AKT · Sexual health/Viral STIs

Anogenital warts (HPV)

Human papillomavirus — types 6 & 11 (warts); 16 & 18 (oncogenic)

Overview

Benign epithelial growths from low-risk HPV (6/11). Distinct oncogenic types (16/18) drive cervical/anal/oropharyngeal cancer and are targeted by vaccination and screening.

Recognise

Soft fleshy papular or filiform warts on genital/perianal skin
Usually painless; may itch or bleed
Low-risk 6/11; oncogenic 16/18 cause neoplasia (not warts)

Red flags

Pigmented/atypical/bleeding lesions → biopsy to exclude neoplasia; immunocompromise

Differentials & how to tell them apart

Condylomata lata (secondary syphilis)flatter, moist, syphilis serology positive

Molluscum contagiosumumbilicated pearly papules

Normal anatomy (pearly papules, Fordyce)symmetrical, physiological

Intraepithelial neoplasiapigmented/atypical — biopsy

Investigations

Clinical diagnosis. Do NOT routinely biopsy typical warts. Cervical screening (HPV primary) is separate. Consider HIV test.

Management

Podophyllotoxin or imiquimod (soft warts); cryotherapy if keratinised/pregnant

1Refer to sexual health where possible. Soft non-keratinised warts: self-applied podophyllotoxin or imiquimod.Gate: Podophyllotoxin and imiquimod are contraindicated in pregnancy → use cryotherapy or trichloroacetic acid
2Keratinised/large: cryotherapy, excision, electrocautery.
3Prevention: HPV vaccination (Gardasil 9) covers 6/11/16/18 + others.

Podophyllotoxin — self-applied for soft non-keratinised warts; NOT in pregnancy

Imiquimod — immune modulator; NOT in pregnancy

Cryotherapy — physical ablation; safe in pregnancy

Key points

HPV vaccination is now offered to all adolescents (and to MSM/at-risk). Warts ≠ cancer (6/11 vs 16/18).

Monitor & prognosis

Recurrence common; reassure benign.

Often self-resolve; recurrences frequent.

Source: NICE CKS Warts - anogenital (2025); BASHH