Condylomata acuminata (anogenital warts) in children

Author
Latanya T Benjamin, MD
Section Editor
Moise L Levy, MD
Deputy Editor
Abena O Ofori, MD
Disclosures: Latanya T Benjamin, MD Nothing to disclose. Moise L Levy, MD Grant/Research/Clinical Trial
Support: Anacor [atopic dermatitis (investigational drug)]; Stiefel/GlaxoSmithKline [psoriasis (calcipotriene foam)].
Consultant/Advisory Boards: Galderma [acne (adapalene/benzoyl peroxide)]; Anacor [atopic dermatitis
(investigational drug)]; Promius [atopic dermatitis (investigational drug)]. Patent Holder: Incontinentia pigmenti
(NEMO gene mutations). Abena O Ofori, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed
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All topics are updated as new evidence becomes available and our peer review process is
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Literature review current through: Jun 2015. | This topic last updated: Feb 03, 2014.
INTRODUCTION Condylomata acuminata (also known as anogenital warts or venereal warts)
are manifestations of human papillomavirus (HPV) infection that typically appear as flesh-colored or
hyperpigmented verrucous papules or plaques in the perianal or genital region. Condyloma
acuminatum may develop as a result of the acquisition of HPV infection via sexual or nonsexual
means. In very young children, transmission of HPV via nonsexual contact may be the most
common precipitator of these lesions.
The transmission, diagnosis, and management of condyloma acuminatum in children will be
discussed here. Condyloma acuminatum in adults and cutaneous warts are reviewed separately.
(See "Condylomata acuminata (anogenital warts) in adults" and "Treatment of vulvar and vaginal
warts" and "Cutaneous warts".)
EPIDEMIOLOGY Epidemiologic data on condyloma acuminatum in children are limited, and the
prevalence of this condition in infants and children is unknown. Estimates of the average age at
which children present with condyloma acuminatum range between 2.8 and 5.6 years [1]. A female
predominance is suggested by several studies [2-4].
ETIOLOGY Condyloma acuminatum is caused by infection with human papillomavirus (HPV), a
double-stranded DNA virus with more than 100 serotypes [2]. Although condyloma acuminatum in
adults is commonly caused by HPV 6 and 11, the HPV types detected in lesions from children are
more variable. HPV types associated with cutaneous warts (eg, HPV 1 to 4 and others) are
frequently detected in anogenital lesions from children [2,5]. In one review of approximately 200
pediatric cases of condylomata acuminata in which HPV DNA was detected, HPV 6 or 11 was
detected in 56 percent, HPV 1 to 4 in 12 percent, and HPV 16 or 18 in 4 percent [5]. A separate
series in which 40 children under the age of 12 with condyloma acuminatum underwent wart
excision and HPV testing found that HPV types 6, 11, and/or 16 were present in only one-third of
cases [2]. (See "Epidemiology of human papillomavirus infections".)

TRANSMISSION The possibility of sexual abuse is a major concern in the evaluation of children
with condyloma acuminatum. However, other modes of viral transmission may account for the
majority of pediatric cases [6]. The potential methods for human papillomavirus (HPV) acquisition in
children are described below:
Heteroinoculation Transmission of HPV may occur during nonsexual contact with a
caregiver, such as bathing or diaper changing.
Autoinoculation Children may acquire anogenital lesions from self due to transmission of
HPV from other cutaneous or mucosal sites of infection.
Sexual abuse Estimates of the proportion of children with condyloma acuminatum who
have been sexually abused vary widely, ranging from <10 percent to 90 percent [4,6].
The likelihood of sexual abuse as the cause of HPV infection increases as children age [2,6,7].
In a retrospective study of 55 children under the age of 13 with condyloma acuminatum who
were evaluated for sexual abuse, children between the ages of four and eight years were 2.9
times more likely than children under the age of four years to have been sexually abused
(95% CI 0.7-12.4) [6]. In addition, children between the ages of 8 and 12 were 12.1 times
more likely than the youngest group of children to have been sexually abused (95% CI 2.363.6).
Perinatal or prenatal transmission HPV infection in newborn infants may occur during
vaginal delivery through an infected maternal genital tract. In addition, HPV DNA has been
detected in amniotic fluid and umbilical cord blood, suggesting that ascension of the infection
into the uterus and hematogenous dissemination of the virus may be routes of prenatal HPV
transmission [8,9]. A report of perianal warts in a neonate supports the possibility of prenatal
HPV transmission [10].
Transmission via fomites Transmission of HPV via fomites, such as contaminated towels
or underwear, has been proposed as a method of HPV infection [1,11]. However, fomites are
likely to account for very few cases of condyloma acuminatum in children.
The identification of the route of virus acquisition in children with condyloma acuminatum is
complicated by the variable incubation period of HPV. Data in adults indicate that a typical
incubation period ranges from three weeks to eight months [11]. The average duration of the
incubation period is three months [11].
In addition, serotyping is not a reliable method for determining the mode of HPV acquisition in
children. The detection of a primarily cutaneous subtype of HPV is insufficient to rule out sexual
abuse. As an example, cutaneous HPV infection on the hand of a sexual perpetrator could be
transmitted to the anogenital region of a child through manual-genital abuse. Moreover, the HPV
serotypes most commonly associated with sexually transmitted condyloma acuminatum in adults
(eg, HPV 6 and 11) are detected with variable frequency in condyloma acuminatum in children
[2,5,7].
CLINICAL MANIFESTATIONS Condylomata acuminata initially appear as flesh-colored, pink, or
brown soft moist papules that are a few millimeters in diameter (picture 1A-B). Over the course of
weeks to months, the papules may coalesce into larger plaques that often demonstrate a
"cauliflower appearance" (picture 2). In boys, condylomata acuminata are most commonly detected
in the perianal area and are less frequently found on the penile shaft. Girls may present with lesions

on the perianal area, vulva, hymen, vaginal vestibule, and/or periurethral areas. Anogenital warts
may also occur on the internal mucosal surfaces of vagina or rectum.
Although occasional lesions are pruritic or painful, condyloma acuminatum is usually asymptomatic.
Rarely, bleeding occurs.
CLINICAL COURSE Few data are available on the natural history of condyloma acuminatum in
children, but there is evidence that many infections resolve spontaneously within a few years. In a
retrospective and prospective study of 41 children with condyloma acuminatum, spontaneous
resolution occurred within five years in six of eight children who never received treatment [3]. The
average duration of these lesions prior to resolution was nine months (range 5 to 12 months).
Among the 33 children who were treated, 9 (27 percent) had resolution that appeared attributable to
treatment and 16 (48 percent) had resolution that appeared to be spontaneous (the disappearance
of condylomata acuminata failed to correlate with the timing of treatment). The average duration of
lesions in the group with apparent spontaneous resolution was 25 months (range 2 to 58 months).
Similar to many other infections, immunosuppression influences the course and prognosis of
condyloma acuminatum. Immunosuppressed children may develop extensive lesions that are
challenging to treat [12].
DIAGNOSIS AND EVALUATION The diagnosis of condyloma acuminatum is usually made via
clinical examination. Biopsies are rarely required, and are usually reserved for patients in whom the
diagnosis is uncertain or when the warts demonstrate atypical features, such as ulceration.
Common histopathologic features of condyloma acuminatum include [13]:
Marked acanthosis with some papillomatosis and hyperkeratosis
Vacuolated koilocytes (less prominent than other viral warts)
Coarse keratohyaline granules
Viral serotyping can be performed by polymerase chain reaction (PCR) or nucleic acid hybridization
assays [14]. However, viral serotyping is not routinely performed since it is not necessary for
diagnosis and is not reliable for identifying the source of infection. (See 'Transmission' above.)
Assessment for sexual abuse Although it is likely that many children with condyloma
acuminatum acquire the disorder through nonsexual means, the possibility of sexual abuse
warrants serious consideration during patient evaluation. Children under four years of age with
condyloma acuminatum are less likely to be victims of sexual abuse than older children, but the
possibility of sexual abuse cannot be definitively excluded based upon age.
(See 'Transmission' above.)
Interviews with the caregivers and the child (if old enough to participate), as well as clinical or
laboratory examination to evaluate for sexual abuse and other sexually transmitted infections are
important components of the patient assessment. If any findings suggestive of sexual abuse are
detected, reporting to child protective services or legal authorities in accordance with local policies
is indicated.
Due to the greater likelihood of sexual abuse as a precipitator of condyloma acuminatum in older
children, a higher level of suspicion should exist for children over the age of four [1]. Exceptions
include adolescents who report consensual sexual activity and immunosuppressed children with
multiple nongenital warts who lack other findings suggestive of abuse.

We agree with the following approach to the initial evaluation for sexual abuse in children with
condyloma acuminatum [1]:
Interview of primary caregivers to determine whether the child may be at risk for sexual
abuse and to establish the presence of cutaneous or anogenital warts in the caregivers or
other family members
Interview of the child regarding sexual abuse by a professional trained in this field (provided
the child is old enough to participate - usually three to four years of age)
Assessment for signs or symptoms that may accompany a history of sexual abuse (eg,
nightmares, advanced sexual knowledge, sexual behavior with peers)
Physical examination for evidence of physical or sexual abuse, including magnified
examination of genital and anal sites looking for signs of acute trauma (hymenal bruising,
petechiae, anal tears) or chronic trauma (absent hymen at the posterior hymenal rim,
anogenital scarring)
Screening for other sexually transmitted diseases as determined appropriate by the scenario
(eg, gonorrhea, chlamydia, trichomoniasis, human immunodeficiency virus, hepatitis B and C,
syphilis)
Referral to a child abuse specialist if the clinicians involved are not comfortable or adequately
trained to perform this assessment
The evaluation and reporting of sexual abuse in children is discussed in greater detail separately.
(See "Evaluation of sexual abuse in children and adolescents" and "Child abuse: Social and
medicolegal issues".)
DIFFERENTIAL DIAGNOSIS Condylomata acuminata share clinical features with several
disorders. Examples of disorders to consider in the differential diagnosis are provided below:
Molluscum contagiosum Molluscum contagiosum is a cutaneous viral infection
commonly seen in children. The recognition of round, smooth, skin-colored papules with
central umbilication supports a diagnosis of molluscum contagiosum (picture 3).
(See "Molluscum contagiosum".)
Pyramidal perianal papules Pyramidal perianal papules (infantile perianal pyramidal
protrusions) are solitary, fleshy perianal protrusions that occur in prepubertal children (picture
4). These lesions are found anterior to the anus and are less than 2 cm in diameter. Female
children are most frequently affected. Pyramidal perianal papules usually resolve
spontaneously with time. (See "The pediatric physical examination: The perineum", section on
'Anus and rectum'.)
Condylomata lata of syphilis Condylomata lata of secondary syphilis are highly
infectious, moist papules and small plaques that may develop in the anogenital region (picture
5). Serologic testing is useful for diagnosis. (See "Pathogenesis, clinical manifestations, and
treatment of early syphilis", section on 'Rash' and"Pathogenesis, clinical manifestations, and
treatment of early syphilis", section on 'Diagnosis'.)
Epidermal nevi Epidermal nevi are uncommon skin lesions that present at birth or in early
childhood as skin-colored to hyperpigmented verrucous plaques (picture 6). A linear
distribution or a distribution that follows Blaschkos lines (figure 1) is suggestive of an
epidermal nevus.

TREATMENT Multiple therapies have been utilized for the treatment of condyloma acuminatum
in children and adults. The therapeutic options consist of interventions that mechanically or
chemically destroy infected tissue or that upregulate the host immune response against infected
cells.
Since many cases of condyloma acuminatum in children resolve spontaneously within a few years
[3,14] and the response to treatment is variable, treatment of condyloma acuminatum is optional.
Nonintervention with a wait and see approach is frequently utilized for the management of
condyloma acuminatum in children [1,4]. Treatment is preferred over nonintervention when patients
develop symptoms (eg, pruritus, bleeding, or pain) [1] or when concern over the appearance of
lesions causes emotional distress in the child or is socially detrimental. In addition, warts that persist
for more than two years may be less likely to resolve spontaneously than younger lesions [3].
(See 'Clinical course' above.)
Therapeutic options Multiple therapies (eg, topical cytotoxic agents, topical and systemic
immune modulators, cryotherapy, electrocauterization, lasers, and surgery) have been utilized for
the treatment of condyloma acuminatum. However, no single treatment is consistently effective and
lesion recurrence often occurs [1]. (See"Condylomata acuminata (anogenital warts) in adults",
section on 'Treatment'.)
The ability of the child to tolerate treatment strongly influences treatment selection. Young children
are often fearful of painful treatments such as cryotherapy, and general anesthesia is typically
required for surgical and ablative laser therapy. Thus, topical therapy is frequently utilized as the
initial treatment for condyloma acuminatum in children.
The most common topical agents utilized for pediatric condyloma acuminatum are imiquimod and
podophyllotoxin. Data on the efficacy and safety of these and other therapies for condyloma
acuminatum in children are limited. In a randomized trial of 45 adults with condyloma acuminatum
that directly compared imiquimod 5% cream (three times per week for up to 16 weeks) and
podophyllotoxin 0.5% solution (three days per week for up to four weeks), the efficacy of these
agents was similar [15]. Surgical and laser therapy are typically reserved for children with large or
recalcitrant lesions.
Imiquimod Imiquimod 5% cream and a newer formulation, imiquimod 3.75% cream, are topical
immune response modifiers for which randomized trials have demonstrated efficacy for the
treatment of external genital and perianal warts [16-18]. Imiquimod 5% cream is applied three times
weekly on nonconsecutive days for a maximum of 16 weeks. The 3.75% formulation is applied once
daily for up to eight weeks. (See "Condylomata acuminata (anogenital warts) in adults", section on
'Imiquimod'.)
Data are limited on the safety and efficacy of imiquimod in children under the age of 12 years. The
use of imiquimod in children is supported by several case reports [19-23] and a retrospective study
in which eight children with anogenital warts (six under the age of five years) were treated with
imiquimod three times per week for two to four months [24]. Six children (75 percent) in the
retrospective study had clearance of warts that persisted for at least 6 to 12 months. Imiquimod has
also been well-tolerated by children treated with this agent for molluscum contagiosum [25].
(See "Molluscum contagiosum", section on 'Imiquimod'.)

The most common side effect of topical imiquimod is local skin irritation. In our experience, this
occurs most frequently at sites of skin occlusion. Infrequently, flu-like symptoms may occur during
treatment.
Podophyllotoxin Podophyllotoxin is an antimitotic agent that is effective for the treatment of
condyloma acuminatum [26-28]. Podophyllotoxin is commercially available as podofilox 0.5%
solution and gel (typically applied twice daily for three consecutive days per week for up to four
weeks) and as podophyllin 25% liquid, which must be applied in the office by a clinician.
(See "Condylomata acuminata (anogenital warts) in adults", section on 'Podophyllin'.)
Although the efficacy of podophyllotoxin for condyloma acuminatum is supported by randomized
trials performed in adults [15,28-31], data on the efficacy and safety of podophyllotoxin in children
are limited. In a retrospective study of 17 children with condyloma acuminatum, including 11
children who were under the age of five years, treatment with podofilox 0.5% gel for one to four
months (initially once weekly and increased as tolerated to twice daily for three consecutive days
per week) led to clearance of lesions for at least four months in 88 percent of children [24]. One
child failed to respond to treatment and a second child was unable to tolerate therapy.
The comparative efficacy of podophyllotoxin 0.5% and podophyllin 25% was evaluated in a
randomized trial of 358 adults that compared treatment with podophyllotoxin 0.5% solution,
podophyllotoxin 0.15% cream, and podophyllin 25% liquid [28]. Podophyllotoxin 0.5% solution was
more effective than podophyllin 25% liquid for the clearance of all warts (84 versus 62 percent of
patients had clearance of lesions). Relapse was common after the discontinuation of all treatments.
Local skin irritation, discomfort, and ulceration are potential adverse effects of podophyllin therapy.
Relapse is common after the discontinuation of treatment [28].
Surgical and laser therapy Surgical and laser procedures are usually reserved for children with
extensive or large warts (eg, 1 cm or greater) or warts recalcitrant to topical therapy. Options for
surgical treatment include cryotherapy, electrodesiccation, carbon dioxide laser ablation, and
surgical debulking or excision. Clearance of childhood perianal warts has also been reported after
treatment with a pulsed dye laser [32].
Similar to medical therapy, warts may recur after destructive procedures. Additional information on
these procedures is reviewed separately. (See "Condylomata acuminata (anogenital warts) in
adults", section on 'Surgery'.)
Other Multiple other treatments have been utilized for the treatment of condyloma acuminatum in
adults, including trichloroacetic acid, 5-fluorouracil, sinecatechins,
topical cidofovir, cimetidine [33,34], and additional agents. The efficacy and safety of these
treatments in children has not been established. These treatments are reviewed in greater detail
separately. (See "Condylomata acuminata (anogenital warts) in adults", section on 'Treatment'.)
FOLLOW-UP Although human papillomavirus (HPV) infection has been associated with
increased risk for cervical, anal, and penile cancer, the impact of childhood HPV infection on the risk
for these malignancies is unknown (table 1) [11,35,36]. (See "Virology of human papillomavirus
infections and the link to cancer" and "Invasive cervical cancer: Epidemiology, risk factors, clinical
manifestations, and diagnosis", section on 'Risk factors' and "Invasive cervical cancer:
Epidemiology, risk factors, clinical manifestations, and diagnosis", section on

'Pathogenesis' and "Clinical features, staging, and treatment of anal cancer", section on 'Clinical
features' and "Anal squamous intraepithelial lesions: Diagnosis, screening, prevention, and
treatment", section on 'Clinical manifestations and diagnosis'.)
Long-term, periodic follow-up for signs or symptoms of anal cancer is recommended for children
with anogenital warts that extend beyond the anal verge and involve the mucosa. (See "Clinical
features, staging, and treatment of anal cancer", section on 'Clinical features' and "Anal squamous
intraepithelial lesions: Diagnosis, screening, prevention, and treatment", section on 'Clinical
manifestations and diagnosis'.)
PREVENTION Avoidance of autoinoculation or heteroinoculation of human papillomavirus (HPV)
into the anogenital region is the primary mode of prevention of condyloma acuminatum. The
quadrivalent HPV vaccine, which protects against HPV 6, 11, 16, and 18 is discussed in greater
detail separately. (See "Recommendations for the use of human papillomavirus vaccines".)
SUMMARY AND RECOMMENDATIONS
Condylomata acuminata (also known as anogenital warts or venereal warts) are cutaneous
lesions caused by infection with human papillomavirus (HPV). Both mucosal and cutaneous
HPV serotypes can lead to the development of condyloma acuminatum in children.
(See 'Etiology' above.)
Condyloma acuminatum in children may arise from HPV transmission through a variety of
mechanisms. Although the possibility of sexual abuse is a major concern, many children,
particularly those under the age of four years, acquire HPV infection through nonsexual
interactions. (See 'Transmission' above.)
Condyloma acuminatum usually begins as single or multiple flesh-colored, pink, or brown
papules (picture 1A-B). As the infection progresses, lesions may develop into large verrucous
plaques with a cauliflower-like appearance (picture 2). (See 'Clinical manifestations' above.)
Spontaneous resolution of condyloma acuminatum is possible, and many infections resolve
within a few years. Lesions that persist for more than two years or develop in
immunosuppressed individuals may be less likely to resolve without treatment. (See 'Clinical
course' above.)
The possibility of sexual abuse should be considered in all children who present with
condyloma acuminatum. Children over the age of four years are more likely to have a history
of sexual abuse than younger children. The evaluation for sexual abuse typically begins with
interviews with the caregivers and child, a complete physical examination, and screening for
other sexually transmitted diseases. (See 'Assessment for sexual abuse' above
and "Evaluation of sexual abuse in children and adolescents".)
Treatment is optional for children with condylomata acuminata since lesions may resolve
spontaneously. Warts that persist for longer than two years may be less likely than earlier
lesions to resolve without treatment. (See 'Treatment' above.)
Since most condylomata acuminata in children resolve within a few years, treatment is not
required for most children with asymptomatic lesions. For children with symptomatic lesions,
lesions that fail to spontaneously resolve, immunosuppression, or lesions that lead to
emotional distress or social problems, we suggest treatment with imiquimod 5% or 3.75%
cream or podophyllotoxin 0.5% gel or solution (Grade 2B). Children with lesions recalcitrant to
topical therapy may benefit from laser therapy or surgical procedures. (See 'Therapeutic

options' above and "Condylomata acuminata (anogenital warts) in adults", section on

'Surgery'.)
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