1. GENITAL WARTS
PROF:AKMAL JAMAL
FCPS;FRCSEd:
30 APRIL 2012

2. Condyloma acuminata
HPV

3. Human Papilloma Virus
 Condyloma Acuminata represents
the most common STI
 Caused by a DNA virus that is a
member of the Papovirus group-
HPV
 Most Commonly seen in
Homosexual Male population

4. Human Papilloma Virus
 19 % of patients with HIV have been found to
have anal condyloma
 It is recommended
 that all patients with anal condyloma undergo
HIV testing

5. Genital Warts (HPV)
 There is NO cure for the virus.
 can spread the virus to anyone you
have sex with.
.
can still get HPV even when you
use a condom.

6. HPV
Human Papillomavirus
 Many types of Human Papillomavirus (HPV),
some of which infect the genital area
 Incubation period unclear
 Can infect men, women, and newborns
 The person can easily pass it on to sex
partners
6

7. HPV
Genital HPV: Two Types
 The types of HPV that infect the genital area
are labeled “low-risk” or “high-risk”
depending on whether they can cause cancer
or not.
 Low-risk HPV types can cause genital
warts.
 High-risk HPV types can cause serious
cervical lesions, cervical cancer, and other
genital cancers.
7

8. Condylomata Acuminata
 Over 40 subtypes of HPV
 Most common 6 and 11
 16, 18, 31, and 32 are associated with
squamous cell carcinoma

9. TRANSMISSION
 Genital warts are very
contagious.
 Infection is Acquired
 oral,
 vaginal, or
 anal sex .

10. Epidemiology
· Genital warts caused by HPV 6
and 11 are the most common
· Direct contact with the lesion is
believed to result in spread of the
disease.

11. 
HPV Histology
Hyperplastic Epithelial Growth with irregular
acanthosis and marked Hyperkeratosis

12. Epithelial Hyperplasia in a Condyloma
When epithelia cells are infected by
HPV, they undergo a transformation in
which they divide continuously causing a
buildup of abnormal tissue that
eventually becomes a wart

13. Perinuclear Halos = Koilocytosis

14. Features of
CONDYLOMATA
soft, moist, or flesh colored
appear in clusters that resemble
cauliflower-like bumps,
either raised or flat, small or large

15. cauliflower-like lesions

16. Symptoms of HPV
 discharge,
 pruritis,
 difficulty with defecation,
 anal pain,
 tenesmus,
 foul odor, and
 rectal bleeding

17. Manifestations
Warts are usually, small,
discrete, elevated pink to grey vegetative
excrescences
· Soft, fleshy,
cauliflower-like lesions on the skin,
genitalia, perineum, and perianal
regions .

18. Diagnosis
For the cauliflower-like lesions, clinical
presentation is enough.
These must be differentiated from condyloma
lata and molluscum contagiosum.
cytology
PCR
immunofluorescence
electron microscopy

19.  COMPLICATIONS
Cancer
 cervical cancer.
 vulvar cancer,
 anal cancer, and
 cancer of the penis (a rare cancer).
.

20. LOCATION of
GENITAL WARTS
 Although genital warts are most often found
on or inside the genitals, they can also be
found on the mouth, eyelid, lip, nipple, and
around the anus.

21. Male locations: Genital Warts
: Anal verge/canal
just inside the opening of the urethra,
frenulum,
head of the penis,
coronal ridge,
inner surface of the foreskin,
along the penile shaft.

26. Female locations: Genital
Warts
Opening to the vagina,
inner third of the vagina,
and cervix.
.

27. www.skinchoice.com

28. Condyloma Acuminata

29. Condyloma Acuminata

30. Condyloma Acuminata

31. Perianal Condyloma Acuminata

32. HPV Warts on the Thigh
32

33. Possible HPV on the
Tongue
33

34. Condyloma on Tongue

35. HPV
HPV Penile Warts
Source: Cincinnati STD/HIV Prevention Training Center 35

36. HPV
Genital Warts in a
Woman
Source: CDC/NCHSTP/Division of STD, STD Clinical Slides 36

37. HPV
Perianal Wart
Source: Cincinnati STD/HIV Prevention Training Center 37

38. Condylomata Acuminata

39. Condylomata Acuminata

40. Condylomata Acuminata

41. Condylomata Acuminata

42. Condylomata Acuminata

43. Condylomata Acuminata
 Successful therapy requires accurate
diagnosis and eradication of all warts
 All patients undergo anoscopy and genital
examination
 Once identified, there are many different
treatments depending on disease progression
 Each treatment has advantages and
disadvantages

44. Treatment Modalities
 1. Podophyllin- cytotoxic chemical agent
very toxic to normal skin. Can only be used
on external warts.
.
 Local complications include necrosis, fistula,
and anal stenosis
 Multiple treatments are usually required
 Other caustic agents are available
 Eg. Bichloracetic Acid

45. Immunotherapy
 2. A Vaccine is created and the patient is
vaccinated with six consecutive weekly
injections

46. HPV Vaccine - Gardisil
 Approved for use in women only, 9-26
 Recommended at ages 11-12
 Catch-up older patients
 3 vaccine series (0,2,6 mo)
 Efficacy varies, outcomes studied vary
 But efficacy in the 90+ percentile for reduction of
type-specific dysplasia
 Targets HPV 6/11,16/18
 Based on primary capsid proteins

47. Immunomodulators
(Imiquimod/Aldara)
 3. Imidazoquinolines- a new class of
immune-response modulators
 Mechanism of action unknown, but thought to
play a role in cytokine-induced activation of
the immune system
 Application 3/week qhs x 16weeks

48. Condylomata Acuminata
 Two therapies that are more commonly
practiced today are interferon injections
and Aldara (imiquimod) cream
 Both therapies are very potent with many
side-effects
 LFT’s should be checked routinely with
interferon injections
 Aldara should be used every other day,
because it can burn normal tissue and make
it necrotic

49. Topical Cytostatics
 4. Chemotherapeutic agents such as 5-FU,
Thiotepa and Bleomycin
 Bleomycin is given as an intra-lesional
injection q2-3weeks
 70% success rate reported

50. Cryotherapy and Laser
 Therapy
5. Cryotherapy- topical application of Liquid
Nitrogen commonly used by dermatologists for the
treatment of conventional warts
 6. Laser Therapy- work through
thermonecrosis
 Success rate from 88-95%
 Higher rate of recurrence seen than
electrocoagulation
 No difference in healing time, pain or scarring
reported

51. Fulgaration/Electrocoagu
lation
 7. Fulgaration with excision of a portion to
send to pathology
 Gold Standard
 Very Painful if done too deeply, should not be
into the dermis or fat
 Risk of stricture formation if a large area is to
be treated
 Less than 50% have full resolution after one
treatment

52. Anal Condylomata
Summary
 External Condylomata without evidence of
Internal Warts can usually be effectively
treated by chemical means
 If the response is unsatisfactory, physical
destruction by electrocoagulation is the
preferred approach
 Obtaining tissue for pathologic confirmation,
especially with respect to premalignant or
malignant change is a a prudent philosophy

53. Sores
Secondary Syphilis -
Clinical Manifestations
 Represents hematogenous dissemination of
spirochetes
 Usually 2-8 weeks after chancre appears
 Findings:
 rash - whole body (includes palms/soles)
 mucous patches
 condylomata lata - HIGHLY INFECTIOUS
 constitutional symptoms
 Sn/Sx resolve in 2-10 weeks
53

54. Sores
Secondary Syphilis –
Condylomata Lata
Source: Florida STD/HIV Prevention Training Center 54

56. MOLLUSCUM
CONTAGIOSUM
 Molluscum contagiosum (MC) is a common,
self-limited, benign viral infection of the skin
caused by a member of the pox-virus group.
 MC is transmitted by close personal contact
including sexual contact

57. DIAGNOSIS

 Diagnosis is usually done on clinical grounds
alone by the typical appearance of the lesions.
 Expression of materials stained with Giemsa,
Wright or Gram stain reveals molluscum bodies.
 Biopsy, which shows characteristic features of
epidermal hyperplasia.

61. Complications:

 Secondary infections
 Eczematization
 Conjunctivitis/keratitis from eyelid infection

62. DIFFERENTIAL
DIAGNOSIS
 Acne whiteheads
Warts
Pyoderma
Cryptococcosis

63. Questions?