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); and may occur in the anogenital tract (vagina, cervix, rectum, urethra, anus); also conjunctival, nasal, oral, and laryngeal warts
• System(s) affected: skin/exocrine, reproductive, occasionally respiratory

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) (1).
• American Academy of Pediatrics recommends all school-aged children who present with lesions be evaluated for abuse and screened for other STDs (1).

Pregnancy Considerations

• Warts often grow larger, increase in number, and become more friable in pregnancy (2). They can regress spontaneously after delivery.
• Neonatal infection is thought to occur through vertical transmission. Incidence remains controversial.
• Few documented cases of 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 (2).
• Cervical infection has been found to be 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 (2).There is an emerging data that shows imiquimod is low risk in pregnancy.

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 very well go unrecognized, so a “new” outbreak may be a relapse of an infection acquired years prior.
• Predominant age: 15 to 30 years
• Predominant sex: 1:1 male to female
• Most infections are transient and clear spontaneously within 2 years.

Incidence
One study population demonstrated that from 2007 to 2010, with the introduction of HPV vaccines, the incidence of genital warts decreased 35% (from 0.94% per year to 0.61% per year) in females aged <21 years and decreased 19% in males aged <21 years.

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 that cause genital warts do not cause anogenital cancers.

Risk Factors

• Usually acquired by unprotected sexual activity
  • Young adults and adolescents
  • Multiple sexual partners; short interval between meeting new sex partner and first intercourse
  • Not using protective barriers
  • Young age of commencing sexual activity
  • History of other STI
• Immunosuppression (particularly HIV)
• Cigarette smoking
• Use of oral contraceptives
• Radiation therapy

General Prevention

• Sexual abstinence or monogamy
• HPV vaccination is for prevention of HPV infections and HPV-associated cancers. This vaccine is targeted to adolescents before the period of their greatest risk for exposure to HPV. The vaccine does not treat previous infections:
  • 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 (2).
  • 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.
  • Bivalent HPV, quadrivalent HPV (4vHPV), and 9vHPV vaccines (Gardasil and Gardasil 9) are licensed for use in females and males aged 9 through 45 years, but as of late 2016, only the 9vHPV vaccines are distributed in the United States.
• 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

• >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