Peer Reviewed

Photoclinic

Genital Warts

Log in or register to view.

Alexander K. C. Leung, MD
University of Calgary and Alberta Children’s Hospital, Calgary, Alberta, Canada

Benjamin Barankin, MD
Toronto Dermatology Centre, Toronto, Ontario, Canada

Citation:
Leung AKC, Barankin B. Genital warts [published online September 29, 2017]. Consultant360.

 

A 17-year-old adolescent presented with 2 asymptomatic warty growths on the external genitalia of 16 months’ duration. The growths had appeared as small papules and had become significantly larger in recent months. The patient was uncircumcised. He had multiple sexual partners and used condoms only occasionally. There was no urethral discharge. His past health was unremarkable.

Physical examination revealed 2 soft, flesh-colored, velvety, cauliflower-like lesions on the inner surface of the prepuce and the coronal sulcus, respectively. The rest of the physical examination findings were unremarkable.

genital warts adolescent

Based on the clinical appearance, a diagnosis of genital warts was made. His dermatologist treated the lesions every 2 weeks with liquid nitrogen, and the warts resolved after 4 treatments. The patient was also advised to get the human papillomavirus (HPV) vaccination from his family physician.

Discussion

Genital warts, also known as condylomata acuminata, are the most common clinical manifestations of genital HPV infections.1 HPV is a double-stranded DNA virus of the Papovaviridae family.

It is estimated that 1% of sexually active individuals aged 16 to 35 years have clinically evident genital warts.2 Males are more commonly affected.3,4

Approximately 90% of cases of genital warts are caused by HPV-6 and 11.1 HPV-40, 42, 43, 44, 54, 70, 72, and 81 account for the rest. In adults, genital HPV infection is transmitted predominately by sexual intercourse and less commonly by oral sex, skin-to-skin transmission, and fomites. In children, HPV infection may result from sexual abuse, vertical transmission, heteroinoculation, autoinoculation, and transmission via fomites.5 The incubation period for genital infection varies from 3 weeks to 8 months, with an average of 2 to 4 months.4,6 The disease is more common in individuals with immunodeficiency, multiple sexual partners, sexual intercourse at an early age, and unprotected sexual intercourse. Moisture, maceration, trauma, and epithelial defects are other predisposing factors.

Histological findings include papillomatosis, focal parakeratosis, acanthosis, vacuolated koilocytes, and coarse keratohyalin granules.4

Genital warts are usually asymptomatic but at times can cause itching, burning, bleeding, and pain.1 They are most commonly found on the external genitalia. In males, genital warts are usually located on the frenulum, glans penis, inner surface of the prepuce, and coronal sulcus. In females, there is a predilection for the smooth, moist mucosa of the posterior vaginal introitus and the labia.7 Genital warts can occur singularly or in clusters and can be pedunculated or sessile. They typically present as discrete, soft, pink, flesh-colored or brown, exophytic, papillomatous growths.1,2 They may be verrucous or filiform and may coalesce to form cauliflower-like lesions, as is illustrated in the present case. Giant condylomata acuminata are referred to as Buschke-Löwenstein tumors. Other variants include flat warts and papular warts.1 Flat warts appear only slightly raised.2 Papular warts are small, flesh-colored, smooth, dome-shaped papules.1

Diagnosis

The diagnosis is mainly clinical, based on the history and physical examination findings. Dermoscopy and in vivo reflectance confocal microscopy help to increase the diagnostic accuracy.8 The morphologic features may vary from a fingerlike to a knoblike pattern, and the vascular pattern may vary from glomerular to hairpin to dotted.8,9 Skin biopsy is seldom warranted. A biopsy or referral to a dermatologist should be considered for atypical cases, when the diagnosis is unclear, or for warts resistant to treatment.

The differential diagnosis includes pearly penile papules, skin tags, condylomata lata of syphilis, molluscum contagiosum, epidermoid cyst, granuloma annulare, lichen nitidus, lichen planus, seborrheic keratosis, angiofibroma of the scrotum or vulva, Fordyce spots, bowenoid papulosis, squamous cell carcinoma, traumatic neuromas, vulvar intraepithelial neoplasia, and vulvar papillomatosis.2

Complications

Genital warts can cause significant anxiety or distress to the patient and his or her sexual partner because of the lesions’ disfiguring appearance and transmissibility and their association with other sexually transmitted diseases. It is estimated that 20% to 34% of affected patients have concomitant sexually transmitted diseases.4 Individuals with genital warts have higher rates of sexual dysfunction, depression, and anxiety compared with the general population.10 The condition may adversely affect the quality of life, and the impact is greater in women than in men.11,12 Large exophytic lesions may bleed and cause urethral or anal obstruction, problems with sexual intercourse, and vaginal delivery.2,13 Individuals with genital warts are at increased risk for anogenital cancers.14

If left untreated, genital warts may resolve spontaneously, stay the same, or increase in size and number.1 The average duration prior to resolution is approximately 9 months.15 Proper treatment has a clearance rate of 35% to 100% in 3 to 16 weeks.16 The recurrence rate ranges from 25% to 67% within 6 months of treatment.2,17

Management

Active treatment of genital warts is preferable to watchful observation to speed clearance of the lesions, assuage fears of transmission and autoinoculation, improve cosmetic appearance, reduce social stigma associated with visible lesions, and alleviate discomfort.1,2 Sexual partners should be offered informational counseling.

Patient-administered therapies include podofilox solution, 0.5%; imiquimod cream, 3.75% or 5%; and sinecatechins ointment, 15%.2,18 Podofilox is an antimitotic, and its use in pregnancy is contraindicated. Imiquimod enhances the host’s innate and cellular immune response and combats HPV infection by binding to the dermal dendritic cells and macrophages through toll-like receptor 7. This results in the production and release of proinflammatory cytokines such as interferon α, tumor necrosis factor α), and interleukins 1, 6, 8, and 12. The secreted cytokines stimulate local immune effects that are cytotoxic against HPV. Imiquimod also acts on cell-mediated immunity by activating Langerhans cells, thereby increasing the presentation of antigens for the T cells. Sinecatechins are extracts of green tea leaves and work by decreasing viral replication among other mechanisms.2

Clinician-administered therapies include podophyllin resin, cryotherapy with liquid nitrogen, bichloroacetic or trichloroacetic acid, surgical excision, electrocautery, and laser therapy.2,18 Podophyllin resin, a fairly potent antimitotic, is contraindicated during pregnancy or for use on mucosal surfaces. Liquid nitrogen is a treatment of choice for genital warts and is safe to use during pregnancy. Bichloroacetic and trichloroacetic acid, also safe to use during pregnancy, can be used on keratinized and mucosal surfaces. The medication works by protein coagulation with resultant destruction of the genital wart. Surgical excision, electrocautery, or laser therapy may be required if the lesion is extensive, bulky, or resistant to conservative treatment.

Effectiveness varies among treatments. However, head-to-head comparisons of available modalities are lacking. The choice of the treatment method should depend on the physician’s comfort level with the various treatment options, the number and severity of lesions, and the preference and budget of the patient.

Prevention

Genital warts can be prevented, to a certain extent, by delaying sexual initiation and limiting the number of sexual partners.1 Latex condoms, when used consistently and properly, reduce HPV transmission. The HPV vaccination is effective in the primary prevention of HPV infection. The Centers for Disease Control and Prevention19 and the American College of Obstetricians and Gynecologists20 recommend routine HPV vaccination for girls and boys. The target age for vaccination is 11 to 12 years. Catch-up vaccination is indicated for men and women through age 26 years if not vaccinated in the target age.20

References
  1. Leung AKC, Kellner JD, Davies HD. Genital infection with human papillomavirus in adolescents. Adv Ther. 2005;22(3):187-197.
  2. Karnes JB, Usatine RP. Management of external genital warts. Am Fam Physician. 2014;90(5):312-318.
  3. Fleischer AB Jr, Parrish CA, Glenn R, Feldman SR. Condylomata acuminata (genital warts): patient demographics and treating physicians. Sex Transm Dis. 2001;28(11):643-647.
  4. Sehgal VN, Koranne RV, Srivastava SB. Genital warts: current status. Int J Dermatol. 1989;28(2):75-85.
  5. Stefanaki C, Barkas G, Valari M, et al. Condylomata acuminata in children. Pediatr Infect Dis J. 2012;31(4):422-424.
  6. Dunne EF, Burstein GR, Stone KM. Anogenital human papillomavirus infection in males. Adolesc Med. 2003;14(3):613-632.
  7. Darville T. Genital warts. Pediatr Rev. 1999;20(8):271-272.
  8. Veasey JV, Framil VMdS, Nadal SR, Marta AC, Lellis RF. Genital warts: comparing clinical findings to dermatoscopic aspects, in vivo reflectance confocal features and histopathologic exam. An Bras Dermatol. 2014;89(1):137-140.
  9. Dong H, Shu D, Campbell TM, Frühauf J, Soyer HP, Hofmann-Wellenhof R. Dermatoscopy of genital warts. J Am Acad Dermatol. 2011;64(5):859-864.
  10. Kucukunal A, Altunay IK, Mercan S. Sexual dysfunction in men suffering from genital warts. J Sex Med. 2013;10(6):1585-1591.
  11. Paradisi A, Capizzi R, Ricci F, Di Pietro C, Abeni D, Tabolli S. Quality of life in patients with anogenital warts. Eur J Dermatol. 2013;23(6):837-842.
  12. Vriend HJ, Nieuwkerk PT, van der Sande MAB. Impact of genital warts on emotional and sexual well-being differs by gender. Int J STD AIDS. 2014;25(13):949-955.
  13. Cervigni M, Scotto V, Panei M, Sbiroli C. Acute urethral obstruction due to condylomata acuminata. Obstet Gynecol. 1991;78(5 pt 2):970-972.
  14. Blomberg M, Friis S, Munk C, Bautz A, Kjaer SK. Genital warts and risk of cancer: a Danish study of nearly 50 000 patients with genital warts. J Infect Dis. 2012;205(10):1544-1553.
  15. Allen AL, Siegfried EC. The natural history of condyloma in children. J Am Acad Dermatol. 1998;39(6):951-955.
  16. Lacey CJN, Woodhall SC, Wikstrom A, Ross J. 2012 European guideline for the management of anogenital warts. J Eur Acad Dermatol Venereol. 2013;27(3):e263-e270.
  17. Jablonska S. Traditional therapies for the treatment of condylomata acuminata (genital warts). Australas J Dermatol. 1998;39(suppl 1):S2-S4.
  18. Workowski KA, Bolan GA; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.
  19. Markowitz LE, Dunne EF, Saraiya M, et al; Centers for Disease Control and Prevention. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1-30.
  20. Immunization Expert Work Group, Committee on Adolescent Health Care. Committee opinion No. 704: human papillomavirus vaccination. Obstet Gynecol. 2017;129(6):e173-e178.