Description

• Condylomata acuminata are soft, skin-colored, fleshy lesions (commonly called genital warts) that are caused by human papillomavirus (HPV):
  • Warts appear singly or in groups (a single wart is a “condyloma”; multiple warts are “condylomas” or “condylomata”); small or large; typically appear on the anogenital skin (penis, scrotum, introitus, vulva, perianal area) but may occur in the anogenital tract (vagina, cervix, rectum, urethra, anus). Reports of conjunctival, nasal, oral, and laryngeal warts.
• System(s) affected: Skin/Exocrine; Reproductive; occasionally Respiratory

• Consider sexual abuse if seen in children, although children can be infected by other means (e.g., transfer from wart on another child’s hand or prolonged latency period).
• American Academy of Pediatrics recommends all school-aged children who present with lesions be evaluated for abuse and screened for other STDs (1).

• Warts often grow larger during pregnancy and regress spontaneously after delivery.
• Virus does not cross the placenta. Treatment during pregnancy is somewhat controversial. Cesarean section is not absolutely indicated for maternal condylomata.
• Cervical infection has been found to be a risk factor for preterm birth.
• There have been a few documented cases of laryngeal papillomas due to HPV transmission at the time of delivery. Although rare, the condition is life threatening.
• HPV vaccination is contraindicated in pregnancy.

Epidemiology

• HPV types 6 and 11 associated with 90% of condylomata acuminata. Also types 16, 18, 31, 33, and 35 may be found in warts, and may be associated with high-grade intraepithelial dysplasia in immunocompromised states such as HIV.
• Highly contagious; incubation period may be from 1–8 months. Initial infections may very well go unrecognized, so a “new” outbreak may be a relapse of an infection acquired years prior.
• Predominant age: 15–30 years
• Predominant sex: Male = Female
• Most infections are transient and clear spontaneously within 2 years.

• One study population demonstrated that from 2007–2010, with the introduction of HPV vaccines, the incidence of genital warts decreased 35% (from 0.94% to 0.61%) in females <21 years, and decreased 19% in males <21 years (2).
• Increased size and number of warts in immunocompromised patients

• Most common viral sexually transmitted infection (STI) in the US. Most sexually active men and women will have acquired a genital HPV infection, usually asymptomatic, at some time.
• Peak prevalence in ages 17–33
• 10–20% of sexually active women may be actively infected with HPV. Studies in men suggest a similar prevalence.
• Pregnancy and immunosuppression favor recurrence and increased growth of lesions.

Risk Factors

• Usually acquired by sexual activity:
  • Young adults and adolescents
  • Multiple sexual partners; short interval between meeting new sex partner and first intercourse
  • Not using condoms
  • Young age of commencing sexual activity
  • History of other STI

• Immunosuppression (particularly HIV)

General Prevention

• Sexual abstinence or monogamy
• Quadrivalent HPV vaccine available against genital warts and cervical cancer. This vaccine is targeted to adolescents before the period of their greatest risk for exposure to HPV. The vaccine does not treat previous infections:
  • Immunity has been documented to last at least 5 years after HPV vaccination.
  • The HPV quadrivalent vaccine (Gardasil) protects against the 2 most common HPV serotypes (types 6 and 11, which cause most anogenital warts), and the 2 most cancer-promoting types (16 and 18) (3)[A].
  • Quadrivalent vaccine is indicated for females and males ages 9–26 (3): Vaccine is administered IM; 3 doses at 0, 2, and 6 months to achieve optimal seroconversion.
• Bivalent HPV vaccine is available, but does not cover the HPV types that cause most condyloma lesions (Cervarix).
• Quadrivalent vaccine has been proven effective in prevention of external lesions in males 16–26 years of age (4).
• Use of condoms is partially effective, although warts may be easily spread by lesions not covered by a condom (e.g., 40% of infected men have scrotal warts).
• Abstinence until treatment completed

Etiology

HPV is a circular, double-stranded DNA molecule. There are >70 HPV subtypes. HPV types that cause genital warts do not cause anogenital cancers.

Commonly Associated Conditions

• >90% of cervical cancer associated with HPV types 16, 18, 31, 33, and 35.
• 60% of oropharyngeal and anogenital squamous cell carcinomas are associated with HPV (5).
• STIs (e.g, gonorrhea, syphilis, chlamydia); AIDS