Genital Wart

1. See Also
   1. Verruca plana (Flat wart)
   2. Verruca Vulgaris (Common Wart)
   3. Verrucae plantaris (Plantar Wart)
   4. Molluscum Contagiosum
2. Pathophysiology
   1. Human Papillomavirus (HPV) infection of abraded skin
   2. HPV Types 6 and 11 most common visible types
      1. Rarely associated with invasive squamous cell cancer
   3. HPV Types 16 and 18 most aggressive
      1. Associated with cervical and anal dysplasia
      2. Other type associated with SCC: 31, 33, 35
3. Epidemiology
   1. Prevalence
      1. Affects 15-40% of sexually active adults
      2. Present in 20 Million U.S. adults
   2. Sexually Transmitted
      1. Evaluate for other STDs if present
      2. Penile warts confer 50% transfer risk to Cervix
   3. Incubation period
      1. Four weeks to more than a year after exposure
4. Pathophysiology
   1. Human Papilloma Virus types 16, 18
   2. Human Papilloma Virus types 30,31, 34, 35, 39, 48
5. Signs
   1. Characteristics
      1. Flesh colored exophytic lesions on genitalia
      2. Variable appearance
         1. Small, soft, fleshy Papules or
         2. Larger cauliflower-like or vegetating masses
   2. Accentuated by:
      1. Acetic acid (3-5%) or white vinegar
         1. Not all acetowhite lesions are warts
      2. Plain water soaks for 10 minutes
   3. Distribution
      1. Penis and Scrotum, vulva, perineum, and perianal skin
      2. May spread to Urethra and Bladder
      3. Intra-anal warts may result
      4. May result in Hematuria
6. Differential Diagnosis
   1. Molluscum Contagiosum
   2. Condyloma Lata
   3. Fibroepithelioma
   4. Pearly penile Papule
   5. Squamous Cell Carcinoma
   6. Bowen's Disease
7. Evaluation
   1. All women with HPV should undergo Colposcopy
   2. Direct association with Cervical Cancer
8. Labs: Biopsy Indications
   1. Uncertain diagnosis
   2. Immunocompromised status
   3. Refractory to standard therapy
   4. Pigmented, indurated, fixed or ulcerated warts
   5. High risk for HPV-related malignancy
      1. See prognosis below
9. Management: Overall treatment strategy
   1. Non-Keratinized Warts
      1. First line: Podofilox or Imiquimod
      2. Alternative: Cryotherapy
      3. Refractory: Podophyllin, TCA, ablation
   2. Keratinized warts
      1. First line
         1. Warts <10 mm: Cryotherapy
         2. Warts >10 mm: Surgical excision (or if persistent)
      2. Adjunctive: Imiquimod applied as pretreatment
   3. Warts on mucosal surface (Vagina, Cervix, anal)
      1. First line: Cryotherapy
      2. Alternative: Trichloroacetic Acid
   4. Pregnancy
      1. Indications for HPV treatment in pregnancy
         1. Treat only to minimize neonatal HPV exposure
      2. Contraindicated medications
         1. Absolute contraindications
            1. Avoid Podophyllin, Podofilox, and fluorouracil
         2. Relative contraindications
            1. Imiquimod is not FDA approved
      3. Agents with relative safety for use in pregnancy
         1. Trichloroacetic acid
         2. Cryotherapy
         3. Surgical excision
         4. Electrocautery
   5. Subclinical warts
      1. General HPV screening is not recommended
   6. Reference
      1. Kodner (2004) Am Fam Physician 70:2335-46
10. Management: Topical agents applied by patient
    1. Podofilox (Condylox) 0.5% solution or gel
       1. Podophyllotoxin extract applied to wart by patient
       2. Do not use for mucosal lesions
          1. Avoid on perianal, rectal, Urethral, vaginal warts
    2. Imiquimod cream 5% (Aldara)
       1. Preferred option among many gynecologists
       2. Do not use on mucous membranes
11. Management: Physician applied agents
    1. Podophyllin 10-25% in tincture of Benzoin
       1. Apply to each wart up to once weekly; allow to dry.
    2. Trichloroacetic acid (TCA) 60-90% solution
       1. Apply to each wart up to once weekly; allow to dry.
       2. If excessive application to normal skin
          1. Clean skin with liquid soap or Sodium Bicarbonate
12. Management: Ablation
    1. Cryotherapy
       1. Apply to each wart up to once every 1-2 weeks
    2. Surgical excision to dermal-epidermal junction
       1. Risk of scarring if excision too deep
       2. Excision Techniques
          1. Electrosurgical (ED&C)
          2. Shave excision
          3. LEEP
    3. Carbon Dioxide laser (CO2 Laser)
       1. Use cautiously to avoid scarring
       2. May be used on mucosal lesions (vagina, Urethra)
       3. Used by specialists
13. Management: Agents for refractory warts (specialist use)
    1. Intralesional alpha interferon
    2. Topical alpha interferon
    3. Topical 5-FU 2% Solution
       1. No longer recommended due to adverse effects
14. Prognosis
    1. Response to topical agents mixed
       1. Response in 60-70% of patients
       2. Recurrence in at least 20-30%
    2. No absolute cure
       1. Warts can be removed, but virus may not be eradicated
    3. HPV-related malignancy risk factors
       1. Chronic Genital Warts
       2. Tobacco abuse
       3. Cervical Dysplasia history
       4. High risk HPV-type (especially HPV 16 and 18)
15. Complications: Cancers related to HPV Infection as STD
    1. Cervical Cancer
    2. Anal cancer
    3. Vulvar Cancer
    4. Vaginal cancer
    5. Penile Cancer
    6. Oral and pharyngeal cancer