Laboratory Studies
Most cutaneous and external genital warts can be recognized clinically. In the case of genital intraepithelial neoplasia, determining the extent of disease is essential. This involves careful inspection, as well as colposcopy. In females, frequent PAP tests are useful. The detection of human papillomavirus (HPV) DNA is now FDA approved and is valuable as a screening tool in women older than 30 years.
Imaging Studies
In general, imaging studies have a limited role in diagnosing HPV infections. In rare instances, CT scan or MRI can be used to determine the extent of spread of cervical carcinoma and, in rare instances, extensive anogenital papillomatosis that has spread into the pelvis.
Histologic Findings
Histology of condyloma acuminata generally demonstrates disruption of the epidermis with hyperkeratosis, coarse keratohyaline granules, and koilocytes in a prominent granular layer. The epidermis or mucosa of flat condylomata demonstrates acanthosis. Koilocytes, the characteristic cytological feature of HPV infection, are present. Koilocytes are keratinocytes with pyknotic, deeply blue nuclei surrounded by a halo and clear cytoplasm with a paucity of keratohyaline granules.
Histology of Bowenoid papulosis reveals psoriasiform hyperplasia and hyperkeratosis of the epidermis. Mitotic figures are increased at all epidermal levels. Keratinocytes display enlarged pleomorphic and hyperchromic nuclei.
Histology of common cutaneous warts demonstrates marked hyperkeratosis, acanthosis, parakeratosis, and papillomatosis. Three features used to distinguish warts from other papillomas include the presence of koilocytes, vertical columns of parakeratosis, and foci of clumped keratohyaline granules.
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| Lesion | Location | HPV Genotype |
| Common wart | Mostly hands | 2, 4 |
| Plantar wart | Bottom of feet | 1 |
| Mosaic wart | Hands and feet | 2 |
| Flat wart | Arms, face, knees | 3, 10, 28, 41 |
| Butcher wart | Hand | 7 |
| Extragenital Bowen disease | Upper and lower extremities, head | 2, 3, 5, 16, 18, 20, 31, 33, 34, 54, 56, 58, 61, 62, 73 |
| Macular plaques of epidermodysplasia verruciformis | Light-exposed areas | 5, 8, 9, 12, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 36, 47, 50 |
| Lesions | HPV Genotype |
| Genital warts | 6, 11 |
| Flat condylomata | 6, 11, 16, 18, 31 |
| Cervical intraepithelial neoplasia | 16, 18, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 56 |
| Bowen disease | 6, 11 |
| Buschke-Löwenstein tumors | 6, 11 |
| Vulvar intraepithelial neoplasia | 16 (occasionally 6, 11) |
| Cervical cancer | 16, 18 (strong association) |
| 31, 33, 35, 45, 51, 52, 56 (moderate association) | |
| 6, 11, 42, 43, 44 (weak association) | |
| Penile intraepithelial neoplasia | 16, 18 |
| Anal intraepithelial neoplasia | 16 (rarely 6, 11, 18, 33) |
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