Condylomata Acuminata

Descriptive text is not available for this image BASICS

  • Condylomata acuminata are soft, skin-colored, fleshy lesions (commonly called genital warts) that are caused by human papillomavirus (HPV). The flat, papular, or pedunculated warts can appear singly or in groups (a single wart is a “condyloma”; multiple warts are “condylomas” or “condylomata”); typically appear on the anogenital skin (penis, scrotum, introitus, vulva, perianal area); and may occur in the anogenital tract (vagina, cervix, rectum, urethra, anus) or outside the genital tract (conjunctival, nasal, oral, and laryngeal warts).
  • System(s) affected: skin/exocrine, reproductive, occasionally respiratory

DESCRIPTION

Pediatric Considerations

  • 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). Consider screening for STDs.

Pregnancy Considerations

  • Warts often grow larger, increase in number, and become more friable in pregnancy (1). They can regress spontaneously after delivery.
  • Neonatal infection is thought to occur through vertical transmission. Incidence remains controversial.
  • Few documented cases of infant laryngeal papillomas due to HPV transmission at the time of delivery; although rare, the condition is life-threatening. Cesarean section solely to prevent transmission of HPV to the newborn is not indicated (1).
  • Cervical infections are a risk factor for preterm birth.
  • HPV vaccination is contraindicated in pregnancy.
  • Treatment during pregnancy is somewhat controversial because it can be incomplete, but accepted treatments are trichloroacetic acid (TCA), cryotherapy, electrocautery, or surgical excision.
  • The safety of sinecatechins, podophyllin, and podofilox in pregnant women has not been established, and these agents are not recommended for use during pregnancy (1). Imiquimod appears to pose low risk but should be avoided until more data are available.

EPIDEMIOLOGY

  • HPV types 6 and 11 are associated with 90% of condylomata acuminata. 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 to 8 months. Initial infections may go unrecognized.
  • Predominant age: 15 to 30 years
  • Predominant sex: 1:1 male to female
  • Most infections are transient and clear spontaneously within 2 years.

Incidence

After the introduction of the HPV vaccine, the incidence of condyloma acuminata decreased by more than 50% for females under 24 and similarly for males (1).

Prevalence

  • Most common viral sexually transmitted infection (STI) in the United States. Most sexually active men and women will have acquired a genital HPV infection, usually asymptomatic, at some time.
  • Estimated 6.2 million Americans become infected with genital HPV each year.
  • Peak prevalence in ages 17 to 33 years
  • 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.

ETIOLOGY AND PATHOPHYSIOLOGY

HPV is a circular, double-stranded DNA molecule. There are >120 HPV subtypes. HPV types 6 and 11 cause 90% of genital warts and do not cause anogenital cancers. Rarely oncogenic strains of HPV exist alongside HPV 6 and 11 (1).

RISK FACTORS

  • High risk sexual activity
  • History of STI
  • Immunosuppression (particularly HIV)
  • Cigarette smoking
  • Use of oral contraceptives
  • Radiation therapy

GENERAL PREVENTION

  • HPV vaccination is for prevention of HPV infections and HPV-associated cancers.
  • The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination at age 11 or 12 years for females (since 2006) and males. Vaccination can start at as early as 9 years old.
    • A 2-dose schedule (0, 6 to 12 months) will have efficacy equivalent to a 3-dose schedule (0, 1 to 2, 6 months) if the HPV vaccination series is initiated before the 15th birthday.
    • For any immunocompromised patient regardless of age, a 3-dose schedule (0, 1 to 2, and 6 months) is recommended (1).
    • The 9-valent HPV (9vHPV; Gardasil 9) vaccine protects against the two most common HPV serotypes (types 6 and 11, which cause most anogenital warts) and the two most cancer-promoting types (16 and 18) as well as 31, 33, 45, 52, and 58.
  • 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.)
  • After treatment, encourage abstinence until treatment is completed.

COMMONLY ASSOCIATED CONDITIONS

  • Cervical dysplasia; >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.
  • STIs (e.g., gonorrhea, syphilis, chlamydia), AIDS

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