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External Genital Warts
General Considerations
Human papillomavirus (HPV) is one of the most common sexually transmitted diseases (STDs) and is the cause of genital warts (condylomata acuminata), anogenital dysplasia, and invasive cancer. Oral warts may also occur as a direct consequence of HPV infection during sexual activity. At least 75% of sexually active men and women acquire one or more genital HPV types at some point in their lifetime. The incubation period from HPV infection to condyloma is usually 3–4 months, with a range of 1 month to 2 years, but many infected persons have subclinical disease or have regression of disease before it becomes clinically apparent. HIV-infected patients have a higher prevalence of genital warts than HIV-uninfected patients. These may proliferate further during immune reconstitution following the initiation of antiretroviral therapy.

There are more than 100 different HPV types; 40 of these can cause anogenital lesions. HPV types 6 and 11 are most commonly associated with genital warts; these types have a low risk of malignant transformation. Other types (eg, 16, 18, 31, 33, and 35) have a strong association with cervical and other anogenital cancers. Thus, genital warts lie on one spectrum of a continuum of HPV-associated disease, with warts being one variant of low-grade disease that has little risk of malignant potential. High-grade HPV-associated disease such as cervical intraepithelial neoplasia (CIN) types 2 and 3 are likely the direct precursors to invasive cancer and are the target of screening programs that utilize the Papanicolaou (Pap) test.

The primary goal of treating visible genital warts is the removal of the warts. Treatment of genital warts should be guided by the preference of the patient, the available resources, and the experience of the health-care provider.