus
- Discomfort
- Rarely bleeding
- Location:
- Women:
- Labia majora
- Vagina
- Cervix
- Anus
- Men:
- Glans penis
- Scrotum
- Urethra
- Anus
- Women:
Diagnosis
- Clinical diagnosis:
- Characteristic appearance
- Appropriate patient population
- Biopsy performed:
- To confirm etiology
- If dysplasia suspected
- Lesions in inguinal region: Panel to rule out other accompanying STI
Multiple enlarged warts present in the anal region of a patient
Image: “4151” by Dr. Wiesner. License: Public Domain
Numerous genital warts on the labia majora:
Image: “17418” by Dr. M.F. Rein. License: Public Domain
Condylomata acuminata appear as flesh-colored, raised, cauliflower-like lesions of the anogenital area. In women, they can be seen on the labia majora, vagina, cervix, and anus.Genital warts present on the shaft of a penis in this patient:
Image: “16280” by Dr. M.F. Rein. License: Public Domain
Condylomata acuminata appear as flesh-colored, raised, cauliflower-like lesions of the anogenital area. In men, they can be seen on the glans penis, scrotum, urethra, and anus.
Management and Complications
Management
Spontaneous and complete resolution can take up to 24 months.
- Removal:
- Surgical excision
- Cryotherapy (liquid nitrogen) → used in pregnant patients
- Electrocautery
- Topical (antimitotic) agents:
- Podofilox (derivative of podophyllin) → avoid during pregnancy
- Imiquimod
- Vaccination (Gardasil):
- Preventive measure
- Covers HPV types 6 and 11
- Recommended for children (regardless of sex) ages 9–12 years, with 2nd dose after 6 months
Complications
- After treatment:
- Hypopigmentation or scarring
- Recurrence
- Psychosocial impact
- Co-infection with high-risk types of HPV may result in development of carcinoma.
Differential Diagnosis
- Condylomata lata (CL): second stage of syphilis (STI caused by Treponema pallidum): Condylomata lata present with wartlike lesions that are similar to those of HPV. These lesions are confined to areas with moisture and are usually gray-white in color. The patient may have a history of a chancre. Workup must include an STD panel.
- Seborrheic keratosis (SK): the most common benign epithelial cutaneous neoplasm, consisting of immature keratinocytes: Seborrheic keratosis presents as a sharply demarcated, exophytic, skin lesion that may be tan or black and has a “stuck-on” appearance similar to the genital warts caused by HPV. This condition is usually present on limbs or face. Management is similar to cryotherapy.
- Molluscum contagious: presents with lesions that are grouped, flesh-colored, dome-shaped papules with central umbilication: Usually seen in children. Management is supportive; may consider cryotherapy for cosmesis.
References
- Rosen T. Condylomata acuminata (anogenital warts) in adults: epidemiology, pathogenesis, clinical features, and diagnosis. UpToDate. Retrieved March 3, 2021, from https://www.uptodate.com/contents/condylomata-acuminata-anogenital-warts-in-adults-epidemiology-pathogenesis-clinical-features-and-diagnosis
- Kaderli R, Schnüriger B, Brügger LE. (2014). The impact of smoking on HPV infection and the development of anogenital warts. Int J Colorectal Dis 29(8), 899–908. https://pubmed.ncbi.nlm.nih.gov/24935346/
- Fleischer AB Jr, Parrish CA, Glenn R, Feldman SR. (2001). Condylomata acuminata (genital warts): patient demographics and treating physicians. Sex Transm Dis 28(11), 643–647. https://pubmed.ncbi.nlm.nih.gov/11677386/
- Park IU, Introcaso C, Dunne EF. (2015). Human papillomavirus and genital warts: a review of the evidence for the 2015 Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis 61(8), 849–855. https://pubmed.ncbi.nlm.nih.gov/26602622/
- Varma S, Lathrop E, Haddad LB. (2013). Pediatric condyloma acuminata. J Pediatr Adolesc Gynecol. 26(6), e121–122. https://pubmed.ncbi.nlm.nih.gov/24001431/
- Maw R, HPV Special Interest Group of BASHH. (2006). Anogenital warts. Sex Transm Infect. 82(4), iv40–41. https://pubmed.ncbi.nlm.nih.gov/17151053/
