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Genital Warts

Presentation. Warts are a common problem presenting to primary care physicians. The majority are common warts of the hands and extremities that cause little morbidity. However, when these warts grow on the nail folds or on the soles, they can cause significant discomfort or disfigurement. Rarely, warts of the hands or feet may transform into squamous cell carcinoma. Venereal warts, or condylomata acuminata, may involve mucosae and cause symptoms, and are a major cause of cervical cancer.

Etiology. All warts are caused by papilloma viruses, certain viral types preferring specific epithelia. Some viral types such as HPV 16 and 18 have a propensity to transform the infected epithelium into squamous cell carcinoma.

Diagnosis. Common warts are small, round, rough-topped papules. Flat warts are smaller, flatter, and often grouped on the face or legs. Venereal warts may be sessile or polypoid papules of the groin or genitals. Plantar warts are more subtle.

Therapy. Warts are treated by methods that destroy the virus-infected epithelial cells. Salicylic acid compounds are most often used.

Destructive methods like cryotherapy, curettage, and cautery are similarly effective, with cure rates from 50% to 70%. CO2 laser ablation is efficient but usually no more effective than other destructive methods, with a possible exception in periungual warts, where CO2 laser can spare some tissue. Other chemicals that have been used include cantharidin, podophyllin, tretinoin, and 5-fluorouracil.

A derivative of podophyllin, podofilox (Condylox), is available by prescription for the treatment of condylomata acuminata. It appears to be more effective on smaller warts and those on occluded skin.

Pulsed dye laser has recently been used as a treatment for plantar warts. The warts are pared and treated at intervals until clearing is achieved. The procedure does not require anesthesia and may carry a lower risk of scarring.

Diagnostic and therapeutic challenges. Occasionally, cancers are mistaken for warts; squamous cell carcinoma of the digit in particular may resemble a common wart. Squamous cell carcinoma in situ developing from venereal warts (bowenoid papulosis) may appear larger than typical venereal warts; the risk of invasive cancer.

Lastly, verrucous carcinoma is a vitally-induced cancer of the plantar surface or genitals that may be passed over as a large wart. Diagnosis is often delayed until the lesion has already displayed its tendency.

Complications of therapy for warts can result when destructive methods used are inappropriate for the given area. Excision, cautery and curettage, or cryotherapy on the plantar surface can result in a permanent scar, which on a weight-bearing surface.

Presentation. Nonmelanoma skin cancers account for one-third of all cancers diagnosed in the United States, and the incidence has risen over the past 30 years with increased sun exposure. Basal cell carcinomas (BCC) account for more than 75% of these, making them the most common human malignancy.¹² Although it may occur as early as the third decade, it often appears beginning in the fifth decade, almost exclusively in white patients.