Condyloma Acuminata

Description of Medical Condition

Condyloma acuminata are soft skin colored, fleshy warts that are caused by the HPV (human papilloma virus). There are now > 100 known types of HPV and types 6, 11,16,18, 31, 33, 35 have been associated with condyloma acuminata. The disease is highly contagious, can appear singly or in groups, small or large. They appear in the vagina, on the cervix, around the external genitalia and rectum, in the urethra, anus, also conjunctival, nasal, oral and laryngeal warts and occasionally, the throat. The incubation period may be from 1-6 months.

System(s) affected: Skin/Exocrine, Reproductive

Genetics: N/A

Incidence/Prevalence in USA:

Most common viral sexually transmitted disease in the U.S.
=1% of sexually active population in U.S. has genital warts
26% transmission after single encounter
Minimum of 10-20% of sexually active women may be infected with HPV. Studies in men suggest a similar prevalence.
750,000 new cases per year; rates are increasing
Peak prevalence is in ages 17-33
Pregnancy and immunosuppression favor recurrence and increasing growth of lesions

Predominant age: 15-30 years of age

Predominant sex: Male = Female

Medical Symptoms and Signs of Disease

Tumors, soft, sessile
Surface smooth to very rough
Multiple fingerlike projections
Perianal condylomata acuminatum usually rough and cauliflower-like
Penile lesions often smooth and papular
Penile lesions often occur in groups of three or four
Male sites — frenulum, corona, glans, prepuce, meatus. shaft, scrotum
Female sites — labia, clitoris, periurethral area, perineum, vagina, cervix (flat lesions)
Pruritus
Irritation
Bleeding (result of trauma)
Perianal area (both sexes)
Subclinical HPV infection
May be detected by Pap test

What Causes Disease?

Human papillomaviruses. These are circular double-stranded DNA molecules. There are over 70 HPV subtypes. The cause of common venereal warts is types 6 and 11. Cervical dysplasia and carcinoma in situ are likely caused by types 16. 18, 31,33, and 35.

Risk Factors

Young adult
Sexually active
Not using condoms
Possibly subclinical infection
Young age of commencing sexual activity
Cigarette smoking
Poor hygiene
Pregnancy
Caucasian
History of genital warts

Diagnosis of Disease

Differential Diagnosis

Condyloma lata (flat warts of syphilis)
Lichen planus
Normal sebaceous glands
Seborrheic keratosis
Molluscum contagiosum
Keratomas
Scabies
Crohn disease
Skin tags
Melanocytic nevi
Vulvar intraepithelial neoplasia
Buschke-Lowenstein tumor

Laboratory

Serologic test for syphilis — negative

Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

Pathological Findings

Possible cervical dysplasia in females
Benign
Well organized basal layer
Underlying infiltration of lymphocytes
Plasma cells
Hyperplastic epithelial changes
Basement membrane intact
Sometimes difficult to differentiate from squamous cell carcinoma

Special Tests

Aceto-whitening: Subclinical lesions can be visualized by wrapping the penis with gauze soaked with 5% acetic acid for 5 minutes. Using a ten X hand lens or colposcope, warts appear as tiny white papules. A shiny white appearance of the skin represents foci of epithelial hyperplasia (subclinical infection). Not highly specific, low positive predictive value.

Diagnostic Procedures

Biopsy with highly specialized identification techniques (not clinically useful). HPV DNA detection is done by PCRon biopsy tissue.
Colposcopy, antroscopy, anoscopy, Pap smear
Urethroscopy may be required to visualize intraurethral lesions

Treatment (Medical Therapy)

Appropriate Health Care

Outpatient

General Measures

May resolve on their own
Treatment determined by location and size of warts
Small warts may be treated with topical applications
Cryotherapy
Change therapy if no improvement after 3 treatments, no complete clearance after 6 treatments, or therapy exceeding manufacturer’s recommendations
Appropriate screening and counseling of partners

Surgical Measures

Larger warts require laser treatment or electrocoagula-tion
Surgical excision for large warts
Intraurethral, external (penile and perianal), anal and oral lesions can be treated with fulgurating C02 laser. Oral or external penile/perianal lesions can also be treated with electrocautery or surgery.

Activity

No restrictions

Diet

No special diet

Patient Education

Explain preventive measures and chronic nature of the infection
Numerous pamphlets on HPV, STD prevention, condom use
Emphasize need for women to get regular Pap smears

Medications (Drugs, Medicines)

Drug(s) of Choice

Imiquimod (Aldara) 5% cream applied overnight 3times weekly until warts clear for up to 16 weeks
Cryotherapy- liquid nitrogen is applied to warts in 5-10 second bursts. Usually requires 2-3 weekly sessions.
Podophyllin in tincture of Benzoin. Apply directly to warts. Leave on for 1-4 hours, then wash off. Repeat treatment every 7 days until gone (in office procedure) OR
Podofilox (Condylox) — for external warts. Apply to external warts every 12 hours (allowing to dry) for 3 consecutive days. May repeat after 4 days (home application).
Trichloroacetic acid — 25-85%. Apply only to warts. Use powder/talc to remove unreacted acid. Repeat in office at weekly intervals.
Topical cidofovir gel — undergoing trials; applied once daily for 5 days every other week for maximum of 6 cycles
Intralesional interieron has been shown to be effective in refractory cases and should be reserved for such cases

Contraindications:

Podophyllin — do not use during pregnancy or on oral, cervical, urethral or perianal warts. Can use on small number of vaginal warts with careful drying after application.
Cryotherapy — cryoglobulinemia

Precautions:

Podophyllin — to minimize local and systemic reactions, wash treated areas 1 -4 hours after application and use ointments to protect surrounding skin from contact with podophyllin
Cryotherapy — none
Electrocautery — don’t use in patient with pacemaker

Significant possible interactions: N/A

Alternative Drugs

External (penile and perianal)
- Podophyllin
- Podofilox (Condylox) self-treatment
- Intralesional interieron
- Small study of topical BCG use for penile lesions
Urethral meatus
- Podophyllin
- Topical fluorouracil
Anal
- Trichloroacetic acid (TCA) — apply weekly
- Topical fluorouracil
Oral
- Trichloroacetic acid is ideal for isolated lesions in pregnant women
- Oral cimetidine 30-40 mg/kg divided tid for 3 months in children with genital and perigenital condyloma. Used as a primary and adjunctive therapy.

Patient Monitoring

Every 2 weeks for treatment until clear
Pap test every 1 year for indefinite period
Biopsy for persistent warts
Monitor sex partners
Treatment does not decrease infectivity

Prevention / Avoidance

Use of condoms by male sexual partners of individuals who have been treated for HPV infection
Use of condoms by infected men (preventive effects not adequately evaluated; 40% of infected men have scrotal warts)
Abstinence by women until treatment completed
Circumcision may prevent recurrence in some men
HPV vaccine — phase II trial in progress, appears encouraging

Possible Complications

Cervical dysplasia
Malignant change: Progression to cancer rarely, if ever occurs
Male urethral obstruction
The prevalence of high grade dysplasia (HGD) and cancer in anal canal is higher in HIV-positive than in HIV-negative patients, probably because of HPV activity

Expected Course / Prognosis

Warts clear with treatment or spontaneous regression
Recurrences: Frequent and may necessitate repeated treatment
Some studies identified 3 independent risk factors for condyloma relapse: Positive HIV, male sex, and Langerhans’ cells — LCs/mm anal tissue (15 vs. 30)
Without treatment: May remain stable, worsen, or resolve completely
Asymptomatic infection persists indefinitely

Miscellaneous

Associated Conditions

90% of cervical cancer contains evidence of HPV infection
Gonorrhea
Syphilis
AIDS
Chlamydia
Other sexually transmitted disease

Age-Related Factors

Young adults, infants and children

Pediatric: Consider sexual abuse if seen in children;

although can acquire by other means (eg, transfer from wart on child’s hand)

Geriatric: N/A

Others:

Venereal warts are increasing in an ever younger population. A recent study of 487 college women showed an infection rate of 48%.
Increased size and number in immunocompromised states

Pregnancy

Warts often grow larger in pregnancy and regress spontaneously after delivery. Use cryotherapy.
Virus does not cross the placenta. Treatment during pregnancy is somewhat controversial. C-section is not indicated.
HPV can be transmitted to infant at time of delivery and cause laryngeal papillomas, a rare and life threatening condition

Synonyms

Genital warts
Venereal warts
Papilloma acuminatum

International Classification of Diseases

078.11 Condyloma acuminata