What Are Some Possible Treatments for Condylomata?

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Patient Presentation
A 17-year-old female came to clinic with a history of genital itching for several weeks. She actually had noticed that there were some genital “bumps” that had also been present which had initially been small but had increased in size. These were now becoming pruritic and sometimes painful. She denied any systemic problems and also denied any rashes, vaginal discharge, and abdominal or pelvic pain. Her menstruations were monthly and had not altered over the past 2 years.

The past medical history showed she had initiated sexual intercourse at age 15 and had 3 lifetime male partners. The newest relationship had been 6 months. She had been screened for sexually transmitted infections (STIs) twice since age 15. She stated that she always used condoms and a spermicide but was not using other contraception. She was not immunized against human papilloma virus and some other routinely recommended vaccines.

The pertinent physical exam showed a healthy appearing female with normal vital signs and growth parameters. HEENT and skin exams were negative. Her genitourinary examination showed no vaginal discharge and normal labia. She had multiple skin-colored papular lesions from 1-10 mm in size along the perineum and around the anus, that showed some minor excoriations.

The diagnosis of genital warts was made. The physician explained the natural history and offered some options. The patient decided to try to use some emollients to the area and also use an antihistamine to try to help with the pruritis while waiting for possible spontaneous regression but was going to return if the lesions increased significantly or she had more pain or pruritis than she could tolerate. She also wanted to start using a more consistent form of contraception and was referred to a provider for a Nexplenon&reg: placement. She also wanted to have STI testing as she had not had this completed with her new partner. Confidentiality issues were discussed and as her parents were aware of her sexual health status, there were no issues with evaluation, treatment and followup.

Discussion
Condylomata acuminata or genital warts are caused by human papilloma virus (HPV) from the Papillomaviridae family. There are about 200 different types of HPV with ~30 of them causing genital infections. HPV serotype 6 and 11 are the most common causing condylomata (90% of infections). HPV serotypes 6, 11, 16 and 18 are the most common ones causing dysplastic changes and/or cancer. Types 16, 18, 31 and 45 are high risk oncogenic types. There are 2 different vaccines available. Data for the quadra-valent vaccine (for types 6, 11, 16 and 18, original Gardasil&reg:) has extremely high rates of effectiveness for condylomata prevention (~99%) and for cervical cancer prevention (~97%). There is also data supporting cross-reactivity with other serotypes and herd immunity. In the United States, Gardasil-9® (with the addition of serotypes 31, 33, 45, 52 and 58 from the original) can be given from 9-45 years for males and females, and requires a 2- or 3- dose series depending on age at vaccine initiation. A bivalent vaccine for serotypes 16 and 18 is also manufactured.

Learning Point
HPV causes epithelial cell proliferation producing skin-colored papules of 1-5 mm to large pedicaled or cauliflower type lesions . Transmission is usually via sexual contact but auto/heteroinnoculation and vertical transmission are also common. The incubation period is about 10-14 weeks and physical symptoms begin about 8-10 weeks after infection. Patients do not have to have clinical symptoms because the virus may be dormant but present within epithelial cells for long time periods. Children who present with condylomata may raise the suspicion of child abuse but like many sexually transmissive infections is not specific for it. Pediatric patients should have potential child abuse considered as part of the evaluation and treatment process.

Patients may need treatment but up to 30% have spontaneous regression within 4 months of symptoms, but many patients have recurrence within the following 3 months. In general watchful waiting is the best treatment, but if lesions are persistent > 2 years or are symptomatic then treatment is recommended.
Potential treatments include:

  • Physical removal
    • Cryotherapy causes thermal destruction which also triggers an immunological response. This requires professional application usually with several treatments needed. Side effects are mainly local, and potential but less likely cutaneous and vascular damage. Success in adult population is ~60-80%
    • Electrocautery causes thermal destruction and cautery. It requires professional application. Side effects are local but more extensive tissue damage could occur. Effectiveness is cited at ~55-90% in adult populations.
    • CO2 laser therapy causes thermal damage and cautery. It requires professional application with specific training and unfortunately is also expensive. It is precisely applied with little to no scarring. Side effects are local. Environmental controls and virus-resistant masks for those in the procedure room are needed because of potential aerosolization of the viral particles during the procedure.
    • Pulsed light therapy is a 2 step process where a keratolytic agent is used along with phototherapy. It requires professional application with specific training and unfortunately is also expensive. Side effect include burning, itching and pain.
  • Topical treatment
    • Imiquimod is an immunomodulator. It is self-applied. Side effects are mainly local with burning, erythema and erosions. Effectiveness is up to 75% in pediatric patients.
    • Podophyllotoxin is a anti-mitotic agent. It is self-applied. Side effects are mainly local with edema, erythema and erosions. Systemic effects mainly include the liver and neurological systems.
    • Trichloroacetic acid is a chemical cautery. It is usually requires professional application. Side effects are irritation, edema, erythema, and burn. Effectiveness is up to 80% with recurrence of 36%
    • Other keratolytic agents such as salicylic acid or 5-fluoracyl are also sometimes used.

Questions for Further Discussion
1. What are the immunization rates for HPV in your own practice and/or local environment?
2. What is your practice standard for the types of verrucae? Why?
3. How common are STIs in your location? A review can be found here
4. What is respiratory papillomatosis and how is it treated? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Genital Warts and HPV.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Drolet M, Benard E, Boily MC, et al. Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2015;15(5):565-580. doi:10.1016/S1473-3099(14)71073-4

Costa-Silva M, Fernandes I, Rodrigues AG, Lisboa C. Anogenital warts in pediatric population. An Bras Dermatol. 2017;92(5):675-681. doi:10.1590/abd1806-4841.201756411

Yuan J, Ni G, Wang T, et al. Genital warts treatment: Beyond imiquimod. Hum Vaccin Immunother. 2018;14(7):1815-1819. doi:10.1080/21645515.2018.1445947

Kore VB, Anjankar A. A Comprehensive Review of Treatment Approaches for Cutaneous and Genital Warts. Cureus. 15(10):e47685. doi:10.7759/cureus.47685

Deak P. What I Tell Every Patient About the HPV Vaccine. ACOG. Accessed July 15, 2024. https://www.acog.org/womens-health/experts-and-stories/the-latest/what-i-tell-every-patient-about-the-hpv-vaccine

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published