Condyloma Acuminatum

Condyloma Acuminatum 

Condyloma acuminatum, also known as anogenital warts, is a sexually transmitted viral disease of the penis, vulva, vagina, cervix, perineum, and perianal area caused by the human papillomavirus (HPV).

More than 100 subtypes of the HPV virus have been identified, yet 90% of genital warts are caused by HPV types 6 or 11.

Synonyms

  • Genital warts
  • Venereal warts
  • Anogenital warts

Epidemiology & Demographics

  • •The estimated prevalence rate of HPV anogenital infection in the U.S. adult population is 10% to 20% among unvaccinated individuals
  • •Seen mostly in young adults, with peak age of onset of 16 to 25 yr
  • •A sexually transmitted disease spread by skin-to-skin contact
  • •Highly contagious, with 75% of sexually active adults in the U.S. having been infected with at least one genital HPV type at some time
  • •Virus shed from both macroscopic and microscopic lesions
  • •Average incubation time is 2 months (range, 1-8 months)
  • •Predisposing conditions: Diabetes, pregnancy, local trauma, and immunosuppression (e.g., transplant recipients, those with HIV infection)

Physical Findings & Clinical Presentation

  • •Usually found in genital area but can be present elsewhere on the body (larynx, oropharynx, trachea, and extremities)
  • •Lesions usually in similar positions on both sides of perineum
  • •Initial lesions are pedunculated, soft papules about 2 to 3 mm in diameter, 10 to 20 mm long; may occur as single papule or in clusters
  • •Size of lesions varies from pinhead to large cauliflower-like masses
  • •Usually asymptomatic, but if infected can cause pain, odor, or bleeding
  • •Vulvar condyloma more common than vaginal and cervical
  • •Four morphologic types: Condylomatous, keratotic, papular, and flat warts
  • •Intra-anal warts are observed predominantly in persons who have had receptive anal intercourse

What causes Condyloma Acuminatum?

  • •HPV is a group of nonenveloped, double-stranded DNA viruses belonging to the family Papillomaviridae.
  • •HPV DNA types 6 and 11 usually found in exophytic warts and have no malignant potential. 90% of genital warts are caused by HPV 6 and 11.
  • •HPV types 16 and 18 usually found in flat warts and are associated with increased risk of malignancy.
  • •Recurrence associated with persisting viral infection of adjacent normal skin in 25% to 50% of cases.

Differential Diagnosis

  • •Molluscum contagiosum
  • •Seborrhea keratosis
  • •Fordyce spots
  • •Lichen planus
  • •Lichen nitidus
  • •Condylomata lata of syphilis
  • •Malignancy
  • •Abnormal anatomic variants or skin tags around labia minora and introitus
  • •Dysplastic warts
  • The below table summarizes treatment options for anal warts.

Treatment Options for Anal Warts

From Feldman M et al: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.

TreatmentSuccess RateComments
Podophyllin20%-50%May need repeat applications
Skin irritation can occur
Not used in the anal canal
Poorly absorbed by keratinized lesions (most chronic warts are keratinized)
Trichloroacetic or dichloroacetic acid75%Can be used in the anal canal
Care is required to control the size of the slough
Cryotherapy75%Can be used in the anal canal
Care is required to limit the size of the wound
Fumes from the therapy can contain active HPV 
Topical 5-fluorouracil50%-75%Probably better used after surgical excision to decrease the frequency of recurrence
Imiquimod75% in women33% in menCannot be used in the anal canal; works better in women than in men
Surgical excision (usually combined with cautery)60%-90%Fumes from the cautery may contain HPV 
May need to be done in more than one session to avoid excising or burning excessive anoderm if a thick carpet of lesions is present
Intralesional interferon-α>70%Injected into the base of up to 5 warts 3 times a wk for 3-8 wk
Approved by the FDA for refractory condyloma
HspE7ExperimentalPromising treatment involving subcutaneous injections
Fusion protein that combines immune-stimulating properties and a target antigen from HPV
External-beam radiation therapyVariableReserved for giant cavitating condyloma (Buschke-Löwenstein lesions)
Used as a last resort, usually when bleeding or tissue invasion cannot be controlled

FDA, Food and Drug Administration; HPV, human papillomavirus.

∗ The risk of HPV transmission from such fumes is unknown.

How is Condyloma Acuminatum diagnosed?

  • •Colposcopic examination of lower genital tract from cervix to perianal skin with 3% to 5% acetic acid
  • •Biopsy of vulvar lesions that lack the classic appearance of warts and that become ulcerated or do not respond to treatment
  • •Biopsy of flat, white, or ulcerated cervical lesions

Laboratory Tests

  • •HPV tests are available to detect oncogenic types of HPV infection and are used in the context of cervical cancer screening and management or follow-up of abnormal cervical cytology or histology.
  • •Cervical cultures for Neisseria gonorrhoeae and Chlamydia
  • •Serologic test for syphilis
  • •HIV testing offered
  • •Wet mount or DNA testing for trichomoniasis, Candida albicans, and Gardnerella vaginalis (if patient has abnormal vaginal discharge)

How is Condyloma Acuminatum treated?

Nonpharmacologic Therapy

  • •Cryotherapy with liquid nitrogen
  • •Surgical removal

Acute General Treatment

Factors that influence selection of treatment include wart size, wart number, anatomic site of wart, wart morphology, patient preference, cost of treatment, convenience, adverse effects, and provider experience.

Keratolytic agents:

  • •Podophyllin (Podofilox 0.5% solution or gel)
    • 1.Acts by poisoning mitotic spindle and causing intense vasospasm
    • 2.Applied by patient directly to lesion weekly and washed off in 6 hr
    • 3.Used in minimal vulvar or anal disease
    • 4.Applied cautiously to nonkeratinized epithelial surfaces
    • 5.Contraindicated in pregnancy
    • 6.Discontinued if lesions do not disappear in 6 wk; switch to other treatment
  • •Sinecatechins 15% ointment (green tea flavonoid extracts)
    • 1.Acts by upregulating apoptosis-associated genes
    • 2.Applied by patient three time daily (0.5 cm strand of ointment to each wart)
    • 3.Should not be continued longer than 16 wk
  • •Trichloroacetic acid (30%-80% solution)
    • 1.Acts by destruction of the warty lesions through precipitation of surface proteins
    • 2.Applied weekly to lesion by a trained clinician
    • 3.Indicated for vulvar, anal, and vaginal lesions; can be used for cervical lesions
    • 4.Less painful and irritating to normal tissue than podophyllin
  • •5-Fluorouracil
    • 1.Acts by causing necrosis and sloughing of growing tissue
    • 2.Can be used intravaginally or for vulvar, anal, or urethral lesions
    • 3.Better tolerated; 3 g (two thirds of vaginal applicator) applied weekly for 12 wk
    • 4.Possible vaginal ulceration and erythema
    • 5.Patient’s vagina examined after four to six applications
    • 6.80% cure rate

Physical agents:

  • •Cryotherapy with liquid nitrogen or cryoprobe
    • 1.Acts by causing tissue damage by formation of ice crystals, leading to disruption of cell membranes and cell death
    • 2.Can be used weekly for 3 to 6 wk
    • 3.62% to 79% cure rate
    • 4.Not suitable for large warts
  • •Laser therapy
    • 1.Done by physician with necessary expertise and equipment
    • 2.Painful; requires anesthesia
  • •Electrocautery or excision
    • 1.For recurrent, very large lesions
    • 2.Local anesthesia needed

Immunotherapy:

  • •Interferon A
    • 1.Injected intralesionally at a dose of 3 million U/m2 three times weekly for 8 wk
    • 2.Side effects: Fever, chills, malaise, headache
  • •Imiquimod 5% cream: Immunomodulatory drug that increases the immune response to warts
    • 1.Applied by patient at night, 3× per wk; wash off after 6 to 10 hr
    • 2.Usage for 16 wk maximum
    • 3.Increases wart clearance after 3 mo
  • •40% to 77% cure rate
  • •Interferon, topical: Increases wart clearance at 4 wk

Disposition

  • •Most genital warts resolve without therapy.
  • •Follow-up exam every 6 to 12 months as needed.
  • •Referral to a specialist experienced in the treatment of anogenital warts (e.g., dermatologist, urologist, or colorectal surgeon) is appropriate for patients who are immunosuppressed or who have treatment-refractory anogenital warts.
  • •Patients with large, bulky perianal or genital warts that may require extensive surgical removal should be referred to a colorectal surgeon or urologist.

How is this prevented?

  • •Male and female condoms should be used consistently and correctly to lower the risks of acquiring and transmitting HPV. However, because HPV can infect areas not covered by a condom, condoms will not fully protect against HPV.
  • •Guidelines for the routine vaccination of young adolescents (females and males) ages 9 to 14 are two doses of the HPV vaccine given at a 6- to 12-mo interval, which offers the same protection as the three-dose vaccination.
  • •Young women from ages 15 to 26 should receive three doses of the HPV vaccine (the 9vHPV, 4vHPV, and 2vHPV are approved for females).
  • •Young males from ages 15 to 21 should receive three doses of the HPV vaccine. The age limit for male HPV vaccination may be extended up to age 26 (only the 4vHPV and 9vHPV vaccines are approved for males). For men who have sex with men (including young men who identify as gay and bisexual), for young transgender adults, and for young adults who are immunocompromised (secondary to HIV, chronic steroid usage, or prior history of transplant), HPV vaccination is recommended up to age 26. Three-dose HPV vaccination series are administered as IM injections over a 6-mo period, with the second and third doses given 1 to 2 and 6 mo after the first dose, respectively. The same vaccine type should be used for the entire three-dosage series.
  • •4vHPV (Gardasil) vaccinates against types 6, 11, 16, and 18, which account for 66% of all cervical cancers.
  • •2vHPV (Cervarix) vaccinates against types 16 and 18 (licensed for females only).
  • •9vHPV (Gardasil 9) vaccine is available for preventing infection against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. It offers protection against five additional types of HPV accounting for 15% of cervical cancers not covered by Gardasil or Cervarix.
  • •HPV vaccines are not recommended for use in pregnant women.

Seek Additional Information

  • Workowski K.A., Bolan G.A.: Centers for Disease Control and Prevention: sexually transmitted diseases treatment guidelines 2015. MMWR Recomm Rep 2015; 64 (RR-03): pp. 1-137.

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