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
• HIV considerations:
  • Treatment of external genital warts should not be different for HIV-infected persons (1).
  • Lesions may be larger or more numerous (1).
  • May not respond as well to therapy as immunocompetent persons (1)

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) (2).
• American Academy of Pediatrics recommends all school-aged children who present with lesions be evaluated for abuse and screened for other STDs (2).

Pregnancy Considerations

• Warts often grow larger during pregnancy and regress spontaneously after delivery.
• Neonatal infection is thought to occur through vertical transmission. Incidence remains controversial. Cesarean section is not absolutely indicated for maternal condylomata (3).
• Cervical infection has been found to be a risk factor for preterm birth (3).
• 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.
• Treatment during pregnancy is somewhat controversial but may include topical trichloroacetic acid (TCA), cryotherapy, electrocautery, or surgical excision.
• The safety of imiquimod, sinecatechins, podophyllin, and podofilox during pregnancy has not been established (3).

Epidemiology

• HPV types 6 and 11 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 <21 years and decreased 19% in males <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:
  • 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 (4).
  • 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 (4).
  • Quadrivalent HPV (4vHPV) and 9vHPV vaccines (Gardasil and Gardasil 9) are licensed for use in females and males aged 9 through 45 years (5).
  • The Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination at age 11 or 12 years for females since 2006 and since 2011 for males (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

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