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Condyloma acuminatum,Etiology,Clinical Manifestation(s) and Treatment

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Condyloma acuminatum is a sexually transmitted viral disease of the vulva, vagina, cervix, and perianal area in women and on the penis, perianal area, and scrotum in men.

Etiology
• HPV infection: more than 150 types of viral DNA have been identified. Transmission of warts is by direct contact. Approximately 40 different types of HPV are
transmitted through sexual contact.
• Genital warts: 90% are caused by HPV types 6 or 11. HPV types 16, 18, 31, 33, and
35 are found occasionally in visible genital warts (usually as coinfections with HPV
6 or 11) and can be associated with foci of high-grade, intraepithelial neoplasia,
particularly in persons who are infected with HIV infection. In addition to warts
on genital areas, HPV types 6 and 11 have been associated with conjunctival, nasal,
oral, and laryngeal warts.
• Virus is shed from both macroscopic and microscopic lesions.
• Predisposing conditions include diabetes, pregnancy, local trauma, and immunosuppression (e.g., transplant patients, those with HIV infection).

KEYS TO DIAGNOSIS

Clinical Manifestation(s)
• Condyloma acuminatum is seen mostly in young adults, with a mean age of onset
of 16 to 25 years.
• The average incubation time is 2 months (range: 1–8 months).
• Lesions are usually found in the genital area (Fig. 3.79) or perianal area (Fig. 3.80)
but can be present elsewhere.
• Lesions are usually in similar positions on both sides of perineum.
• The condition is usually asymptomatic, but the lesions can cause pain, odor, or bleeding.
• Vulvar condyloma is more common than vaginal and cervical.

Physical Examination
• Initial lesions are pedunculated, soft papules about 2 to 3 mm in diameter, 10 to
20 mm long; they may occur as a single papule or in clusters. There are four morphologic types: condylomatous, keratotic, papular, and flat warts.
• Size of the lesions varies from pinhead to large cauliflowerlike masses.
• Intraanal warts occur predominantly in patients who have had receptive anal intercourse, in contrast with perianal warts, which may occur in men and women
without a history of anal sex.

Diagnostic Tests
• Colposcopic examination of the lower genital tract from cervix to perianal skin
with 3% to 5% acetic acid
• Biopsy of vulvar lesions that lack the classic appearance of warts and that become
ulcerated or fail to respond to treatment
• Biopsy of flat white or ulcerated cervical lesions

DIFFERENTIAL DIAGNOSIS
• Molluscum contagiosum
• Condyloma latum

Acrochordon (skin tags) or seborrheic keratosis
• Epidermal nevi
• Hypertrophic actinic keratosis
• Squamous cell carcinomas
• Acquired digital fibrokeratoma
• Varicella-zoster virus in patients with AIDS
• Recurrent infantile digital fibroma
• Plantar corns (may be mistaken for plantar warts)
• Abnormal anatomic variants or skin tags around labia minora and introitus
• Pearly penile papules
• Dysplastic warts
• Seborrheic keratosis
• Erythroplasia of Queyrat
• Lichen planus
• Verrucous carcinoma
• Bowenoid papulosis

TREATMENT

First Line
• Cryosurgery with liquid nitrogen delivered with a probe or as a spray is effective for
treating smaller genital warts.
• Twenty percent podophyllin resin in compound tincture of benzoin is applied with
a cotton tip applicator by the treating physician and allowed to air dry. The treatment can be repeated weekly if necessary. Podofilox (Condylox 0.5% gel) is available for application by the patient. Local adverse effects include pain, burning, and
inflammation at the site.

Second Line
• Imiquimod cream is a patient-applied immune response modifier effective in the
treatment of external genital and perianal warts (complete clearing of genital warts
in >70% of females and >30% of males in 4–16 weeks). Sexual contact should be
avoided while the cream is on the skin. It is applied three times per week before
normal sleeping hours and is left on the skin for 6 to 10 hours.

Third Line
• CO2 laser ablation
• Sinecatechins (Veregen), a botanical drug product, is also effective for treatment
of external genital and perianal warts. Formulation is a 15% ointment applied to
affected area tid for up to 16 weeks.
• Application of trichloroacetic acid or bichloracetic acid 80% to 90% is also effective
for external genital warts. A small amount should be applied only to warts and
allowed to dry, at which time a white “frosting” develops. This treatment can be
repeated weekly if necessary.

CLINICAL PEARL(S)
• This condition is highly contagious, with 25% to 65% of sexual partners developing it.
• Two HPV vaccines (Gardasil, Cervarix) have been licensed in the United States.
ACIP recommends routine vaccination with HPV4 or HPV2 for females aged 11 to
12 years and HPV4 for males aged 11 to 12 years. Vaccination is also recommended

for females aged 13 to 26 years and for males aged 13 through 21 years who were
not vaccinated previously. Males aged 22 through 26 may be vaccinated. ACIP recommends vaccination of men who have sex with men and immunocompromised
persons (including those with infection) through age 26 years if not previously
vaccinated. The FDA has also approved a 9-Valent HPV vaccine (Gardasil-9) for
use in girls and women 9 to 26 years old and boys 9 to 15 years old

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