Doctors Revision

HIV, STI & TB

Genital Warts

Superficial mucocutaneous growths on the genitals caused primarily by Human Papillomavirus (HPV). Differentiated from syphilitic warts (condylomata lata) and Molluscum contagiosum.

Also known as: Condylomata Acuminata, HPV Warts, Venereal Warts

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Referral and warning signs

When to refer

Refer for specialist management (Dermatology/Gyn/Surgery/GU) if: Diagnosis uncertain. Lesions atypical (pigmented, ulcerated, bleeding, fixed). No response to standard topical therapy (e.g., podophyllin after 3 applications). Warts are very large, numerous, or intra-urethral/intra-anal/cervical. Patient is pregnant (Podophyllin contraindicated). Patient is significantly immunocompromised. Patient requests alternative treatments (cryo, surgery, etc.).

Red flags

  • Atypical appearance (ulcerated, bleeding, pigmented, hard/fixed)
  • Suspicion of malignancy
  • Failure to respond to standard treatment
  • Rapid enlargement or change in appearance

Signs and symptoms

  • Presence of growths on genitals (penis, foreskin, labia, vagina, perineum, anus).
  • Variable number and size (few to multiple, small to large).
  • HPV warts (Condylomata acuminata): Typically soft, fleshy, cauliflower-like appearance, skin-colored, pink, or brownish.
  • Syphilitic warts (Condylomata lata): Flat-topped, broad-based, moist, greyish-white papules/plaques (sign of secondary syphilis).
  • Molluscum contagiosum: Small, firm, pearly, dome-shaped papules with central umbilication (dimple).

Risk factors

  • Unprotected sexual intercourse
  • Multiple sexual partners
  • Immunosuppression (e.g., HIV infection - warts may be larger, more numerous, harder to treat)
  • Smoking

Diagnosis

Clinical assessment

Diagnosis is usually clinical, based on the characteristic appearance of the warts. Differentiate between HPV warts, syphilitic warts (requires syphilis testing), and molluscum.

Investigations

  • Visual inspection
  • Acetic acid application (acetowhitening) may help visualize subclinical flat warts (less commonly used for external warts).
  • Syphilis testing (RPR/VDRL) is essential to rule out condylomata lata.
  • HIV testing.
  • Biopsy if diagnosis is uncertain, lesions are atypical, pigmented, ulcerated, bleeding, or unresponsive to treatment (rule out malignancy - esp. Bowenoid papulosis, SCC).

Diagnostic criteria

Clinical appearance of characteristic lesions. Syphilis serology needed to differentiate condylomata acuminata (HPV) from condylomata lata (Syphilis).

Management

Non-pharmacological management

  • Advise on personal hygiene.
  • Counseling about HPV (common, often clears spontaneously, link to cancer - though low-risk types cause most visible warts, vaccination).
  • Advise abstinence or consistent condom use (reduces but does not eliminate transmission risk as virus can be on non-covered skin).

Pharmacological treatment

  • HPV viral warts (Condylomata Acuminata):
  • - Podophyllum resin paint 15-25% applied by HEALTH WORKER weekly.
  • - Protect surrounding skin with petroleum jelly.
  • - Apply precisely to warts.
  • - Patient must wash off thoroughly 4 hours after application.
  • - CONTRAINDICATED in pregnancy.
  • - Repeat weekly for up to 4-6 weeks.
  • - Alternative/Specialist options: Podophyllotoxin cream/solution (patient applied), Imiquimod cream (patient applied), Cryotherapy (liquid nitrogen), Trichloroacetic acid (TCA) application, Surgical excision, Electrocautery, Laser therapy.
  • - If no improvement after 3 provider-applied treatments or full course of patient-applied therapy, or if warts are very large/numerous, refer for specialist management.
  • Syphilitic Warts (Condylomata Lata):
  • - Treat for Secondary Syphilis:
  • - Benzathine Penicillin G 2.4 million units IM single dose (1.2 MU in each buttock).
  • - Alternative if penicillin allergic: See Syphilis section (STI007).
  • Molluscum Contagiosum:
  • - Often self-limiting, may resolve spontaneously over months.
  • - Treatment options (if desired/persistent): Cryotherapy, Curettage, Cantharidin application (specialist).
  • - Treat underlying immunosuppression if present (e.g., optimize ART).

Monitoring

Monitor for resolution of warts with treatment. Assess for side effects of treatment (local irritation). Regular cervical cancer screening for women (regardless of wart history, due to HPV link).

Complications

  • Local irritation/pain from treatment
  • Scarring (less common with topical treatments)
  • Psychological distress, body image issues
  • Rarely, malignant transformation (especially in immunosuppressed or with high-risk HPV types, though these less commonly cause visible warts)
  • Obstruction (if very large warts affect urethra/anus/vagina)

Prevention

  • HPV Vaccination (prevents infection with common wart-causing types and high-risk cancer-causing types)
  • Consistent condom use (reduces risk)
  • Limiting number of sexual partners

Patient education

  • Explain HPV is common, treatment aims to remove visible warts but may not eradicate virus.
  • Discuss recurrence possibility.
  • Explain treatment options, application procedures, and potential side effects.
  • Advise on condom use.
  • Discuss HPV vaccination if appropriate.
  • Explain importance of ruling out Syphilis.
  • Emphasize regular cervical screening for women.

Uganda-specific notes

Podophyllum paint application is the primary treatment available at lower levels. Syphilis testing is crucial to differentiate from condylomata lata. Refer persistent or atypical cases. HPV vaccination program availability should be considered.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 3, Section 3.2.6

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