553. Condyloma acuminata: etiology, ddx, rx // Rule for distinguishing between chlamydia and gonorrhea

October 26th, 2008
by reuben in STD

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Responses to “553. Condyloma acuminata: etiology, ddx, rx // Rule for distinguishing between chlamydia and gonorrhea”

  1. BMJ 337 (171) a 1171 Delaney & Baguley

    Diagnosis?Warts are generally diagnosed from physical appearance. Examine his genitalia in good light (in women, use a speculum to examine vagina and cervix).

    Differential diagnosis includes molluscum contagiosum, epidermoid cysts, hair follicles, sebaceous glands, pearly penile papules, and, rarely, condylomata lata of secondary syphilis and (pre)malignant tumours. In women, remnants of the hymen and vulval papillomatosis (a variant of the normal vulva anatomy) can sometimes be mistaken for warts. If diagnosis is unclear, refer the patient to the genitourinary medicine department.

    Management?The patient can be advised to attend the genitourinary medicine clinic for treatment and a sexually transmitted infection screen. Alternatively, he can be offered treatment and further testing by his general practitioner.

    Treating warts?Correct treatment will speed clearance of the warts. Most treatments can be applied by the patient, thus avoiding repeated visits to the surgery. Ensure the patient fully understands the treatment, finding warts, and applying the cream or liquid. If there is any doubt, the general practitioner or practice nurse can supervise treatment. About 75% of people are clear of warts a month after starting treatment.

    A few warts only?first line treatment is freezing with liquid nitrogen; second line treatment depends on the site (see below).
    Many soft warts?for example, at vaginal introitus, underneath foreskin. First line treatment is podophyllotoxin 0.15% cream. Apply twice daily for three days, then have a four day break before resuming if warts persist. Use for a maximum of five weeks before review. Second line treatment is podophyllotoxin 0.5% liquid with same dosing as cream above, or imiquimod cream, applying half or whole sachet on alternate night, washed off after 6-10 hours. Use for maximum of 16 weeks with a review every four to six weeks.
    Many keratinised warts and site is accessible to patient?for example, the penile shaft. First line treatment is podophyllotoxin 0.5% liquid. Second line treatment is imiquimod cream.
    Perianal warts?first line treatment is imiquimod or liquid nitrogen. Refer to general surgeons if warts persist.
    Cervical warts?refer to your local colposcopy department.
    Urethral meatus?difficult to treat; refer to either genitourinary medicine or urology.
    Warn patients that all treatments can cause discomfort and local skin reactions. If these are severe, they should stop treatment and seek advice. Advise patients to stop treatment once the warts disappear. If they are using podophyllotoxin, normal surrounding skin can be protected by applying some petroleum jelly.

    Lesions larger than 4 cm must be treated under direct medical supervision. Giving no treatment is also an option, as warts can regress spontaneously.

    If the patient is female, reassure her that cervical screening intervals can stay the same. Avoid imiquimod and podophyllotoxin in pregnancy, or if there is any risk of pregnancy.

    Investigations for other sexually transmitted infections?Send off a urethral swab or a urine sample, ensuring the patient has not urinated in the past one to two hours, for chlamydia and gonorrhoea. Offer tests for HIV, syphilis, hepatitis B and C, as indicated by his sexual history. All positive results can be referred to genitourinary medicine or the chlamydia screening office for follow-up. See the RCGP/BASHH primary care guideline (http://www.bashh.org/documents/702/702.pdf) for additional advice.

    Follow-up?About 20% of patients have a recurrence in the following three months. If the warts are visible and you are confident that the patient can identify them correctly, then follow-up is usually unnecessary. Review if the warts persist or if the patient has side effects from treatment.

    Key points
    Most anogenital warts are associated with human papillomavirus types 6 and 11, whereas cervical intraepithelial neoplasia is associated with types 16 and 18
    They may go away spontaneously, so one option is no treatment
    Most treatment can be applied by patient
    Up to 75% of genital warts clear within a month
    20-30% patients may have another sexually transmitted infection so screening should be offered

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