Acuminate condyloma A63.0

Author: Prof. Dr. med. Peter Altmeyer

Co-Autor: Dr. Maryam Ardestani

All authors of this article

Last updated on: 09.10.2021

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anogenital warts; condylomas pointed; Dampening nipples; genital warts; Genital warts; Pointed condylomas; Viral warts of the mucosal type; warts genital warts

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STD (= sexually transmitted diseases) is an infectious disease caused by human papillomaviruses (HPV), which has increased significantly in recent decades. It initially develops fewer, sharper, soft papules with a tendency to rapid seeding and the formation of wartlike, large nodular or beet-like growths.

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Viruses of the Papova group (HPV, see below Papillomaviruses, human), mostly HPV 6 and 11. At the same time, co-infections with other different HPV types may be present, e.g. HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 66.

HPV 16, 18, 31, 45 are considered to have a high risk of carcinoma (almost always detectable in cervical carcinoma), HPV 33, 35, 39 are considered to have an intermediate risk (detected in 1-5% of invasively growing cervical carcinomas), and HPV 6 and 11 are considered to have a lower risk (only rarely detected in invasively growing cervical carcinomas). HPV 16 is found in nearly 100% of bowenoid papulosis. HPV 6 and 11 are also causative agents of laryngeal papillomas.

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Worldwide and panethnically very common (worldwide most common STD). Proven in approx. 1% of sexually active adults in Europe between the ages of 15 and 45.

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  • Transmission from person to person through direct contact, especially during sexual intercourse. Moist environments, e.g. fluorine vaginalis, urethritis, intertrigo, phimosis, eczema, anal eczema, possibly ovulation inhibitors, immunodeficiency, have a favourable effect.
  • For children with condylomata in the genital and anal areas, the duty of care requires that possible indications of child abuse be investigated. A psychosocial anamnesis is important. It is also important to eliminate a possible source of infection. Behavioural disorders of the children, disorders in the relationship between the child and his or her parents must be investigated together with a child psychologist if necessary.

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Women and men are affected about equally often. The age peak lies between the ages of 20 and 24.

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In women: peri- and intraanal; large and small labia, introitus vaginae, in 20% of cases also intravaginally, in 6% at the cervix. In the man: coronary sulcus, inner preputial leaf, frenulum.

Clinical features
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  • Initially small, 0.2- 0.5 cm in size, reddish to greyish yellow, soft nodules, which rarely occur singly, but usually multiple, disseminated, or can aggregate to form large, warty, fissured plaques or nodules. In maceration, transition to greasy, foul-smelling, decomposing growths.
  • Condylomas can also occur beyond the mucosal area; they appear e.g. on the shaft of the penis, then as soft pigmented papillomas, which then resemble pigmented seborrhoeic keratoses (atypical localisation).
  • Special forms: Condylomata gigantea, Condylomata plana.

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Sharply limited, exophytic neoplasm with voluminous acanthosis with widened and extended reticulum, low hyperkeratosis and focal parakeratosis. In contrast to the vulgar warts there is no accentuation and widening of the str. granulosum. Koilocytes are diagnostically important, but often occur as distinctly as in verruca vulgaris. Subepidermal mostly sparse round cell infiltrate.

Differential diagnosis
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AIN, anal carcinoma: important differential diagnosis; scaly, whitish, erythematous, eczematous, papillomatous, papular, pigmented or fissured plaques described. Induration and ulceration may be evidence of invasion.

Marisci: common; nonreducible, solitary or multiple, indolent, flaccid skin folds that do not fill on pressing. Condylomata lata: rare; weeping, broad-based papules and plaques; foul foetor, masses of spirochetes detectable in dark field chronic anal eczema of various etiologies: bulging thickening and lichenification of skin and semi-mucous membrane with erythema and rhagades as well as punctate and extensive erosions, line-shaped scratch marks as an expression of the usually intense itching.

Penis and glans penis:

Pseudocondyloma = Hirsuties papillaris penis: Formation of row-like, reactionless papillary or filiform, whitish-red nodules at the proximal edge of the glans before the transition into the sulcus coronarius; never aggregation of the papules. PIN: - usually corresponds to the findings of erythroplasia - with usually painless, solitary, rich red, sharply circumscribed, velvety granular, sometimes plate-like focus; never verrucous. Bowenoid papules: Usually multiple, 0.2-0.5 cm in size, flat, reddish-brown (reminiscent of lichen planus) irregularly circumscribed papules with usually smooth or velvety, but occasionally verrucous, then usually whitish tinged surface.

Penile shaft

Scabies granulomatosa: rarely found in the glans penis area, usually penile shaft, there as solitary or grouped red, itchy firm papules. Verruca seborrhoica: Usually sharply circumscribed, mostly disseminated, roundish to oval, 0.5 - 1.0 cm in size, soft, raised, gray-brown or also black papules or nodules with a fissured, warty surface, sitting broadly on the lower surface.

General therapy
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  • The choice of procedure (conservative or surgical) depends on the number and localisation, size and morphology of the lesions as well as the personal experience of the therapist. Since human papilloma viruses only infect epithelial cells, the aim is to completely remove the epithelial layer.
  • Common to all surgical procedures is the necessity of an adequate anaesthesia. A surface anaesthesia is usually not sufficient for extensive infestation, so that local, conduction, spinal or general anaesthesia should be used depending on the findings.
  • Concomitant diseases: If necessary, the treatment of a basic disease such as gonorrhoea, candidiasis, phimosis, syphilis, oxyuriasis, immune deficiencies, etc. must be considered.
    • In the anal region: exclusion of rectal diseases such as internal haemorrhoids, chronic proctitis, rectal gonorrhoea and other sexually transmitted diseases. Partner treatment or prophylaxis of the infection of the partner (condoms!) are of crucial importance!
    • Especially in the case of anal condylomata acuminata in homosexual men, a test for HIV should always be carried out.

External therapy
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  • For self-treatment for small non-inflammatory condylomas on the penis, podophyllotoxin can be applied as a cream (Wartec-Creme®) or solution (Condylox-Lsg.®). Side effects may include painful erosions and inflammatory swelling of the treated areas.
  • Good results can be obtained with Imiquimod (e.g. Aldara ®5%): application 3 times/week over 6-10 hours (e.g. overnight) for a total of 12 weeks. The procedure is also indicated for the "post-treatment" of condylomata acuminata, e.g. after surgical removal of condylomas. For perianal condylomata, the magistral formulation of suppositories with 5% imiquimod has proven effective.
  • Application of trichloroacetic acid (concentration up to 85%) by means of a cotton swab 1 time/week (by the physician). Use only in very small quantities. In case of overdosage, neutralisation with sodium bicarbonate solution is necessary. Healing without scarring. Safe to use during pregnancy. Local side effects are burning and pain in the area of application.
  • Alternatively, the locally well tolerated active agent polyphenone ( epigallocatechin gallate) is recommended, a catechin extract(see below tannins) which is extracted from the leaves of the green tea (Veregen®). The ointment is available as a 10% application form and has been evaluated in 2 large placebo-controlled (>600 patients) studies. The catechin extract inhibits the excessive proliferation of HPV-infected keratinocytes. The green tea extract ointment (Veregen®) must not be applied vaginally, cervically, anally, perianally and intraurethrally as it may cause ulceration there.

Operative therapie
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Small condylomata:

  • General: Targeted surgical methods offer higher success rates and fewer side effects in small condylomas.
    • Therapy of the first choice is curettage with a sharp spoon in LA or under icing; then electrocautery with spherical cautery. Careful inspection intravaginally and anally to detect all foci.
    • Alternative: Electrocautery with conventional monopolar electrodesiccation. The skin around the condylomas should also be coagulated, as these usually contain keratinocytes with viral genome. The depth effect cannot always be estimated.
    • Alternative: ablation with CO2, YAG or diode laser systems. Advantage of laser procedures: bloodless operation area, less postoperative complaints. Disadvantage: greater effort. Remark: The vaporization of the condylomas is intensive with extensive findings. Possibly infectious virus particles are released into the ambient air. Protective goggles and masks as well as smoke evacuation are obligatory!

Large condylomata:

  • If there are only a few circumscribed condylomas, ablation with a diathermy loop is favourable in LA. Otherwise curettage and subsequent electrocoagulation with a ball probe (if necessary, ablation in layers).
  • Alternatively: ablative laser procedure (see above).
  • Alternative: see above.

Extended condylomata:

  • For disseminated condylomata acuminata in the genital area and intraanal, electrocautery, curettage and layered ablation under general anaesthesia is indicated.
  • Circumcision of the penis, reduces the recurrence rate.

Recurrent condylomata:

  • Treatment schemes see above.
  • Circumcision in case of penile involvement.
  • Alternative: After OP adjuvant interferon therapy (3 million IU interferon alpha s.c. 3 times/week for at least 16 weeks).
  • Alternatively Imiquimod (e.g. Aldara) 3 times/week for 3 months if necessary in combination with an ablative Co2 laser therapy.
  • Experimental: monotherapy with 2 times " photodynamic therapy".

Condylomata in pregnancy:

Condylomata manifesting in pregnancy may be an initial infection or they may be the result of reactivation of a subclinical HPV infection.

The risk of transmission is low but possible. The perinatal infection of the larynx with HPV 6 or HPV 11 is particularly feared, which can lead to juvenile laryngeal papillomas.

Local trichloroacetic acid and surgical procedures or the CO2 laser can be used for treatment.

A caesarean section is only indicated if the birth canal is blocked by condylomas.

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Practically never spontaneous healing; malignant degeneration is possible with a long period.

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In a multicenter study, a quadrivalent HPV vaccine in young women aged 16-23 years achieved a significant decrease in HPV 6, 11, 16 and 18 induced infections for the first time. Meanwhile, the nine-valent vaccine (Gardasil®9) has also been shown to protect against condylomata acuminata. Up to 90% of these are caused by HPV types 6 and 11.

Currently, statutory health insurance companies in Germany cover the cost of vaccinations for young women and men aged 9-15 years. If the vaccination is missed, it can and should be made up until the age of 17.

Currently, therapeutic HPV vaccination for (recurrent) condyloma in males is not recommended, but all available HPV vaccines are licensed with no age limit starting at age 9 years. The costs for vaccinations of adult males after completion of the 18th year of age must be clarified with the health insurance companies in advance. Whether a booster vaccination is necessary in the course cannot be answered with certainty at present. However, initial studies of women show no decrease in HPV protection 12 years after the last vaccination.

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Accompanying immunostimulating therapy with ecchinacea, Uncaria tomentosa, papaya products (e.g. the carotenoid lycopene) is considered helpful.

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Regular follow-ups, possibly over many years, due to the known high risk of recurrence (patients should be advised of the high recurrence rate!).

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HP viruses are involved in over 95% of the pathogenesis of cervical cancer.

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  2. Kreuter A et al (2006) 5% imiquimod suppositories decrease the DNA-load of intra-anal HPV-types 6 and 11 in HIV-infected men after surgical ablation of condylomata acuminata. Arch Dermatol 142: 243-244
  3. Lacey CJ et al (2003) Randomised controlled trial and economic evaluation of podophyllotoxin solution, podophyllotoxin cream, and podophyllin in the treatment of genital warts. Sex Transm Infect 79: 270-275
  4. Ockenfels HM (2016) Therapeutic management of cutaneous and genital warts. J Dtsch Dermatol Ges 14:892-899.
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