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Condylomata Acuminata (Genital Warts)

Basics

  • Description:
    Soft, skin-colored, fleshy warty lesions caused by HPV, appearing singly or in groups on anogenital skin and mucosa. Can also rarely occur in conjunctiva, nasal, oral, and laryngeal mucosa.

  • Pediatric Considerations:
    Sexual abuse must be considered if seen in children, though nonsexual transmission is possible. Evaluate for abuse and other STDs in affected children.

  • Pregnancy Considerations:
    Warts may grow larger and more friable during pregnancy; treatments such as trichloroacetic acid, cryotherapy, electrocautery, and excision are preferred. HPV vaccination contraindicated in pregnancy.

Epidemiology

  • HPV types 6 and 11 cause ~90% of condylomata acuminata.
  • Other HPV types (16, 18, 31, 33, 35) may be present and linked to high-grade dysplasia in immunocompromised patients.
  • Incubation period: 1–8 months; infections often transient and clear spontaneously within 2 years.
  • Peak age: 15–30 years; equal male-to-female ratio.
  • HPV vaccination has reduced genital wart incidence in vaccinated populations.

Etiology and Pathophysiology

  • HPV: circular, double-stranded DNA virus with >120 subtypes.
  • Genital wart-causing types are generally low-risk for cancers.

Risk Factors

  • Unprotected sexual activity
  • Young age at sexual debut
  • Multiple sexual partners
  • Immunosuppression (e.g., HIV)
  • Cigarette smoking
  • Oral contraceptive use
  • Radiation therapy

General Prevention

  • Sexual abstinence or monogamy
  • HPV vaccination (9-valent vaccine Gardasil 9 covers common wart-causing and oncogenic types)
  • Condom use reduces but does not eliminate transmission risk
  • Post-treatment abstinence until warts clear

Commonly Associated Conditions

  • High-risk HPV types associated with cervical, oropharyngeal, and anogenital cancers
  • Co-existing STIs (gonorrhea, syphilis, chlamydia)
  • HIV/AIDS

Diagnosis

  • History: sexual activity, symptoms (pruritus, burning, bleeding, discharge), lesion onset
  • Physical exam: rough, warty lesions with fingerlike projections, often clustered; common sites: penis, vulva, perianal, vaginal introitus
  • Differential: condylomata lata (syphilis), lichen planus, molluscum contagiosum, skin tags, nevi, vulvar intraepithelial neoplasia, squamous cell carcinoma
  • Acetowhitening test (5% acetic acid) for subclinical lesions, though not routinely recommended
  • Biopsy if lesions are refractory or suspicious for malignancy
  • Screening: Pap smear, STI screening as appropriate

Treatment

  • Patient-applied therapies:
  • Podofilox 0.5% solution or gel (apply twice daily for 3 days, then 4 days off; up to 4 cycles)
  • Imiquimod 5% cream (apply 3 times weekly at bedtime up to 16 weeks)

  • Sinecatechins ointment (green tea extract, apply 3 times daily up to 16 weeks)

  • Provider-applied therapies:

  • Cryotherapy with liquid nitrogen (2-3 weekly sessions)
  • Podophyllin resin (10-25%) in tincture of benzoin, weekly in office
  • Trichloroacetic acid (TCA) 80% solution, weekly, especially in pregnancy

  • Surgical excision, laser, or electrocautery for large or refractory warts

  • Special sites treatment:

  • Cervical, vaginal, urethral, anal warts: cryotherapy, TCA/BCA, surgical removal as indicated

  • Pregnancy:

  • Avoid podophyllin, podofilox, imiquimod, sinecatechins
  • Use cryotherapy, surgery, or TCA

Ongoing Care

  • Follow-up every 1–2 weeks until resolution
  • Reassess 3 months after treatment completion
  • Biopsy persistent lesions
  • Counsel sexual partners and recommend monitoring

Patient Education

  • Explain HPV transmission, prevention, and vaccination
  • Clarify that HPV infection is common and often asymptomatic
  • Emphasize that diagnosis does not indicate partner infidelity
  • Stress importance of regular Pap smears in women

Prognosis

  • Most infections are asymptomatic and clear spontaneously
  • Treatment does not eradicate HPV but removes warts
  • Recurrence common, especially within first 3 months

Complications

  • Rare malignant transformation, typically not with types 6 and 11
  • Coexistence with squamous cell carcinoma possible in large warts
  • Obstruction of urethra, vagina, or anus from large lesions
  • Increased risk of high-grade anal dysplasia in HIV-positive individuals

Clinical Pearls:
- Condylomata acuminata are the most common viral STI in the U.S.
- No single therapy is universally superior; treatment choice depends on lesion size, location, and patient preference.
- HPV vaccination before sexual debut is the most effective prevention method.