Condylomata acuminata (anogenital warts) in adults
- Elizabeth Breen, MD
Elizabeth Breen, MD
- Assistant Professor of Surgery
- Harvard Medical School
- Ronald Bleday, MD
Ronald Bleday, MD
- Associate Professor of Surgery
- Harvard Medical School
Anogenital warts (condylomata acuminata) are the most common viral sexually transmitted disease in the United States. Although condylomata affect both genders, data from office visits for warts obtained from the 1994 to 1998 National Ambulatory Medical Care Survey showed that women accounted for 67 percent of the patient population .
Condylomata acuminata in children are discussed separately. (See "Vulvovaginal complaints in the prepubertal child", section on 'Condylomata acuminata'.)
ETIOLOGY AND ASSOCIATION WITH MALIGNANCY
Condyloma acuminatum is caused by human papilloma virus (HPV) infection. HPV encompasses a family of highly infectious and primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from three weeks to eight months. Most infections are transient and cleared within two years .
Individuals with condylomata acuminata are at an increased risk for anogenital cancers [3,4]. In a large Danish cohort study of 16,155 men and 32,933 women, individuals who were diagnosed with condylomata acuminata were at increased risk for anogenital and head and neck cancers for greater than ten years following the diagnosis (anal [SIR for men, 21.5; SIR for women, 7.8], vulvar [SIR, 14.8], vaginal [SIR, 5.9], cervical [SIR, 1.5], penile [SIR, 8.2], and head and neck cancer [SIR, 2.8], including subsites of head and neck cancer with confirmed HPV association [SIR for men, 3.5; SIR for women, 4.8]) . (See "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing" and "Anal squamous intraepithelial lesions: Diagnosis, screening, prevention, and treatment".)
There are over 70 distinct HPV subtypes; approximately 35 types are specific for the anogenital epithelium and have varying potentials to cause malignant change, such as cervical or anal cancer (table 1)  (see "Virology of human papillomavirus infections and the link to cancer"). HPV serotypes 16 and 18 are most commonly associated with squamous cell carcinoma. Low-risk subtypes, such as HPV 6 and 11, do not integrate into the host genome and are most frequently associated with benign condyloma and low grade intraepithelial neoplasia (table 2). Intermediate risk subtypes can cause high grade dysplasia, which persists but rarely progresses to the invasive stage. (See "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing".)
- Fleischer AB Jr, Parrish CA, Glenn R, Feldman SR. Condylomata acuminata (genital warts): patient demographics and treating physicians. Sex Transm Dis 2001; 28:643.
- Burk RD, Kelly P, Feldman J, et al. Declining prevalence of cervicovaginal human papillomavirus infection with age is independent of other risk factors. Sex Transm Dis 1996; 23:333.
- Chua KL, Hjerpe A. Persistence of human papillomavirus (HPV) infections preceding cervical carcinoma. Cancer 1996; 77:121.
- Blomberg M, Friis S, Munk C, et al. Genital warts and risk of cancer: a Danish study of nearly 50 000 patients with genital warts. J Infect Dis 2012; 205:1544.
- Pfister H. The role of human papillomavirus in anogenital cancer. Obstet Gynecol Clin North Am 1996; 23:579.
- Palefsky JM. Cutaneous and genital HPV-associated lesions in HIV-infected patients. Clin Dermatol 1997; 15:439.
- de la Fuente SG, Ludwig KA, Mantyh CR. Preoperative immune status determines anal condyloma recurrence after surgical excision. Dis Colon Rectum 2003; 46:367.
- Schneider V, Kay S, Lee HM. Immunosuppression as a high-risk factor in the development of condyloma acuminatum and squamous neoplasia of the cervix. Acta Cytol 1983; 27:220.
- Habel LA, Van Den Eeden SK, Sherman KJ, et al. Risk factors for incident and recurrent condylomata acuminata among women. A population-based study. Sex Transm Dis 1998; 25:285.
- Van Den Eeden SK, Habel LA, Sherman KJ, et al. Risk factors for incident and recurrent condylomata acuminata among men. A population-based study. Sex Transm Dis 1998; 25:278.
- Ciobotaru B, Leiman G, St John T, et al. Prevalence and risk factors for anal cytologic abnormalities and human papillomavirus infection in a rural population of HIV-infected males. Dis Colon Rectum 2007; 50:1011.
- Piketty C, Darragh TM, Da Costa M, et al. High prevalence of anal human papillomavirus infection and anal cancer precursors among HIV-infected persons in the absence of anal intercourse. Ann Intern Med 2003; 138:453.
- Beck DE, Jaso RG, Zajac RA. Surgical management of anal condylomata in the HIV-positive patient. Dis Colon Rectum 1990; 33:180.
- Conley LJ, Ellerbrock TV, Bush TJ, et al. HIV-1 infection and risk of vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia: a prospective cohort study. Lancet 2002; 359:108.
- Massad LS, Silverberg MJ, Springer G, et al. Effect of antiretroviral therapy on the incidence of genital warts and vulvar neoplasia among women with the human immunodeficiency virus. Am J Obstet Gynecol 2004; 190:1241.
- Tramujas da Costa e Silva I, de Lima Ferreira LC, Santos Gimenez F, et al. High-resolution anoscopy in the diagnosis of anal cancer precursor lesions in renal graft recipients. Ann Surg Oncol 2008; 15:1470.
- Metcalf AM, Dean T. Risk of dysplasia in anal condyloma. Surgery 1995; 118:724.
- Nadal SR, Calore EE, Manzione CR, et al. Hypertrophic herpes simplex simulating anal neoplasia in AIDS patients: report of five cases. Dis Colon Rectum 2005; 48:2289.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 61, April 2005. Human papillomavirus. Obstet Gynecol 2005; 105:905.
- Kazlouskaya V, Shustef E, Allam SH, et al. Expression of p16 protein in lesional and perilesional condyloma acuminata and bowenoid papulosis: clinical significance and diagnostic implications. J Am Acad Dermatol 2013; 69:444.
- Jablonska S. Traditional therapies for the treatment of condylomata acuminata (genital warts). Australas J Dermatol 1998; 39 Suppl 1:S2.
- Greene I. Therapy for genital warts. Dermatol Clin 1992; 10:253.
- Lacey CJ, Goodall RL, Tennvall GR, et al. Randomised controlled trial and economic evaluation of podophyllotoxin solution, podophyllotoxin cream, and podophyllin in the treatment of genital warts. Sex Transm Infect 2003; 79:270.
- Maw RD. Treatment of anogenital warts. Dermatol Clin 1998; 16:829.
- Swinehart JM, Sperling M, Phillips S, et al. Intralesional fluorouracil/epinephrine injectable gel for treatment of condylomata acuminata. A phase 3 clinical study. Arch Dermatol 1997; 133:67.
- Beutner KR, Spruance SL, Hougham AJ, et al. Treatment of genital warts with an immune-response modifier (imiquimod). J Am Acad Dermatol 1998; 38:230.
- Gunter J. Genital and perianal warts: new treatment opportunities for human papillomavirus infection. Am J Obstet Gynecol 2003; 189:S3.
- O'Mahony C, Law C, Gollnick HP, Marini M. New patient-applied therapy for anogenital warts is rated favourably by patients. Int J STD AIDS 2001; 12:565.
- Wagstaff AJ, Perry CM. Topical imiquimod: a review of its use in the management of anogenital warts, actinic keratoses, basal cell carcinoma and other skin lesions. Drugs 2007; 67:2187.
- van Seters M, van Beurden M, ten Kate FJ, et al. Treatment of vulvar intraepithelial neoplasia with topical imiquimod. N Engl J Med 2008; 358:1465.
- Kreuter A, Brockmeyer NH, Weissenborn SJ, et al. Penile intraepithelial neoplasia is frequent in HIV-positive men with anal dysplasia. J Invest Dermatol 2008; 128:2316.
- http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/201153s000,022483s001lbl.pdf (Accessed on April 08, 2011).
- Reichman RC, Oakes D, Bonnez W, et al. Treatment of condyloma acuminatum with three different interferon-alpha preparations administered parenterally: a double-blind, placebo-controlled trial. J Infect Dis 1990; 162:1270.
- Benedetti Panici P, Scambia G, Baiocchi G, et al. Randomized clinical trial comparing systemic interferon with diathermocoagulation in primary multiple and widespread anogenital condyloma. Obstet Gynecol 1989; 74:393.
- Dinsmore W, Jordan J, O'Mahony C, et al. Recombinant human interferon-beta in the treatment of condylomata acuminata. Int J STD AIDS 1997; 8:622.
- Klutke JJ, Bergman A. Interferon as an adjuvant treatment for genital condyloma acuminatum. Int J Gynaecol Obstet 1995; 49:171.
- Fleshner PR, Freilich MI. Adjuvant interferon for anal condyloma. A prospective, randomized trial. Dis Colon Rectum 1994; 37:1255.
- Meltzer SM, Monk BJ, Tewari KS. Green tea catechins for treatment of external genital warts. Am J Obstet Gynecol 2009; 200:233.e1.
- Drug Information: Veregen (kunecatechins). www.centerwatch.com/patient/drugs/dru938.html (Accessed on November 06, 2007).
- Veregen: a botanical for treatment of genital warts. Med Lett Drugs Ther 2008; 50:15.
- Tatti S, Swinehart JM, Thielert C, et al. Sinecatechins, a defined green tea extract, in the treatment of external anogenital warts: a randomized controlled trial. Obstet Gynecol 2008; 111:1371.
- Stockfleth E, Beti H, Orasan R, et al. Topical Polyphenon E in the treatment of external genital and perianal warts: a randomized controlled trial. Br J Dermatol 2008; 158:1329.
- Bellina JH. The use of the carbon dioxide laser in the management of condyloma acuminatum with eight-year follow-up. Am J Obstet Gynecol 1983; 147:375.
- Kraus SJ, Stone KM. Management of genital infection caused by human papillomavirus. Rev Infect Dis 1990; 12 Suppl 6:S620.
- Gormley RH, Kovarik CL. Human papillomavirus-related genital disease in the immunocompromised host: Part II. J Am Acad Dermatol 2012; 66:883.e1.
- Snoeck R, Bossens M, Parent D, et al. Phase II double-blind, placebo-controlled study of the safety and efficacy of cidofovir topical gel for the treatment of patients with human papillomavirus infection. Clin Infect Dis 2001; 33:597.
- Calisto D, Arcangeli F. Topical cidofovir for condylomata acuminata of the genitalia in a 3-year-old child. J Am Acad Dermatol 2003; 49:1192.
- Coremans G, Margaritis V, Snoeck R, et al. Topical cidofovir (HPMPC) is an effective adjuvant to surgical treatment of anogenital condylomata acuminata. Dis Colon Rectum 2003; 46:1103.
- Martinelli C, Farese A, Mistro AD, et al. Resolution of recurrent perianal condylomata acuminata by topical cidofovir in patients with HIV infection. J Eur Acad Dermatol Venereol 2001; 15:568.
- Matteelli A, Beltrame A, Graifemberghi S, et al. Efficacy and tolerability of topical 1% cidofovir cream for the treatment of external anogenital warts in HIV-infected persons. Sex Transm Dis 2001; 28:343.
- Orlando G, Fasolo MM, Beretta R, et al. Combined surgery and cidofovir is an effective treatment for genital warts in HIV-infected patients. AIDS 2002; 16:447.
- Nambudiri VE, Mutyambizi K, Walls AC, et al. Successful treatment of perianal giant condyloma acuminatum in an immunocompromised host with systemic interleukin 2 and topical cidofovir. JAMA Dermatol 2013; 149:1068.
- Böhle A, Büttner H, Jocham D. Primary treatment of condylomata acuminata with viable bacillus Calmette-Guerin. J Urol 2001; 165:834.
- Bekassy Z, Weström L. Infrared coagulation in the treatment of condyloma acuminata in the female genital tract. Sex Transm Dis 1987; 14:209.
- Kumar P, Dar L, Saldiwal S, et al. Intralesional injection of Mycobacterium w vaccine vs imiquimod, 5%, cream in patients with anogenital warts: a randomized clinical trial. JAMA Dermatol 2014; 150:1072.
- Ali H, Guy RJ, Wand H, et al. Decline in in-patient treatments of genital warts among young Australians following the national HPV vaccination program. BMC Infect Dis 2013; 13:140.
- Harrison C, Britt H, Garland S, et al. Decreased management of genital warts in young women in australian general practice post introduction of national HPV vaccination program: results from a nationally representative cross-sectional general practice study. PLoS One 2014; 9:e105967.
- Lee HJ, Kim JK, Kim DH, Yoon MS. Condyloma accuminatum treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, 18). J Am Acad Dermatol 2011; 64:e130.
- Kreuter A, Wieland U. Lack of efficacy in treating condyloma acuminata and preventing recurrences with the recombinant quadrivalent human papillomavirus vaccine in a case series of immunocompetent patients. J Am Acad Dermatol 2013; 68:179.
- ETIOLOGY AND ASSOCIATION WITH MALIGNANCY
- RISK FACTORS
- HIV infected individuals
- CLINICAL MANIFESTATIONS
- Differential diagnosis
- Chemical agents
- - Podophyllin
- - Trichloroacetic acid
- - 5-fluorouracil epinephrine gel
- Immune modulation
- - Imiquimod
- - Interferon alpha
- - Sinecatechins
- - Cryotherapy
- - Laser therapy
- - Excisional procedures
- Other interventions
- - Topical cidofovir
- - Bacillus Calmette-Guerin
- - Infrared coagulation
- - Mycobacterium w vaccine
- VULVAR AND VAGINAL WARTS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS