CM E
The Management of Condyloma Acuminata
in the Pediatric Population
Donna A. Culton, MD, PhD; Dean S. Morrell, MD;
and Craig N. Burkhart, MD
CM E EDUCATIONAL OBJECTIVES
1. Discuss the routes of transmission of
condyloma acuminata in the pediat-
ric population.
2. Determine which factors may
suggest a route of transmission for
condyloma acuminata in children
other than sexual abuse.
3. Outline the available treatment
options for condyloma acuminata in
children.
Donna A. Culton, MD, PhD, is Resident
Physician, Department of Dermatology,
University of North Carolina at Chapel Hill.
Dean S. Morrell, MD, is Associate Professor
and Residency Training Program Direc-
tor, Department of Dermatology, Univer-
sity of North Carolina at Chapel Hill. Craig
N. Burkhart, MD, is Assistant Professor and
Director of Medical Student Education,
Department of Dermatology, University of
North Carolina at Chapel Hill.
Address correspondence to: Donna A.
Culton, MD, PhD, 3100 Thurston-Bowles
Building, Campus Box 7287, Chapel Hill, NC
27599; fax: 919-966-3898; or e-mail DCul-
ton@unch.unc.edu, morrell@med.unc.edu,
or Craig_burkhart@med.unc.edu.
Dr. Culton, Dr. Morrell, and Dr. Burkhart
have disclosed no relevant financial rela-
tionships.
doi: 10.3928/00904481-20090622-05
368 | www.PediatricSuperSite.com
PED0709Culton.indd 368
C
ondyloma acuminata, more
commonly known as genital
warts, are caused by infection
with human papillomavirus (HPV).
Prevalence is increasing in adults, as
well as in the pediatric population.
Management of condyloma in the pe-
diatric population can be difficult given
the possibility of sexual abuse as a mode
of transmission. Moreover, the available
treatment options are only moderately
efficacious and associated with signifi-
cant rates of recurrence. Treatment can
be quite painful, and multiple office
visits are typically required. Finally, no
large studies have been conducted in the
pediatric population, and none of the
medical treatments available is approved
by the Food and Drug Administration
(FDA) for use in children younger than
12 years. Each of these factors compli-
cates management and treatment deci-
sions in children with genital warts.
EPIDEMIOLOGY
Condyloma acuminata is quickly be-
coming the most frequently diagnosed sex-
ually transmitted disease (STD) in the adult
population, with 10% of adults having
clinically evident lesions.1 Strikingly, more
than half of sexually active women have
been shown to harbor HPV virus, even in
PEDIATRIC ANNALS 38:7 | JULY 2009
7/31/2009 10:19:19 AM

the absence of symptoms.2-4 Pediatric cas-
es are also increasing,5 which is thought to
reflect the increase in adult cases; however,
little is known about the epidemiology of
condyloma in the general pediatric popula-
tion. Among children presenting to an STD
clinic, 14.2% were diagnosed with condy-
loma, second only to syphilis (including
congenital syphilis).6,7 Girls are more often
affected than boys by a ratio of 3:1.7
PATHOGENESIS
HPV is a non-enveloped, double-strand-
ed DNA virus with more than 100 reported
subtypes causing both clinical and subclin-
ical infection of the skin and mucous mem-
branes.5,8 Basal keratinocytes are the target
cell infected and as cells become cornified,
PEDIATRIC ANNALS 38:7 | JULY 2009
PED0709Culton.indd 369
© iStockphoto.com
the virion is maintained. As these corni-
fied cells are shed, so is the virion, thereby
spreading potential disease-bearing par-
ticles into the environment, onto fomites,
or onto the skin of another person.9
Although not specific in their clinical
manifestations, HPV types 6 and 11 are
predominantly associated with genital
warts, and HPV types 16 and 18 are more
commonly associated with cervical neo-
plasias. Common warts (verruca vulgar-
is) are caused by many HPV types, but
most often types 1-4. Although certain
viral subtypes are typically associated
with site-specific clinical presentations,
overlap is common, especially in the
pediatric population.10 For example, a
study of 29 cases of genital warts in girls
younger than 5 years of age showed that
41% were due to HPV type 2, whereas
only 3% of vulvar warts in adult women
were caused by HPV type 2.11
The incubation time following infection
may last months; HPV can also remain in
a latent phase. Therefore, the time from
exposure to clinically evident lesions can
range from months to years.12 The poten-
tial for unpredictable durations of latency
make determination of the mode of trans-
mission problematic.
CLINICAL PRESENTATION
Condyloma most often presents as 1-
to 5-mm fleshy, skin-colored, verrucous-
surfaced papules, which can coalesce into
large plaques. They may be sessile or pe-
dunculated and may even become quite
exophytic forming cauliflower-like masses.
They are typically asymptomatic, but may
bleed or become painful or pruritic due to
larger size or local trauma with toileting.8
In prepubertal boys the most common
site of involvement is the perianal area,
while adult males often have lesions on the
penile shaft.7,10 In girls, the perianal region
and vulva are commonly involved.7,10
MODES OF TRANSMISSION
In adults, sexual transmission is the
most common route of inoculation. Al-
though the possibility of sexual abuse
must be considered for each individual
case of condyloma occurring in a child,
other routes of transmission should be
considered as well, particularly in chil-
dren younger than 4 years, a demographic
where non-sexual transmission is more
likely.13,14 Perinatal exposure may occur
in utero via ascending HPV infection. In
a study of HPV-infected pregnant women,
24 of 37 had detectable HPV genome in
the amniotic fluid.15 Cases of congenital
condyloma have been reported,16,17 further
supporting ascending infection as a mode
of transmission. Perinatal exposure can
also occur as the neonate passes through
the birth canal of an HPV-infected moth-
er.10,18 Accordingly, the healthcare pro-
www.PediatricSuperSite.com | 369
7/31/2009 10:19:19 AM
 vider should attempt to elicit a maternal
gynecologic history including any history
of condyloma or abnormal pap smears.
Another potential mode of transmission
is auto- or heteroinoculation from non-
genital warts of the child, parent, or other
care provider.10,19,20 A thorough physical
examination should be performed on any
child with condyloma, inspecting for other
non-genital warts, and parents should be
questioned regarding personal history of
verrucae as well. The long latency from
exposure to clinical presentation must be
considered, as exposure may precede de-
velopment of condyloma by months to
years.12,16 As mothers of pediatric HPV-in-
fected patients may have subclinical cervi-
cal HPV infection (especially mothers of
those who acquired HPV via in utero or
perinatal exposure), physicians should ad-
vise potential carriers to seek medical at-
tention from their primary care physician.
DIAGNOSIS
The diagnosis of condyloma is most
often made clinically. Biopsy is rarely
necessary, but histology shows typical hy-
perkeratosis and viral cytopathic change.
HPV subtyping may be performed if clin-
ical and histologic features are non-diag-
nostic but is not typically necessary.21 As
site-specific subtypes are not as reliable
in children as they are in adults, HPV
subtyping has not been shown to be use-
ful in making a case for or against sexual
abuse as a mode of transmission.20,22
TREATMENT
Approximately 75% of untreated or
treatment-resistant condyloma spontane-
ously resolve within months to a few years
in children and adolescents with healthy
immune systems.7,23,24 Therefore, active
nonintervention is an option in children
with asymptomatic lesions. However, stud-
ies suggest that lesions present for longer
than 2 years are less likely to undergo
spontaneous resolution.24 In these cases
and in cases where the condyloma are
symptomatic or affect function, treatment
370 | www.PediatricSuperSite.com
PED0709Culton.indd 370
should be initiated. However, there are no
FDA-approved treatments of genital warts
in children younger than 12 years.
Treatment of condyloma can be divided
into surgical and non-surgical approaches.
All surgical approaches rely on nonspecif-
ic tissue destruction. Many non-surgical
approaches also utilize nonspecific tissue
The diagnosis of condyloma is
most often made clinically.
destruction, but treatments have expanded
to include immunomodulatory agents
as well. It is important to remember that
no treatment has been shown to result in
complete clearance of disease, that recur-
rences are common, and that multiple
treatment modalities used in combination
are often necessary to achieve significant
improvement.25 In addition, many of the
available treatments have not been studied
in children, and in general no one treat-
ment has been shown to be most effica-
cious. Therefore, treatment must be tai-
lored to the individual patient.
Surgical Approaches
Cryotherapy in the form of liquid
nitrogen is the most commonly utilized
surgical approach to treatment. Complete
clearance rates in the adult population
range from 62% to 86%.25 Longer freeze
time and multiple freeze/thaw cycles are
associated with a higher clearance rate.26
This modality is useful when treating a
limited number of small lesions. Side ef-
fects include local pain and burning dur-
ing treatment, which may persist for a
few hours, and blistering, which is typi-
cally asymptomatic and heals within a
week. Scarring is unusual but may occur
with aggressive treatment, particularly
in children with heavily pigmented skin.
Although no studies using treatment
with cryotherapy have been performed
in children, these side effects often limit
its use in the pediatric population.
Electrodessication is another method
of nonspecific tissue destruction. Com-
plete clearance rates in the adult popu-
lation range from 57% to 94% with
recurrence in one fourth of patients.25
Anesthesia is required, and side effects
include the possibility of scarring and
pain following treatment. Given the need
for anesthesia, this method of destruc-
tion is not often utilized in children.
Carbon dioxide laser ablation can be
effective in children. Complete clearance
rates in adults range from 27% to 100%
but varies widely based on the experience
of the surgeon.25,27 Johnson et al pub-
lished a retrospective review of a single
surgeon’s case series of 17 consecutive
pediatric patients.28 Following one treat-
ment, complete clearance was achieved
in 16 patients with a recurrence rate of
23% at 1-year follow up. Only one patient
(6%) had persistent disease. The authors
argue that carbon dioxide laser ablation
is safe, relatively atraumatic, and effec-
tive in the pediatric population. However,
postoperative pain can be severe and gen-
eral anesthesia is necessary. These factors
should be taken into consideration.
Pulsed-dye laser is another alterna-
tive that has been shown to be effective in
treating flat, plantar, and periungal warts.29
Treatment has been extended to genital
warts in adults with one study showing
complete resolution in all of 22 patients
after an average of 1.59 (1-5) laser ses-
PEDIATRIC ANNALS 38:7 | JULY 2009
7/31/2009 10:19:21 AM
 sions without evidence of scarring.30 In 13
patients, a single treatment was sufficient,
whereas in the remaining nine patients up
to five treatments were necessary with an
average treatment interval of 14 to 21 days.
Tuncel and colleagues found that treat-
ment with pulsed-dye laser is also safe,
effective, and well-tolerated in children.31
Postoperative pain and scarring are infre-
quent, making this an attractive option for
children with condyloma.
Surgical excision is also an option for
limited disease or single large lesions.
Local or general anesthesia is required,
and the procedure is usually performed
in the office or outpatient surgical suite.
In adults population, complete clearance
rates range from 35% to 72% at 1-year
follow up.27 If shave removal is per-
formed, electrocautery to the base of the
wound may add additional destruction
of any remaining virally infected tissue.
The use of this technique in children
must be carefully considered given the
need for general anesthesia.
Nonsurgical Approaches
Podophyllin is a resin that is derived
from the rhizome of the Podophyllum
species. The active agent of podophyl-
lin resin is podophyllotoxin, which has
antimitotic properties. Podophyllin is
available as a 10% to 25% resin typi-
cally applied by the physician every 1
to 2 weeks until clearance is achieved.32
The resin should be washed off 4 hours
after application to minimize local side
effects such as redness and burning. In
order to increase efficacy, the treatment
is often combined with other destructive
treatment options such as cryotherapy.33
Podophyllotoxin (podofilox) is available
as a 0.5% solution or 0.15% cream and
has increased purity and stability com-
pared to podophyllin.32 It is applied by
the patient or caretaker at home once or
twice daily for several days per week as
tolerated, and it is associated with slightly
higher clearance rates in adults compared
with podophyllin (56% to 79% compared
PEDIATRIC ANNALS 38:7 | JULY 2009
PED0709Culton.indd 371
with 41% to 47%).25,32 Moresi et al re-
ported 15 of 17 children (88%) treated
with podofilox experienced clearance of
lesions over a duration of treatment rang-
ing from 1 week to 4 months without sig-
nificant side effects, suggesting that it is
safe and effective for use in children.34
Imiquimod 5% cream (Aldara) is a
synthetic immune modulator that acts
through the enhancement of both in-
nate and cellular immune responses
via extensive cytokine activation. It has
been shown to be efficacious in treating
external genital warts and is FDA-ap-
proved for use in children 12 and older.
No large studies have been published
on the safety and efficacy in children
below 12 years of age, but case reports
suggest that the compound is both safe
and highly effective in the treatment of
genital warts in children as young as 6
months, with clearance rates of 75%.34-36
Treatment typically involves application
of imiquimod 5% cream overnight three
times weekly with improvement within
weeks to months. Side effects, which are
usually mild and well-tolerated, include
local pain, pruritus, and irritation.34 Be-
cause of the ease of application and the
favorable side effect profile, imiquimod
is quickly becoming first line treatment
for condyloma in children.
Case reports of other topical agents
have been reported. For example, cidofo-
vir is an acyclic nucleoside phosphonate
that acts as a DNA polymerase inhibitor.
It is used primarily to treat cytomegalo-
virus retinitis in AIDS patients. Calisto
et al reported improvement in condylo-
ma of the glans penis in a 3-year-old boy
using compounded topical cidofovir 1%
cream applied daily for 5 consecutive
days per week for 2 weeks.37 A second
cycle was initiated after a 30-day pause
and resulted in complete clearance with-
out local or systemic side effects. There
was no recurrence after 12 months.
Cimetidine is a histamine receptor
antagonist that is often used to treat pep-
tic ulcer disease. However, cimetidine
also possesses immunomodulatory ef-
fects and has been reported to be useful
in treating other conditions including
verruca vulgaris. Although randomized
controlled trials failed to show a sig-
nificant benefit in non-genital warts in
adults, Franco reported a case series of
four children with condyloma treated
with oral cimetidine.38 In two children,
cimetidine was given as primary treat-
ment, while in the other two children
cimetidine was given to prevent recur-
rence. Dosing was initiated at 30 to 40
mg/kg/day divided into three doses and
given for 3 months. All patients had com-
plete clearance at 24-month follow-up.38
Cimetidine may be useful for primary
and adjunctive therapy for condyloma in
children, but more studies are needed.39
CONCLUSION
When presented with a case of pe-
diatric condyloma, a thorough physical
examination and history (particularly
of genital or non-genital warts in the
mother or other care providers) must be
performed. The American Academy of
Pediatrics (AAP) recommends that all
school-aged children presenting with
condyloma for the first time should
undergo a medical evaluation for child
abuse including interview of the child
and caretakers and testing for other
sexually transmitted diseases. They
also state that condyloma in children
suggests sexual abuse if the lesions
were not acquired perinatally. Regard-
less of the child’s age, sexual abuse
must be considered in all children with
condyloma. Given the difficulty in de-
termining time of inoculation because
of the long latency period, we advocate
that in children younger than 4 years,
non-sexual transmission is more likely
and an alternative route of inoculation
should be explored.13 When there is any
concern by the parents or health care
provider for sexual abuse, referral to an
agency skilled in handling such cases
should be made.
www.PediatricSuperSite.com | 371
7/31/2009 10:19:22 AM
 REFERENCES
1. Schneider A, Koutsky LA. Natural history
and epidemiological features of genital HPV
infection. IARC Sci Publ. 1992;(119):25-52.
2. Bauer HM, Ting Y, Greer CE, et al. Genital
human papillomavirus infection in female
university students as determined by a PCR-
based method. JAMA. 1991;265(4):472-477.
3. Moscicki AB. Human papillomavirus infec-
tions. Adv Pediatr. 1992;39:257-281.
4. Wiley D, Masongsong E. Human papilloma-
virus: the burden of infection. Obstet Gynecol
Surv. 2006;61(6 Suppl 1):S3-14.
5. Frasier LD. Human papillomavirus infections in
children. Pediatr Ann. 1994;23(7):354-360.
6. Pandhi D, Kumar S, Reddy BS. Sexually
transmitted diseases in children. J Dermatol.
2003;30(4):314-320.
7. Allen AL, Siegfried EC. The natural history
of condyloma in children. J Am Acad Derma-
tol. 1998;39(6):951-955.
8. Gibbs NF. Anogenital papillomavirus in-
fections in children. Curr Opin Pediatr.
1998;10(4):393-397.
9. Brown DR, Bryan JT. Abnormalities of corni-
fied cell envelopes isolated from human papil-
lomavirus type 11-infected genital epithelium.
Virology. 2000 May 25;271(1):65-70.
10. Obalek S, Misiewicz J, Jablonska S, Favre
M, Orth G. Childhood condyloma acumina-
tum: association with genital and cutaneous
human papillomaviruses. Pediatr Dermatol.
1993;10(2):101-106.
11. Aguilera-Barrantes I, Magro C, Nuovo GJ.
Verruca vulgaris of the vulva in children and
adults: a nonvenereal type of vulvar wart. Am
J Surg Pathol. 2007 Apr;31(4):529-35.
12. Sinal SH. Sexual abuse of children and ado-
lescents. South Med J. 1994;87(12):1242-
1258.
13. Cohen BA, Honig P, Androphy E. Anogeni-
tal warts in children. Clinical and virologic
evaluation for sexual abuse. Arch Dermatol.
1990;126(12):1575-1580.
14. Sinclair KA, Woods CR, Kirse DJ, Sinal SH.
Anogenital and respiratory tract human papil-
lomavirus infections among children: age, gen-
der, and potential transmission through sexual
abuse. Pediatrics. 2005;116(4):815-825.
372 | www.PediatricSuperSite.com
PED0709Culton.indd 372
15. Armbruster-Moraes E, Ioshimoto LM, Leão
E, Zugaib M. Presence of human papillo-
mavirus DNA in amniotic fluids of pregnant
women with cervical lesions. Gynecol Oncol.
1994;54(2):152-158.
16. Boyd AS. Condylomata acuminata in
the pediatric population. Am J Dis Child.
1990;144(7):817-824.
17. Gutman LT, Herman-Giddens ME, Phelps WC.
Transmission of human genital papillomavirus
disease: comparison of data from adults and
children. Pediatrics. 1993;91(1):31-38.
18. Jones V, Smith SJ, Omar HA. Nonsexual
transmission of anogenital warts in children:
a retrospective analysis. ScientificWorld-
Journal. 2007;7:1896-1899.
19. Obalek S, Jabłońska S, Orth G. Ano-
genital warts in children. Clin Dermatol.
1997;15(3):369-376.
20. Armstrong DK, Handley JM. Anogenital
warts in prepubertal children: pathogenesis,
HPV typing and management. Int J STD
AIDS. 1997;8(2):78-81.
21. Smith YR, Haefner HK, Lieberman RW, Quint
EH. Comparison of microscopic examination
and human papillomavirus DNA subtyping in
vulvar lesions of premenarchal girls. J Pediatr
Adolesc Gynecol. 2001;14(2):81-84.
22. Handley J, Hanks E, Armstrong K, et al.
Common association of HPV 2 with anogeni-
tal warts in prepubertal children. Pediatr Der-
matol. 1997 Sep-Oct;14(5):339-343.
23. Richardson H, Kelsall G, Tellier P, et al. The
natural history of type-specific human papil-
lomavirus infections in female university stu-
dents. Cancer Epidemiol Biomarkers Prev.
2003;12(6):485-490.
24. Moscicki AB, Shiboski S, Broering J, et al.
The natural history of human papillomavirus
infection as measured by repeated DNA test-
ing in adolescent and young women. J Pedi-
atr. 1998;132(2):277-284.
25. Cook K, Brownell I. Treatments for genital
warts. J Drugs Dermatol. 2008;7(8):801-807.
26. Gibbs S, Harvey I. Topical treatments for cu-
taneous warts. Cochrane Database Syst Rev.
2006;3:CD001781.
27. Duus BR, Philipsen T, Christensen JD, Lund-
vall F, Søndergaard J. Refractory condylomata
acuminata: a controlled clinical trial of carbon
dioxide laser versus conventional surgical treat-
ment. Genitourin Med. 1985;61(1):59-61.
28. Johnson PJ, Mirzai TH, Bentz ML.Carbon di-
oxide laser ablation of anogenital condyloma
acuminata in pediatric patients. Ann Plast Surg.
1997;39(6):578-582.
29. Park HS, Choi WS. Pulsed dye laser treatment
for viral warts: a study of 120 patients. J Derma-
tol. 2008;35(8):491-498.
30. Komericki P, Akkilic M, Kopera D. Pulsed dye
laser treatment of genital warts. Lasers Surg
Med. 2006;38(4):273-276.
31. Tuncel A, Görgü M, Ayhan M, Deren O, Erdo-
gan B Treatment of anogenital warts by pulsed
dye laser. Dermatol Surg. 2002;28(4):350-2.
32. Lacey CJ, Goodall RL, Tennvall GR, et al;
Perstop Pharma Genital Warts Clinical Trial
Group. Randomised controlled trial and eco-
nomic evaluation of podophyllotoxin solution,
podophyllotoxin cream, and podophyllin in the
treatment of genital warts. Sex Transm Infect.
2003;79(4):270-275.
33. Sherrard J, Riddell L.Comparison of the effec-
tiveness of commonly used clinic-based treat-
ments for external genital warts. Int J STD AIDS.
2007;18(6):365-368.
34. Moresi JM, Herbert CR, Cohen BA. Treatment of
anogenital warts in children with topical 0.05%
podofilox gel and 5% imiquimod cream. Pediatr
Dermatol. 2001;18(5):448-50; discussion 452.
35. Majewski S, Pniewski T, Malejczyk M, Jablon-
ska S. Imiquimod is highly effective for exten-
sive, hyperproliferative condyloma in children.
Pediatr Dermatol. 2003;20(5):440-442.
36. Schaen L, Mercurio MG.Treatment of hu-
man papilloma virus in a 6-month-old infant
with imiquimod 5% cream. Pediatr Dermatol.
2001;18(5):450-452.
37. Calisto D, Arcangeli F. Topical cidofovir for con-
dylomata acuminata of the genitalia in a 3-year-
old child. J Am Acad Dermatol. 2003;49(6):1192-
1193.
38. Franco I. Oral cimetidine for the management of
genital and perigenital warts in children. J Urol.
2000;164(3 Pt 2):1074-1075.
39. Fit KE, Williams PC. Use of histamine2-antago-
nists for the treatment of verruca vulgaris. Ann
Pharmacother. 2007;41(7):1222-1226.
PEDIATRIC ANNALS 38:7 | JULY 2009
7/31/2009 10:19:22 AM