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HPV · CommonSTIICD-10 A63.0

Anogenital warts

Condylomata acuminata · genital warts · venereal warts

Anogenital warts are HPV-induced epithelial proliferations of the anogenital region, most commonly caused by HPV types 6 and 11 (low-risk). They affect ~1% of sexually active UK adults annually; UK HPV vaccination (Gardasil-9, since 2008-9 for girls, since 2019 for boys) has substantially reduced incidence. Although warts themselves are caused by low-risk HPV, coexistent high-risk HPV infection drives anal / cervical / vulval / penile / oropharyngeal SCC. Diagnosis is clinical; treatment is patient-administered or clinician-administered. UK BASHH guidelines underpin GUM service practice.

CurrentLast reviewed 16 May 2026
Clinical image of Anogenital warts
Anogenital warts. Image sourced from DermNet New Zealand. Used under CC BY-NC-ND 4.0. No endorsement implied.

Aetiology and epidemiology

  • HPV types: 6 (40-70%) and 11 (30-40%) account for >90%; co-infection with high-risk HPV (16, 18, 31, 33, 45) in ~20%.
  • Transmission predominantly sexual (skin-to-skin); incubation 3 weeks-8 months.
  • Risk factors: number of sexual partners, age 16-25, immunosuppression (HIV, transplant, biologic / ICI), smoking, lack of vaccination.
  • UK HPV vaccination:
    • Gardasil (HPV 6, 11, 16, 18) — initial UK programme 2008.
    • Gardasil-9 (adds HPV 31, 33, 45, 52, 58) — current UK programme since 2021.
    • Boys included since 2019.
    • Single-dose schedule for the routine adolescent cohort (school year 8) since September 2023; immunosuppressed / HIV-positive and older-starting individuals still require multiple doses.
    • UK incidence of genital warts <25 y has fallen >90% post-vaccination.

Clinical features

  • Morphology:
    • Cauliflower / verrucous (condyloma acuminatum) — classic.
    • Flat / papular — keratinised epithelium.
    • Pigmented.
    • Pedunculated.
  • Sites:
    • Penis (shaft, glans, foreskin).
    • Vulva (labia, fourchette, vestibule, clitoris).
    • Vagina, cervix.
    • Perianal, anal canal.
    • Intraurethral.
    • Buschke-Löwenstein tumour (giant condyloma) — verrucous carcinoma spectrum; risk of SCC.
  • Usually asymptomatic; sometimes itching, bleeding, dyspareunia, urinary issues.
  • Spontaneous resolution in ~30% within 6 months; persistence in immunosuppressed.

Differentials

  • Pearly penile papules / Fordyce spots — normal anatomical variants.
  • Molluscum contagiosum — central umbilication.
  • Bowenoid papulosis — HPV-driven cSCC in situ.
  • Condylomata lata — secondary syphilis; broad-based flat papules; serology.
  • VIN / AIN / PeIN — high-grade intraepithelial neoplasia; biopsy.
  • Squamous cell carcinoma (anogenital) — particularly if persistent, ulcerated, indurated.
  • Verrucous carcinoma / Buschke-Löwenstein.
  • Lichen planus, lichen sclerosus, psoriasis in genital region.

Investigations

  • Clinical diagnosis usually adequate.
  • Acetic acid 5% application — turns warts white (acetowhitening); aids visualisation but non-specific.
  • Biopsy when:
    • Pigmented / atypical morphology.
    • Persistent / refractory treatment.
    • Suspected VIN / AIN / PeIN / SCC.
    • Immunosuppressed patients with extensive disease.
  • STI screen at presentation per UK BASHH:
    • HIV, syphilis, HBV / HCV.
    • Chlamydia, gonorrhoea PCR (urethral, cervical, rectal, pharyngeal as appropriate).
  • Speculum / proctoscopy for intravaginal / intra-anal disease.
  • High-resolution anoscopy (HRA) in HIV-positive MSM, immunosuppressed.
  • Cervical screening per UK NHS pathway.

Management (BASHH guidance)

  • Patient-administered:
    • Podophyllotoxin 0.15% cream / 0.5% solution: BD × 3 days, 4-day rest; cycles up to 4-5 weeks; do not use in pregnancy.
    • Imiquimod 5% cream: 3× weekly overnight for up to 16 weeks; avoid in pregnancy.
    • Sinecatechins 10% / 15% ointment (Veregen) — green tea extract.
  • Clinician-administered:
    • Cryotherapy with liquid nitrogen weekly.
    • Electrosurgery (loop / hyfrecation).
    • Curettage and cautery.
    • CO2 / Er:YAG laser ablation.
    • Excision (especially Buschke-Löwenstein).
    • Trichloroacetic acid (TCA) 80-90% — pregnancy-safe.
  • Buschke-Löwenstein / verrucous carcinoma: wide local excision; consider Mohs; oncology MDT.
  • Adjunctive:
    • HPV vaccination — therapeutic role being studied; routine vaccination strongly advocated.
    • Smoking cessation.
    • Treat / counsel partners.
    • Use of condoms reduces but does not eliminate transmission.
  • Counsel:
    • Long incubation; previous partner exposure not necessarily recent contact.
    • Multiple treatments often required; recurrence ~30%.
    • HPV vaccination ≠ cure but reduces future related disease.

References

  1. British Association for Sexual Health and HIV (BASHH). UK national guideline on the management of anogenital warts 2024. London: BASHH; 2024.
  2. Mehta SD et al. Anogenital HPV infection: epidemiology, transmission, and risk factors. Sex Transm Infect. 2018;94:484-490.
  3. Drolet M et al. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes. Lancet. 2015;385:983-996.
  4. Public Health England / UKHSA. Human papillomavirus (HPV) vaccination programme. London: UKHSA; 2024.

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