Papillomavirus Clinical Presentation

The clinical history and presentation of human papillomavirus (HPV) infection vary based on the anatomic area involved. The predilection of certain genotypes of virus to infect certain epidermal sites largely determines areas of involvement.

• Common cutaneous warts, or verrucae vulgaris, generally appear on keratinized skin, presumably at the site of inoculation. These appear as circumscribed, rough, hyperkeratotic papulonodules or plaques with irregular scaly surfaces. They develop most often on the hands, fingers, feet, and knees. In general, they are asymptomatic, but they may be painful with application of pressure. The patient discovers common cutaneous warts due to changes in the skin.
• Palmoplantar warts appear on the acral surfaces of the feet and hands. They are notable for their thickness, which complicates treatment.
• Flat warts, or verrucae plana, generally present as multiple small papules. They are often not obvious but may induce significant disturbances of pigmentation.
• Oral warts are infection of the oral mucosa. Oral warts are subtle and are missed frequently but are fairly common.
• Focal epithelial hyperplasia (Heck disease) is a disseminated HPV infection of the oral mucosa most commonly associated with HPV 32 and HPV 13. This condition may have a family predilection.
• Epidermodysplasia verruciformis (EDV) is an autosomal recessive familial trait that increases susceptibility to a subset of wart generally not observed in populations without EDV. The condition generally begins in childhood and can affect almost any area of the body. The warts are generally subtle and flat and may initially be mistaken for tinea versicolor. The HPV genotypes associated with EDV include 3, 5, 8, 9, 10, 12, 14, 17, 20, 21, 23, 28, 38, 47, and 49. Recently, these viruses have been observed in patients who are immunosuppressed for organ transplantation or in patients with HIV infection. These individuals are at increased risk for skin cancer if not recognized and treated.
• Genital infection manifests as a warty lesion on the genital or anal area, although they are often not initially recognized. Condyloma acuminata are single or multiple papules or nodules but may progress to large exophytic masses that resemble cauliflower. Flat condylomata (squamous intraepithelial neoplasia) are the most common lesions of the cervix but may develop on the vulva, anus, and male genitalia. They appear as white plaquelike growths. An additional malignant variant is the giant condyloma, or Buschke-Löwenstein tumor, generally regarded as a verrucous carcinoma. These most often involve the glans penis, perianal area, and foreskin. In addition to their large cauliflower shape, they tend to form abscesses and fistulas and tend to invade locally. Cervical infection generally goes unnoticed and is discovered during cervical examination or Papanicolaou (PAP) test.
• Lloyd described Bowenoid papulosis as multicentric pigmented Bowen disease of the groin. It manifests as multiple, warty, red-brown papules in the anogenital region. These papules may coalesce.

Abnormal accumulation of keratinized growths generally characterizes warts. Similarly, genital lesions are due to excessive skin growth. In the case of condylomata, the growths may become exuberant. Cervical intraepithelial lesions may be found upon examination of the cervix.

For a detailed discussion of causes, see Pathophysiology.