Condyloma acuminate (anogenital warts)

Notes
  • Condyloma acuminata (anogenital warts or venereal warts) are lesions of skin or mucus membrane of anogenital area caused by the Human papilloma virus (HPV).
  • The condition is more common in the immunosuppressed persons and in pregnancy.
  • HPV types 16 and 18 may cause non-classical flat lesion that is hard to diagnose. They are also responsible for about 70% 0f cervical cancers.
  • HPV vaccination is recommended for both males and females.
Symptoms
  • Cauliflower-like warts (single or multiple) that affect vulva, vagina, cervix, penis, urethra, perineal area and sub preputial.
  • The lesion are painless but occasionally they can be painful.
Diagnosis
  • Diagnosis is mainly done clinically.
  • Test for syphilis (initially and after 3months) to exclude possibility of condyloma lata (which are flat-topped).
  • Biopsy for persistent or bleeding or ulcerated warts to exclude carcinoma.
  • Colposcopy and anoscopy (where a solution of 3-5% acetic acid improve the visualization of lesions as they are whitened by this solution).
  • Nucleic acid test (NAT) for confirmation (when resources are available).
Differential
  • Fibroepithelial polyp / skin tag
  • Nonspecific hyperplasia
  • Verrucous carcinoma
Prevention
  • Avoiding multiple sexual partners
  • Use condoms
  • HPV
Management
  • Surgical removal: either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery
  • Podophyllin 25% in tincture of benzoin: apply on the wart, protect the normal skin, wash after 1-4hrs, repeat after 1-2wks upto 4 applications and if not effective use other medications. This mainly provider-administered medication.

 

  • Podophyllotoxin 5%: Apply BD x 3/7, repeat the cycle after 4 days rest [up to 4 cycles]. This can be patient-administered medication
  • 5-Fluorouracil cream: Applied OD or BD.
  • Silver nitrate pencil 95%: Apply OD x 3/7, by dipping the tip in a drop of water (protecting healthy skin around the area to be treated with a thin layer of petroleum jelly) and rolling the tip on the area to be treated.
  • Cryotherapy (with liquid nitrogen or nitrous oxide using cotton tip applicator or cryoprobe by experts only). Safe in pregnancy.
  • Trichloroacetic acid (80-90%): Applied and allowed to dry once per wk. This mainly provider-administered medication
  • Imiquimod cream 5%: Applied at bed-time 3 times /wk for upto 16 wks and wash the area 6-10hrs after application. This can be patient-administered medication.
  • Sinecatechines (a green-tea extract) 15% Oint: Applied TID for up to 16 wks without washing. This can be patient-administered medication.

 

Other considerations

  • Podophyllotoxin is standardized and stable, whereas podophyllin has a variable composition.
  • To examine and treat the sex partners too.

Circumcision may prevent recurrence in men who are not circumcised.

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