Genital warts are a viral infection that nowadays is considered one of the most frequent and common sexually transmitted diseases. It is estimated that 50 to 70% of sexually active individuals at some point in their life will be infected with HPV (Human Papilloma Virus). During each unsafe or unprotected sexual intercourse with an individual who has been infected with the virus, there is 70% chance for the partner to acquire the infection.
Most people do not develop visible warts, and the infection may only show up on a cervical smear (subclinical infection). Thus, genital warts will appear in only 10% of those who will get infected, as in several cases the immune system fights the virus, a fact that results in non manifestation of the virus which lies dormant (latent).
The HPV types (strains) 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68 are considered high risk HPV types, meaning they are associated with changes in the cervical cells and with developing cervical cancer. These types are implicated in various malformations as well as the development of cancer, particularly cervical cancer. The HPV types 6, 11, 42, 43 and 44 are considered low risk and are mainly responsible for genital warts.
The HPV genotypes 6 & 11 are those mainly responsible for the 90% incidence of genital warts.
Although genital warts can be treated and successfully removed from the affected area, HPV can remain in the body. The virus infects the cells and remains there without being cleared by the body.
In women, genital warts are usually found in the vagina, the cervix, the labia majora and labia minora (vaginal lips), the urethra and sometimes, more rarely, they can also grow on the urinary bladder. Among the causes that aid the growth of Condylomata acuminata are trichomonas infection, some other infections that cause wetting of the area from vaginal secretions and pregnancy. In pregnancy, genital warts can acquire a highly hyperplastic, exophytic form and become easily spread.
In men, genital warts are usually found in the glans, the body of the penis, the scrotum, the mons pubis (pudenda), the inner aspect of the foreskin, the urethra and sometimes, more rarely, they can be detected in the bladder, as seen in women. The causes that aid in the development of condylomata acuminata include the topical use of corticosteroids, urethritis, phimosis, immunosuppression and enterobiasis. High incidence rates of genital warts are found in HIV carriers, in people with chronic use of immunosuppressive drugs and in cases of diabetes mellitus.
The incubation period of genital warts ranges from 1‑8 months and sometimes even longer. In vast majority genital wart infections remain asymptomatic and do not cause pain or pruritus (itching); this means that the patient may not realize that he/she carries the virus.
Standard genital warts (also called condylomata acuminata) occur as pink or skin-colored (more rarely as brown) lesions, soft with smooth or warty surface and with a wide or stalk-like base. They proliferate very easily by transmission from one area to another and sometimes they combine to form larger lesions.
Genital warts can also be detected in the anal area, inside the anal and on the perianal skin. HPV can infect the area during sexual intercourse. The area is likely to become infected even without anal sexual intercourse, with the transfer of bodily secretions or even with fingers. More rarely, genital warts can also be found in other extra genital areas, such as the throat, armpits, conjuctiva, navel, interdigital spaces of the feet, the oral mucosa and particularly on the corners of the lips.
The predisposing factors that contribute to the manifestation of genital warts in the anal region are several, including infection with other HPV subtypes, cortisone administration and/or the topical use of steroid creams, immunosuppression and diabetes mellitus. All the aforementioned causes can cause modifications and/or weakening of the immune system, making it easier for the virus to spread.
Besides genital warts, infections with high risk HPV types can lead to genital malformations both in men and women. The relapsing and left untreated infection with high risk subtypes of the virus, which tends to remain incorporated in the DNA of our cells without being able to be completely eradicated, results in the induction of pre-cancerous lesions.
Such pre-cancerous lesions include Cervical (CIV), Penile, Vulvar and Anal Intraepithelial Neoplasia. Vulvar intraepithelial neoplasia can be further classified in CIN I, II, III depending on the degree of dysplasia formed in cervical cells. The same applies to the vaginal (VIN I, II, III) and anal (AIN I, II, III) neoplasia, respectively.
These lesions are often found along with the genital wart lesions and a significant proportion can lead to cancer in the respective areas.
A large percentage of genital wart lesions have been found to exist before or at the time of diagnosis of CIN in women who presented CIN and cervical dysplasia. Apart from the HPC types responsible for genital wart, HPV DNA testing of these cases results in the detection of the HPV types 16 and 18; More specifically, it is found that these people have been infected by the HPV subtypes 16 and 18.
It should be noted that even though genital warts are a risk factor for cervical cancer (due to co-infection with HPV types 16, 18), this does not mean that a woman who presented genital warts will also develop cervical cancer.
Genital wart complications are classified according to their severity and they can be mild and highly severe complications. Such complications are the following:
Genital wart complications of mild severity include erosion and injury formation on the skin and the mucosa (wounds), bleeding, inflammation as well as problems with urination and bowel movement (defecation). The psychological problems that result from HPV infection are also considered very important.
Genital wart complications of high severity: the enormous growth of their size (giant warts), the pre-cancerous lesions, as well as the malignant neoplasms of the area of the genitals, the anus and even the bowel.
The aforementioned complications are often accompanied with severe psychological stress.
The diagnosis of genital warts is mainly done with clinical and visual inspection and should be carried out by an experienced dermatologist who can suggest the use of an appropriate method for the treatment of the affected area. The diagnosis, therefore, is clinical, since the format of genital warts is characteristic and an experienced dermatologist can conclude to the correct wart diagnosis.
In the past, acetic acid solution was used for the treatment of genital warts. By applying the solution to the affected area, the color of sub-clinical lesions turned to whitish. Nowadays, this method is not widely used because it can lead to irritation of the site of application accompanied by erythema (redness) and burning sensation. Biopsy is rarely required for the diagnosis of genital warts, and is only applied if we need to derive a differential diagnosis, i.e., to differentiate genital warts from lesions of other etiology that occur in the area.
The HPV DNA detection test used today can lead to a very accurate diagnosis of HPV infections and to precisely identify the type of the virus which is responsible for the lesion. With this method we can also determine if the virus is of low or high risk. It can be used for all HPV lesions, in both men and women where the diagnosis can be made using cervical smear samples. This is the most modern diagnostic method used today.
In Cosmetic Derma Medicine clinic this test is applied in all cases of recurrent genital warts and HPV infections.
Both warts and papillomas, due to their HPV etiology, can be mistakenly perceived as genital warts. In this case, the dermatologist is the one who by performing a clinical or histology examination would make the correct diagnosis.
Molluscum contagiosum is also a sexually transmitted disease; however, more innocent compared to genital warts and its clinical distinction from genital warts is of great importance. Differential diagnosis of genital warts from malformations and genital cancers is required more rarely. In this case, a skin biopsy performed on the suspected area is considered necessary.
Many times patients confuse small whitish spots around the glans with genital warts. These are pearly penile papules (hirsuties coronae glandis) that in some cases swell, but their clinical presentation is basically non significant.
Moreover, it has been found that circumcision in men significantly helps reducing the risk of viral transmission as well as the chances of viral infection.
Two vaccines are available for the prevention of HPV infection. Gardasil is specific against HPV types 16, 18, 6 and 11. More than 85% of genital warts are caused by HPV types 6 and 11, and thus, this vaccine effectively protects people against these types. Cervarix offers protection against the HBV types 16 and 18 which are implicated in neoplasia and cervical dysplasia. Both vaccines are preventive rather than therapeutic. These vaccines cannot be used for the treatment of genital warts if HPV is established and has caused damage. If, however, HPV vaccination is offered before the onset of sexual activity (the vaccines are recommended for 12 year old girls) it effectively prevents against genital warts and most types of cervical neoplasia that are caused by HPV.
In Cosmetic Derma Medicine the success rates of genital wart treatment in just one session (visit) are very high. This is achieved by CO2 laser treatment. In some cases genital wart CO2 laser treatment is used in combination with surgical treatment, where required. The advantage of Cosmetic Derma Medicine is that it consists of a Dermatology department and a department of plastic surgery, that provide all possible ranges of treatment of genital warts, even for the most difficult cases.