CONDYLOMATA ACUMINATA

(Venereal Warts)

by M. P. Vora, M.B.B.S, D.V.D.

Honorary Senior Venereologist, St. George’s Hospital, Bombay.

Current Medical Practice

A Monthly Journal Devoted to Modern Medicine and Surgery.

Volume No.- 7, Number. 4 of April 1963.

Page No. 184 to 187.

Venereal warts are only a special variety of ordinary warts or verrucae. They are benign cutaneous tumors or papillomatas. They are localised and circumscribed hypertrophies of the prickle cell layer of the epidermis. The essential pathology of most variety of warts is the same. Under stimulus of a common agent, a filterable virus, the prickle cells undergo hypertrophy and the horny layer gets thickened.

Aetiology- The predisposing cause is the irritating discharge either due to gonorrhoea or chancroid or infection by spirochaet, Vincent’s bacillus or Trichomonas vaginalis. The exciting cause is the filter-passing virus.

Venereal warts may occur in the male on the inner side of the prepuce, the glans penis, at the balano-preputial groove or in the external urethral meatus. In the female, they are found on the vulva. In both sexes, they grow around the anus and may spread on the inner sides of the thighs, the perineum and between the buttocks by auto-inoculation.

Small conical masses of tissue project in a varying degree above the surface of the apparently healthy skin. They may be single or multiple, sessile or pedunculated, small conical projections or exuberant cauliflower-like excrescences. They are usually pinkish red in colour. They begin singly but multiply rapidly and ultimately become lobulated and pedunculated tumors. Their base is invariably soft. The surface tends to become eroded and sodden on account of the warmth, moisture and friction which are natural at the sites. Soon the warts get secondarily infected and dirty, foetid sero-pus begins to ooze from the surface and gives rise to scalding in and around the parts. This foul smelling discharge predisposes to new growths.

On the coronal sulcus, under the prepuce in the male, they may assume a considerable size. If the prepuce is tight, they may ulcerate and actually penetrate through the whole thickness of the skin to the surface or may project through the preputial opening.

Although frequently seen in patients suffering from chancroid or gonorrhoea, especially in the female, they are neither manifestations of either disease nor pathognomic of them. It is quite possible to find condylomata acuminata in a patient with active or latent syphilis; so also it is possible to find condyloma latum in a patient with either gonorrhoea or chancroid when he or she has an additional syphilitic infection. Condylomata acuminata require active surgical treatment while condyloma latum does not, and rapidly disappears with the institution of antisyphilitic treatment.

Diagnosis:- This usually is not difficult. The warts spring from apparently healthy tissue. They have no induration or infiltration at the base, look pinkish red in colour may be pedunculated or sessile, do not show Trepona pallidum on dark-field microscopy, and no other evidence of syphilis is detected. Biopsy reveals papillary proliferation, acanthosis and mitosis of the prickle cell layer. However, the following conditions need differentiation.

Condyloma latum:- It may manifest in generalised syphilis at the muco-cutaneous junctions, at times, even prior to the appearance of the skin rash. At the anus, on the vulva, the scrotum, the upper and inner sides of the thighs, between the buttocks and toes, in the arm-pits, and under pendulous breasts, syphilis appears generally as convex papular eruption. As these areas are essentially warm, moist and subjected to friction, the papules soon become eroded and sodden but still show the characteristic induration at the base so typical of an early syphilitic papule. Soon the papules coalesce to form large patches which undergo hypertrophy and assume the appearance of a warty growth; however, they retain symmetrical extention over the surrounding skin. These hypertrophied papules tend to assume a modified appearance. They become large, flat-topped and are of bluish-grey or purplish colour. The more unclean the patient, the larger these lesions become and assume a vegetative character. They are invariably sessile and most contagious. A serous discharge oozes from the lesions. T. pallidum can be detected on dark field microscopy, in the serum expressed from the base of the papule. The differentiating points between the two condylomata are as follows:

Lymphogranuloma Venereum- In ano-rectal ano-genital and genito-ano-rectal syndromes of L.V., it is common to find elephantiasis of the pudenda, either hypertrophic or ulcerative type, associated with warty polypoid growths of the vulva in the female and lobulated or “bouquet” anus in both sexes. Stricture of the rectum is a frequent accompaniment of these syndromes in the female. In the male, chronic inguinal lymphadenopathy, elephantiasis of the penis, chronic granulomatous ulceration and multiple fistulae with pedunculated growths at the anus are common. Both, the Frei test and the formol-gel test are positive. Fever, arthralgia, negative serological tests for syphilis (S.T.S.) and smears for gonococci, hyperglobulinae and the general clinical picture are convincing. Microscopic examination of the tissue reveals fibrosis of the lymph nodes, islands of epithelial cells with necrotic centres filled with polymorphs, satellite abscesses and large mononuclears with Guma bodies.

Epithelioma:- It grows very slowly, is hard to feel, has a hard base, bleeds easily and forms metastases. Age of the patient and biopsy showing typical “cell nests” will clinch the diagnosis.

Pemphigus vegetans:- It is a grave condition in which bullae appear on the skin and mucous membranes, rapture and give rise to painful lesions. Bullae on the genital region and between the buttocks rupture and the raw surface becomes covered with painful hypertrophic vegetations which give out a foul-smelling discharge. Bullae contain clear fluid and eosinophiles. Involvement of other areas, e.g. mouth, lips, etc., negative serological test for syphilis and grave condition of the patient ending fatally in a few months are suggestive.

Haemorrhoids: - chronically inflamed, thrombosed or prolapsed piles, rectal adenoma, prolapsed rectum and at times intussusception may have to be differentiated from venereal warts. A history of recurrent bleeding of bright red colour, constipation, anaemia, and oval purplish painful swellings bulging into the rectum or protruding from the anus should give a clue to the diagnosis.

Mycoses (Chromoblatomycosis or verrucous dermatitis):- In this condition, prominent papillomatous vegetations are chiefly confined to the feet and the legs. A pigmented organism and large spherical bodies, dark brown in colour, are present in the lesions.

Granuloma inguinale (Nodular and hypertrophic types):- It affects the skin of the genitalia and the neighbouring tissue. These are pale, red, soft, friable and elevated nodules, which bleed easily on the touch, extend peripherally and become eroded. They present bright red granulomatus surface. They are surrounded by apparently healthy skin and have sharply defined borders. When the lesion is fairly advanced, the borders appear heaped up and rolled. The neighbouring lymph nodes are not involved. A smear from the nodule shows the presence of Donovan bodies in the cytoplasm of monocytes. S.T.S. are negative. Histologic examination shows absence of epithelium over the ulcerated lesions, acanthosis at the edges, finger like projections extending into the deeper tissues, the corium is infiltered by histocytes and plasma cells and there is absence of caseation or giant cells. There is good response to antimony or streptomycin treatment.

It is recommended that test for syphilis, a smear for gonococci and the biopsy of the tissue to exclude malignancy should be carried out as a routine in all cases of venereal warts.

Treatment:- Warts are known to disappear spontaneously at times. The use of oral arsenical preparation like ‘Spirocid’ or ‘Stovarsol’ and bismuth preparations like ‘Bistrimate’ tablets and lime water according to the dosage advised, seem occasionally to be associated with the disappearance of the lesions. Local keratolytics, chemical cautery, excision and curettage, electric cautery, fulguration with diathermy, carbon dioxide snow and radiological methods are some of the ways used to deal with the warts in general; however, the last three methods are rarely used in the treatment of venereal warts. It should be noted that penicillin or sulpha drugs have no therapeutic value and should not be prescribed as a trial therapy without indications. Lately the use of gamma Globulin and steroids have been recommended.

The area must be kept scrupulously clean and dry at all times. Success of the treatment will depend on this simple but very essential practice. For, venereal warts have the most obstinate tendency to recur. This tendency may be checked by cleanliness and free use of a drying and dusting powder.

Local keratolytics:- Silver nitrate or chromate, glacial acetic acid, picric acid, salicylic acid, podophylline 20 per cent in tincture Benzoin Co., and canthedine 0.7 per cent in equal parts of acetone and collodin flexide.

Rx

Glacial acetic acid 10%

Phenol 10%

Salicylic acid 10%

Tincture iodine fortis 20%

Methylated spirit to 100%

(For application)

Rx

Podophylline 20%

Trichloroacetic acid 25%

Salicylic acid 30%

Glycerine 25%

(For application)

Rx

Bismuth subgallate

Boric acid Equal parts

Zinc oxide

(Dusting powder)

Rx

Zinc oxide 1 part

Light Magnesium carbonate 2 parts

Bismuth subgallate 2 parts

Starch 3 parts

(Dusting powder)

These keratolytic paints and drying dusting powders have been in use and are found to give good results. The area surrounding the warts is protected by the application of vaseline or Lassar’s paste. Either of the paints is applied over the growths and is allowed to dry. The area is then freely dusted with any of the two powders. The patient is requested to wash the area the next day, preferably with an antiseptic lotion such as hydrogen peroxide or mercury biniodide 1 in 5000, dry the area and dust it two or three times a day. After a day or two, depending on the local reaction, the application of the paint is repeated. As the result, the area becomes at times sore and painful. If the reaction is severe, the application is omitted and calamine lotion is applied for one or two days to sooth the area. Usually four to six applications of the paint are enough for an average sized wart. Very large warts may need more treatments.

Excision and curettage:- This is one of the most satisfactory methods of treating warts especially when they are large. However, this does not mean cutting the warts widely and deeply, thereby giving rise to a prominent scar.

Special care must be taken to avoid damage to the anal sphincter. The procedure is always carried out under local or general anaesthesia. An incision close to the base of the wart is made with a knife, first through the epidermis and then a strong long curette is inserted under the cut margin to lift and lever out the warty growth. Usually it comes right away. If it does, help with a pair of scissors or a scalpel is needed to complete the job. In some cases, the warts can be simply shaved off with a knife. Bleeding does not occur but can be controlled by the application of tincture ferri perchlor, copper sulphate or silver nitrate solution. The base is then cauterized either with an electric or chemical cautery, to destroy the part of the wart left. If electric cautery is not available, pure carbolic acid may be used in its place.

Electric cautery and diathermy:- For small warts especially, multiple electric cautery is excellent but slightly painful. Electro-coagulation is quicker in effect but more painful. Treatment should be superficial and repeated if necessary. It should be never single or deep in order to avoid scars. Diathermy scars are rather thicker and deeper. Local or general anaesthesia is usually employed before this procedure.