eMedicine Specialties > Dermatology > Viral Infections

Warts, Genital: Differential Diagnoses & Workup

Author: Tsu-Yi Chuang, MD, MPH, Clinical Professor, Department of Dermatology, University of Southern California; Staff Dermatologist, Desert Specialty Group, Inc
Coauthor(s): Ryan Brashear, MD, Staff Physician, Department of Dermatology, Indiana University School of Medicine
Contributor Information and Disclosures

Updated: Oct 27, 2009

Differential Diagnoses

Bowen Disease
Pearly Penile Papules
Erythroplasia of Queyrat (Bowen Disease of the Glans Penis)
Sebaceous Hyperplasia
Giant Condylomata Acuminata of Buschke and Lowenstein
Squamous Cell Carcinoma
Lichen Planus
Syphilis

Other Problems to Be Considered

Anogenital malignancy
Anogenital warts in children
Fordyce spots
Laryngeal papillomatosis of neonates and infants
Syphilis (genital warts sometimes can be confused with syphilitic lesions, condyloma lata)
Verrucous carcinoma of genitalia (giant condyloma of Buschke-Löwenstein)

Workup

Laboratory Studies

  • Diagnosis usually is made clinically; it may be helped by the application of acetic acid and biopsy.
  • Identification of precise HPV genotypes is available only in research laboratories by using DNA hybridization techniques.10
    • This technique includes Southern blot (highly sensitive and also most time consuming), dot blot, and in situ hybridization.
    • Others methods include enzyme-linked immunosorbent assay (ELISA) for immunoglobulin G (IgG) antibody (Ab) against HPV 16 capsid.
  • Certain screening tests are available with a relatively high sensitivity and specificity; they include the following:
    • ViraPap
    • ThinPrep Pap
    • Hybrid capture II

Other Tests

  • Acetic acid test
    • Soaking acetic acid into suspicious lesions can enhance the degree of suspicion in lesions without classic features.
    • The method involves applying a 3-5% acetic acid–moistened gauze pad for 5-10 minutes on suspected lesions of the penis, cervix, labia, or perianal area.
    • Inconspicuous, flat, genital lesions that might be difficult to assess become visible. Dysplastic and neoplastic tissues turn white (acetowhite).
    • False-positive results are common and can result from anything that causes parakeratosis (eg, candidiasis, psoriasis, lichen planus, healing epithelium, sebaceous glands).
    • This technique can be combined with the use of colposcopy to examine cervical lesions.
    • The acetic acid test is reserved only for suspicious lesions and should not be used for routine screening.

Histologic Findings

Histopathology can elucidate diagnosis in most cases.

  • Verrucae consist of acanthotic epidermis with papillomatosis, hyperkeratosis, and parakeratosis.
  • Elongated rete ridges may point to the center of the wart and dermal capillary vessels may be thrombosed.
  • Koilocytes are indicative of HPV infection. These are large keratinocytes with an eccentric, pyknotic nucleus surrounded by a perinuclear halo.
  • Anogenital warts lack a granular layer and tend to be more papillomatous and vascular than common warts.
  • An electron microscope may show viral particles in nuclei.
  • Immunohistochemical staining with the peroxidase-antiperoxidase technique stains cells infected by viral particles.

More on Warts, Genital

Overview: Warts, Genital
Differential Diagnoses & Workup: Warts, Genital
Treatment & Medication: Warts, Genital
Follow-up: Warts, Genital
Multimedia: Warts, Genital
References
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References

  1. Chuang TY. Condylomata acuminata (genital warts). An epidemiologic view. J Am Acad Dermatol. Feb 1987;16(2 Pt 1):376-84. [Medline].

  2. Chuang TY, Perry HO, Kurland LT, Ilstrup DM. Condyloma acuminatum in Rochester, Minn, 1950-1978. II. Anaplasias and unfavorable outcomes. Arch Dermatol. Apr 1984;120(4):476-83. [Medline].

  3. Nebesio CL, Mirowski GW, Chuang TY. Human papillomavirus: clinical significance and malignant potential. Int J Dermatol. Jun 2001;40(6):373-9. [Medline].

  4. Rhea WG Jr, Bourgeois BM, Sewell DR. Condyloma acuminata: a fatal disease?. Am Surg. Nov 1998;64(11):1082-7. [Medline].

  5. Chuang TY, Perry HO, Kurland LT, Ilstrup DM. Condyloma acuminatum in Rochester, Minn., 1950-1978. I. Epidemiology and clinical features. Arch Dermatol. Apr 1984;120(4):469-75. [Medline].

  6. Koutsky L. Epidemiology of genital human papillomavirus infection. Am J Med. May 5 1997;102(5A):3-8. [Medline].

  7. Lee LA, Cheng AJ, Fang TJ, Huang CG, Liao CT, Chang JT. High incidence of malignant transformation of laryngeal papilloma in Taiwan. Laryngoscope. Jan 2008;118(1):50-5. [Medline].

  8. Varnai AD, Bollmann M, Griefingholt H, Speich N, Schmitt C, Bollmann R. HPV in anal squamous cell carcinoma and anal intraepithelial neoplasia (AIN). Impact of HPV analysis of anal lesions on diagnosis and prognosis. Int J Colorectal Dis. Mar 2006;21(2):135-42. [Medline].

  9. Clifford GM, Smith JS, Plummer M, Munoz N, Franceschi S. Human papillomavirus types in invasive cervical cancer worldwide: a meta-analysis. Br J Cancer. 2003;88:63-73.

  10. de Villiers EM. Papillomavirus and HPV typing. Clin Dermatol. Mar-Apr 1997;15(2):199-206. [Medline].

  11. Beutner KR, Wiley DJ, Douglas JM, et al. Genital warts and their treatment. Clin Infect Dis. Jan 1999;28 Suppl 1:S37-56. [Medline].

  12. Garland SM, Waddell R, Mindel A, Denham IM, McCloskey JC. An open-label phase II pilot study investigating the optimal duration of imiquimod 5% cream for the treatment of external genital warts in women. Int J STD AIDS. Jul 2006;17(7):448-52. [Medline].

  13. American Academy of Dermatology. Genital warts and sexual abuse in children. American Academy of Dermatology Task Force on Pediatric Dermatology. J Am Acad Dermatol. Sep 1984;11(3):529-30. [Medline].

  14. Beutner KR, Reitano MV, Richwald GA, Wiley DJ. External genital warts: report of the American Medical Association Consensus Conference. AMA Expert Panel on External Genital Warts. Clin Infect Dis. Oct 1998;27(4):796-806. [Medline].

  15. Fitzpatrick T, Eisen A, Wolff K. Fitzpatrick T, Goldsmith L, Austen K, et al, eds. Dermatology in General Medicine. 5th ed. New York, NY: McGraw-Hill; 1999:1371-2, 1390-1, 2484-97, 2550, 2986.

  16. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. St. Louis, Mo: Mosby; 1995:297-302.

  17. Harper DM. Are we closer to the prevention of HPV-related diseases?. J Fam Pract. Jul 2005;Suppl HPV Prevention:S10-6; quiz S23. [Medline].

  18. Simms I, Fairley CK. Epidemiology of genital warts in England and Wales: 1971 to 1994. Genitourin Med. Oct 1997;73(5):365-7. [Medline].

  19. Tortolero-Luna G. Epidemiology of genital human papillomavirus. Hematol Oncol Clin North Am. Feb 1999;13(1):245-57, x. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Tsu-Yi Chuang, MD, MPH, Clinical Professor, Department of Dermatology, University of Southern California; Staff Dermatologist, Desert Specialty Group, Inc
Tsu-Yi Chuang, MD, MPH is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, and International Society of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Ryan Brashear, MD, Staff Physician, Department of Dermatology, Indiana University School of Medicine
Ryan Brashear, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates
Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Society of Dermatopathology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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