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Dermatologists are faced almost daily with a reason for consultation that generates a great deal of doubts and uncertainty in our patients. We will try to answer the most frequently asked questions about genital warts.

What are genital warts?

Genital warts, also called condylomata acuminata, are exophytic neoformations, usually multiple, pink or grayish-white in color, with filiform or papillomatous projections on the surface. They are located in the anogenital area (penis, vulva, vagina, cervix, urethra and around the anus). They are caused by the human papillomavirus (HPV) and are transmitted by sexual contact, representing one of the most common sexually transmitted infections (STI).

What are human papillomaviruses?

Human papillomaviruses (HPV) are a large group of approximately 100 genotypes of DNA viruses that infect the skin and mucous membranes. In addition to causing warts, they are responsible for almost 100% of cervical cancers, 88% of anal cancers, 70% of vaginal cancers, 43% of vulvar cancers, and a significant percentage of oropharyngeal and penile cancers.
Based on this oncological potential, HPVs are classified into high-risk and low-risk types. The International Agency for Research on Cancer (IARC) considers HPV types 16, 18, 31, 33, 35, 35, 39, 45, 45, 51, 52, 56, 58, 59 and 66 to be carcinogenic to humans – high oncological risk types – and other types, including 6 and 11 to be possible carcinogens to humans – low oncological risk types.
Subtypes 16 and 18 are responsible for the highest percentage of precancerous lesions and invasive cancers of the previously described neoplasms (e.g., 70% of cervical cancers and 50% of cervical intraepithelial neoplasms grade 2/3). Subtypes 6 and 11 produce 90% of genital warts and a high percentage of mild cervical dysplasia.

How is HPV transmitted?

HPV is transmitted by sexual contact through genital skin. Penetration and mixing of fluids is not necessary.
We must keep in mind that the destruction of genital warts does NOT mean resolution of the infection, which depends on the immune system. Therefore after treatment of condylomata acuminata we may still be contagious and the lesions may reappear.
Transmission of HPV 6 and 11 to the baby after vaginal delivery is possible, but very rare, and the presence of genital warts is not an indication for cesarean section.

What is the natural evolution of the infection? Can I be cured?

Most HPV infections (about 90%) are transient and clear spontaneously (our immune system eliminates them).
However, they can persist over time in the form of latent infection – detectable by specific techniques such as in situ hybridization or polymerase chain reaction (PCR), but without any manifestation of disease but with the capacity to reactivate at any time -, subclinical infection – microscopic changes detectable by cytology and histological sections of affected tissues -, and clinical infection – appearance of visible lesions -. Persistent infection is of paramount importance in the development of precancerous lesions and invasive cancers.
At present, there is still no specific antiviral treatment available to cure persistent infection.

How common is HPV?

In Spain, the prevalence of HPV infection is one of the lowest in Europe, standing at around 3.4% in studies carried out in the general population.
The prevalence of HPV infection is highest at ages immediately after the onset of sexual intercourse and can be as high as 30-40% in the 15-25 age group. In the intermediate ages (25-40 years) viral detection stabilizes at levels between 3 and 10%. In some populations, a second peak prevalence has been observed in postmenopausal women, which may reflect the reactivation of a latent infection that would have gone undetectable in the middle ages of life and is apparently associated with the physiological reduction of natural immunity in older women.

What are the treatment options for genital warts?

We must not forget that warts are benign lesions and in many cases self-limited, so one option is therapeutic abstention.

There are multiple treatment modalities aimed at eliminating and/or destroying visible lesions. Among the most commonly used are:

– Cryotherapy with liquid nitrogen
– Trichloroacetic acid at 80-90%.
– CO2 laser vaporization
– Surgical resection and electrosurgery
– Intralesional interferon
– Podophyllotoxin solution or cream (Wartec ®)
– Imiquimod cream (Aldara ®)
– Ointment with green tea leaf extract (Veregen®)

Can HPV be prevented?

HPV infection, due to its mechanism of spread, can be prevented just like other STIs, by practicing safe sex.

There are currently two HPV vaccines: Gardasil, a quadrivalent vaccine that includes serotypes 6, 11, 16 and 18, and Cervarix, a bivalent vaccine that includes serotypes 16 and 18. We will discuss some aspects of Gardasil, which prevents the development of genital warts.

Gardasil is approved for the prevention of high-grade cervical, vaginal, vulvar and anal dysplasias (CIN, VAIN, VIN, AIN 2/3) and their associated invasive carcinomas, as well as external anogenital warts.

– Its efficacy in patients without prior infection is 100% for the prevention of cervical and anal pathology, CIN 2-AIN 2 or more severe and anogenital warts related to the four serotypes 6, 11, 16 and 18. Efficacy is not as evident for vulvar and vaginal pathology.
– Efficacy decreases dramatically in studies conducted in the general population, probably due to lack of efficacy in previously infected patients.
– It is administered in three doses over six months: month 0, month 2 and month 6.

*Who should be vaccinated?
It is important to note that the vaccine does not have the ability to cure – it does not accelerate the clearance of HPV infection or cure established HPV-related pathology – only to prevent infection by the HPV serotypes included in the vaccine. Based on this, the best time to vaccinate is before sexual intercourse begins.
The vaccine is approved for females and males between 9 and 26 years of age, although it is only included in the vaccination schedule for girls between 12 and 14 years of age, depending on the autonomous community. If you are over 14 years of age and want to be vaccinated, the vaccine can be purchased at the pharmacy.
In addition, vaccination is recommended for women with a history of persistent HPV infection, abnormal cytology and/or genital warts, as long as they are not infected with any of the serotypes included in the vaccine.
It is contraindicated in pregnant women. It can be administered during lactation.

*How long does the protection last?
It is not yet known whether the effect of the vaccine lasts a lifetime or whether booster doses will be necessary. So far it has only been shown that protection levels remain high for at least 42 months.

*Is it necessary to have a Pap smear if you are already vaccinated?
The vaccine contains only two high-risk HPV serotypes (16 and 28), which cause 70% of cervical cancers. Given that 30% of cancer cases are not caused by these viruses, it is very important to continue having cytology and gynecological check-ups.

I hope I have solved some of your doubts, but do not hesitate to consult with the specialist for your particular case.

Finally, do not forget that the most important thing to prevent infection and its development is to keep your natural defenses at the highest level: live a healthy life, eat well, practice physical exercise and avoid physical and mental stress.