eMedicine Specialties > Dermatology > Viral Infections

Warts, Genital: Follow-up

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

Follow-up

Further Outpatient Care

  • Patients typically are monitored on a periodic basis to assess for efficacy of treatment, unwanted side effects, and the development of complications. Outpatient follow-up care also provides an opportunity to evaluate for other sexually transmitted diseases (STDs) and provides patient education on an ongoing basis.

Deterrence/Prevention

  • A vaccine for human papillomavirus (HPV) infection has been approved by the US Food and Drug Administration.

Complications

  • Disease complications can include progression to malignancy and transmission to other sexual contacts. In the setting of genital warts active during a pregnancy delivery, there is a small risk of laryngeal papillomatosis.
  • Each therapeutic modality carries its own unique set of risks. Risks of individual medical options are enumerated above.
  • Expected effects of cryosurgery include pain, edema, vesicles, bullae, weeping, and some necrosis. There is a small risk of infection, bleeding, abnormal scarring, pigment alteration, paresthesias, and alopecia with cryosurgery.
  • Similarly, laser surgery of genital warts may result in pigment alteration, abnormal scarring, and infection. Special care must be taken to prevent respiratory infection from the laser plume generated by vaporization of virally infected tissue.

Prognosis

  • Prognosis is good, and most cases of genital warts are amenable to treatment.
  • Patients who are immunosuppressed with genital warts may represent a special challenge.

Patient Education

  • STD counseling and evaluation of partners
    • Patients with genital warts deserve a focused history and physical with appropriate testing to assess for other STDs.
      • In a population study, 7% of men and 31% of women who had genital warts had concurrent STDs. In fact, 28% of these men and 71% of women had other STDs before or after their genital warts.
      • Several consort studies documented that 30% of female consorts and 80% of male consorts had HPV infection. Usually, the same type of HPV involved both parties, and often they were HPV 6, 11, 16, and 18.
    • The benefit of evaluating sex partners of patients with genital warts has been apparent.
  • For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education article Genital Warts.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnosis genital warts correctly can result in considerable morbidity. Confusing condyloma lata for genital warts will miss the diagnosis of syphilis and will lead to inappropriate therapy. Confusing pearly penile papules or Fordyce spots with genital warts will result in unnecessary treatment and likely unwarranted psychosocial concern. Missing a diagnosis of verrucous carcinoma or squamous cell carcinoma is likely to delay appropriate therapy and may lead to unneeded morbidity, even mortality.
  • Treatment of genital warts can be difficult and lengthy. Patient expectations should be set appropriately. Patients should be counseled on their risk of infectivity to others. They also should be advised of their increased risk of having acquired other STDs.
  • Each therapy of genital warts has a unique set of potential adverse effects. Patients should be appropriately aware of potential adverse consequences of therapy.

Special Concerns

  • Increased risk of anogenital malignancy
    • Patients with genital warts have an increased risk of anogenital malignancy.
    • Infection with HPV is the primary cause of cervical malignancy, although most patients with HPV-infected cervices have a benign outcome. This mandates that female patients with genital warts should have an annual screening examination and Papanicolaou test. Up to 90% of cervical cancers are caused by HPV infection of the cervix.
    • Strong epidemiologic evidence suggests that 10% of patients who had a high-grade squamous intraepithelial lesion (HGSIL, which includes so-called moderate-to-severe dysplasia, carcinoma in situ, and cervical intraepithelial neoplasia II and III) would have persistence of lesions that eventually would progress to invasive cancer without treatment. Patients with perianal warts, patients who are HIV positive, and those with a history of receptive anal intercourse are at increased risk for anal HGSIL. No direct evidence suggests that this would progress to invasive anal cancer, as lesions of the cervix are capable of doing. Nonetheless, penile, vulvar, vaginal, ovarian, and anal carcinomas have been linked to HPV infection.
  • Anogenital warts in children
    • Anogenital warts are rare in the general pediatric population.
    • More than one half of children with anogenital warts have a manifestation either of viral inoculation at birth or of incidental spread of cutaneous warts. Such cases often are caused by nongenital HPV types.
    • Diagnosis of genital warts in a child requires that the clinician report suspected abuse to begin an evaluation process that may or may not confirm sexual abuse.13,14
  • Laryngeal papillomatosis of neonates and infants
    • Although childhood laryngeal papillomas frequently are acquired from condyloma of the mother (HPV types 6 and 11 are frequently cited), most infants of mothers with condyloma do not contract laryngeal papillomas.
    • Accordingly, cesarean delivery should not be performed solely to prevent transmission of HPV infection to the newborn.
    • Route of transmission in pregnancy is not known, and infants born by cesarean delivery have developed laryngeal papillomatosis. However, it is advisable to remove visible lesions during pregnancy.
  • Patients who are immunosuppressed: Patients who are immunosuppressed such as those with AIDS and those on immunosuppressive therapy (eg, patients with renal transplants) are more likely to develop persistent HPV infection and subsequent dysplasia and malignancy.
  • Verrucous carcinoma of genitalia (giant condyloma of Buschke-Löwenstein): It is a low-grade, locally invasive, squamous cell carcinoma that is associated with HPV types 6 and 11 and should be considered in the differential of lesions measuring greater than 1 cm in diameter. Only radical surgical extirpation is considered appropriate treatment.
 


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Follow-up: Warts, Genital
Multimedia: Warts, Genital
References

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].

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  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].

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Further Reading

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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