Warts and other anogenital lumps

Genital Warts: Condylomata Acuminata

• Genital warts are caused by the human papillomavirus (HPV), most commonly HPV 6/11.
• The majority of sexually active people will be infected transiently and asymptomatically.
• The diagnosis is clinical:

The differential diagnosis of condylomata acuminata includes:

• Penile
• Vestibular
• Pilosebaceous and Tyson’s
• Molluscum contagiosum (see below).
• Skin tags
• Condylomata lata (a feature of secondary syphilis).
  Different types of HPV (especially HPV-16 and HPV-18) are associated with anogenital malignancy.
• Atypical lesions – should always be reviewed by a GUM senior. Features of concern include, large or solitary lesion, pain/itching/bleeding, difference in colour. These lesions may require biopsy.

 Treatment of anogenital warts

• Most anogenital warts in immunocompetent patients undergo spontaneous regression (cell-mediated immune responses) within months.
• Not treating is the best management if warts are very small and should be offered as an option in all cases.
• Smoking may mean warts take longer to clear and are more likely to recur – give smoking cessation advice where appropriate
• If the warts do not resolve spontaneously or if patients seek treatment due to social unacceptability or psychological distress they should contact their GP for topical treatment in the first instance.
• Offer STI testing for other STIs based on Sexual History.
• Be aware of the possible Koebner phenomenon.
• Sometimes warts regress after local inflammation has been controlled. Underlying skin conditions, vulvovaginal candidiasis, local trauma and allergies may trigger recurrences or make warts refractory to topical Treating the underlying cause is often the answer.
• HPV Vaccines are not licensed for treatment of existing HPV infection or HPV associated disease. HPV Vaccines are occasionally used as an adjunct therapy in complex cases – d/w GUM senior if you think may be of value.

Treatment:

Fleshy External Genital Warts

Podophyllotoxin  0.5% solution or 0.15% cream

Apply twice a day for 3 consecutive days

For up to 16 weeks

Or

Catephen 10% ointment

Apply 3 times a day – a small amount covering each wart.

Use for up to 16 weeks.

Or

Imiquimod cream

Apply for 3 non-consecutive days a week

Wash off after 6-10 hours

Use for up to 16 weeks

1st Line:

Podophyllotoxin 0.5% solution or 0.15% cream

How to use:

• Apply twice a day for 3 consecutive days each week (followed by 4 days of no treatment)
• Use for up to 16 weeks

Notes:

Podophyllotoxin solution is more liquid so harder to apply. Podophyllotoxin cream is more viscous so is easier to apply to harder to reach areas.

Podophyllotoxin may cause local skin reactions.

Podophyllotoxin is contraindicated in pregnancy.

Or

Catephen 10% ointment - extract of leaf of green tea plant.

How to use:

• Apply 3 times a day – a small amount covering each wart.
• Do not apply to mucous membranes.
• Use for up to 16

Notes:

Mild local reactions are very common and should not lead to discontinuation - they decrease after the first few weeks of treatment.

Severe reactions occur in up to 26% of patients - an interruption of treatment may be required. Encourage them to restart treatment once the skin has settled.

Cetaphen should be avoided in pregnancy.

Or

Imiquimod cream- an immune response modifier.

How to use:

Apply 3 times a week on non-consecutive days

• Leave for 6-10 hours then wash off
• Use for up to 16 weeks
• Longer use may be considered if ongoping favourable response

Notes:

Imiquimod cream stimulates local tissue macrophages to release interferon alpha and other cytokines as part of a local cell mediated response..

Imiquimod frequently causes local skin reactions particularly after the second or third treatment. Temporarily halting the treatment and restarting once the skin has settled means treatment can be continued. A further reaction is then unlikely. Continuing treatment at reduced frequency (e.g. twice a week only) is a further option for managing local side effects.

Imiquimod is licensed for use in pregnancy.

2)  Keratinised External Genital Warts

Imiquimod is licensed for use on keratinised warts and may be more effective than other topical therapies.

3)  External genital warts: extensive,

As 1), but consider use of Imiquimod particularly if the warts are scattered or recurrent. Imiquimod is an appropriate first line therapy for perianal and intrameatal warts.

4)  Urethral warts:

If clearly visible and do not extend deeply within urethra, use imiquimod. If they persist, refer to consultant for consideration of cryotherapy.

5)  Intra-anal warts:

No treatment is an option. If external warts are being treated with Imiquimod, there is usually a regional effect and the intra-anal warts will regress.

Imiquimod can be used cautiously in the anal canal. This is an off licence indication – discuss with consultant.

6)  Vaginal warts:

No treatment. If warts are very large, or distressing, refer to gynaecology for consideration of surgery.

7)  Cervical warts:

Treat any co-existing external warts as above. BASHH do not recommend referral for colposcopy unless there is diagnostic uncertainty.

8)  Anogenital warts in pregnancy:  (See section 20 – STIs in Pregnancy)

Clearing genital warts in pregnancy is often unsuccessful due to the suppressed immune system. Warts nearly always resolve completely in the immediate post partum period however. Warts often start to reduce in number spontaneously in the third trimester. The only treatment that can be used safely is liquid nitrogen.

Patient Information:

•  Warts are caused by some strains of human papillomavirus
• These strains are different to the cancer causing strains of HPV.
• The vast majority of genital warts (>85%) are caused by viruses having no connection with cervical carcinoma.
• Warts are very common
• Latent period is months or years
• Asymptomatic carriage is common
• No implication of infidelity in regular relationship
• Spread is almost always sexual
• New warts may appear even during treatment
• About 70% of people are clear of warts after 5 weeks of therapy
• Cryotherapy does not make warts disappear immediately.
• Recurrence is very common – whatever treatment has been used.
• Damaged skin may make them worse; give general anogenital skin care advice and advise to shaving the genital skin until warts have resolved Cervical smears:
• People with a cervix who have genital warts require routine cervical smears only and no additional intervention or screening.

HPV Vaccination: see HPV Protocol

• People who are assigned female at birth (AFAB) born in the UK from 1996-1999 were given Cervarix vaccine- which provides protection against HPV 16 and 18
• People assigned female at birth born in 2000 onwards were given Gardasil Vaccination which also protects against HPV 6 and 11 which are the commonest causes of genital warts. Gardasil significantly reduces the risk of developing genital
• From 2016 GBMSM up to age 45 years have been vaccinated in Sexual Health clinics.
• From 2018, people assigned male at birth (AMAB) aged 11-13 in the UK (as well as those AFAB) are also now receiving Gardasil vaccination as part of their school vaccination programme.
• Gardasil 9 was introduced in 2022 covering additional HPV types (31,33,45,52,58)

Condom Use:

• With any new partner, or a partner with whom sex has previously been protected, use condoms while warts are being treated and for six months after clearance although this does not guarantee prevention of transmission
• With a partner with whom sex regularly took place without a condom before warts appeared, there is little evidence of benefit in starting to use condoms. There is some evidence that the rate of clearance of warts is improved in those using condoms.
• Condom use cannot be guaranteed to prevent transmission. Condoms do protect against the acquisition of HPV – young people without warts can be advised that condoms will provide some protection

• This condition is caused by the molluscum contagiosum virus (MCV).
• The diagnosis is clinical – the pearly or waxy umbilicated lesions

Treatment:

Treatment is only necessary if the patient is distressed by their presence. 
Patients should not be brought into Chalmers for treatment of Molluscum.

Spontaneous resolution is the rule in immunocompetent individuals.

• Self Removal of core of lesions is no longer recommended and may cause further spread and scarring
• There is no evidence of the benefit of topical treatments in the management of Molluscum.
• Removing the core of one or two lesions causes inflammation and boosts immune response to MCV virus.

Patient Information:

• Molluscum contagiosum is caused by a virus that is spread by bodily contact (and possibly other routes such as shared towels).
• Common in young children- spread by social
• Spread in adults often
• Resolve spontaneously within six to nine
• There is no need for contact

Clinical Diagnosis:

• Erythema around the hair follicles, +/- pustules.
• If more severe there may be an impetiginous
• Consider Scabies as a differential of folliculitis in view of rising number of cases.

Treatment:

Patient information:

• The condition is often precipitated by shaving of pubic The importance of using a new, sharp razor blade should be discussed with the patient or using another form of hair removal.