Human papillomavirus infection

Last updated: April 26, 2023

Summarytoggle arrow icon

The human papilloma virus (HPV) causes infections of the skin and mucous membranes. The locations and specific manifestations of infection depend on the type of virus and its mode of transmission. Many HPV strains are already spread during infancy and childhood through direct skin-to-skin contact and may remain dormant inside the cell, while others (especially HPV-1, HPV-2, and HPV-4) can cause common warts (verruca vulgaris). Other strains are sexually transmitted (especially in young adults) and can be further divided into low-risk and high-risk HPV types. Low-risk types (especially HPV-6 and HPV-11) can cause benign anogenital warts (condylomata acuminata) and papillomatous nodules in other genital (e.g., squamous intraepithelial lesions of the cervix) or non-genital (e.g., oral warts, respiratory papillomatosis) mucosal areas. Infection with oncogenic high-risk HPV types (especially HPV-16 and HPV-18) may lead to malignant disease. These high-risk strains account for more than 70% of cervical cancers and can also cause genital, oral, and oropharyngeal squamous cell cancers. Risk factors for infection include skin damage, immunocompromise, early first sexual intercourse, and frequent change of sexual partners. Most HPV infections are asymptomatic and self-limiting, although pruritus, tenderness, and bleeding may occur. Diagnosis is often based on the physical exam alone, but can be confirmed with diagnostic tests (e.g., PCR), particularly in asymptomatic HPV infections of the cervix. Treatment of condylomas includes the use of local ointments, cryotherapy, and electrocoagulation. However, surveillance is important since recurrence rates are high and malignant transformation is possible. Prevention includes education about safe sexual practices and the proper use of condoms, as well as vaccination of all persons 9–26 years of age.

Etiologytoggle arrow icon

Human papillomavirus [1]

Route of transmission

  • Transmission occurs between two epithelial surfaces.
    • Close personal contact: cutaneous warts
    • Sexual contact: anogenital lesions

Risk factors [3]


6 comes before 7 and P comes before R: E6 inhibits P53 and E7 inhibits pRb

Pathologytoggle arrow icon

Anogenital manifestationstoggle arrow icon


Genital intraepithelial neoplasms

Bowenoid papulosis

Condylomata acuminata (anogenital warts)

Flat condylomata

  • Pathogen: particularly HPV types 3 and 10
  • Clinical features: flat, white-brown, slightly elevated, scattered plaques in the anogenital region
  • Diagnostics: visual inspection
  • Differential diagnosis: condylomata lata (usually flat, smooth, and moist) in syphilis
  • Treatment

Giant condylomata (Buschke-Löwenstein tumor)

Nonanogenital manifestationstoggle arrow icon


Common warts (verruca vulgaris)

  • Pathogen: : particularly low-risk HPV types 2 and 4
  • Clinical features
    • Lesions are plaques or papules
      • Skin-colored or whitish
      • Usually firm, often with a rough and scaly surface
      • Sometimes have a cauliflower-like appearance
      • Located on the elbows, knees, fingers, and/or palms
    • Often asymptomatic but may cause tenderness (depending on the location) and pruritus scratching → bleeding
  • Treatment

Plantar warts (verruca plantaris)

  • Pathogen: particularly HPV types 1
  • Clinical features
    • Rough, hyperkeratotic lesions on the sole of the foot
    • Often grow inwardly and cause pain while walking

Flat warts (verruca plana)

  • Pathogen: particularly HPV types3 and 10
  • Clinical features
    • Multiple small, flat patches or plaques
    • Localized on the face, hands, and shins

Nonanogenital mucosal manifestations

HPV types that cause mucosal manifestations in the genital area may also lead to nonanogenital mucosal manifestations, such as:

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon


Prognosistoggle arrow icon

  • High rate of recurrence
  • Infection with high-risk types may transition to precancerous or malignant lesions after several years. [3]

Preventiontoggle arrow icon

Special patient groupstoggle arrow icon

Pregnancy [1]

Condylomata acuminata in children

  • Transmission
    • Autoinoculation
      • Transmission of HPV from other cutaneous or mucosal sites of infection (e.g., transmission from the anogenital region to the hands)
      • Most common form in children
    • Heteroinoculation: transmission of HPV from close skin contact (e.g., bathing, diaper changing)
    • Sexual: transmission from sexual abuse [12]
    • Perinatal transmission (e.g., during vaginal delivery) or prenatal transmission (e.g., due to ascension of HPV into the uterus)
    • Fomite transmission (e.g., contaminated towels)
  • Diagnostics
  • Management
    • Watchful waiting: Most lesions resolve spontaneously within a few years. [13]
    • If warts persist or lesions become symptomatic (e.g., pruritus, bleeding, pain):
      • Topical agents (e.g., imiquimod, podophyllotoxin)
      • Surgical or laser therapy for extensive or large warts (≥ 1 cm)

Referencestoggle arrow icon

  1. HPV and Men - Fact Sheet. Updated: November 4, 2016. Accessed: January 3, 2017.
  2. Moscicki AB. Human papillomavirus disease and vaccines in adolescents.. Adolescent medicine: state of the art reviews. 2010; 21 (2): p.347-63, x-xi.
  3. Human Papillomavirus. Updated: August 5, 2015. Accessed: January 3, 2017.
  4. Darragh TM, Colgan TJ, Cox JT, et al. The Lower Anogenital Squamous Terminology Standardization Project for HPV-Associated Lesions: Background and Consensus Recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Arch Pathol Lab Med. 2012; 136 (10): p.1266-1297.doi: 10.5858/arpa.lgt200570 . | Open in Read by QxMD
  5. Other Sexually Transmitted Diseases. Updated: November 17, 2015. Accessed: January 3, 2017.
  6. Workowski KA, Bolan GA, Centers for Disease Control and Prevention.. Sexually transmitted diseases treatment guidelines, 2015.. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 2015; 64 (RR-03): p.1-137.
  7. Fox PA, Tung MY. Human papillomavirus: burden of illness and treatment cost considerations.. Am J Clin Dermatol. 2005; 6 (6): p.365-81.doi: 10.2165/00128071-200506060-00004 . | Open in Read by QxMD
  8. Human papillomavirus (HPV) and cervical cancer. Updated: June 1, 2016. Accessed: January 2, 2017.
  9. Sexually Transmitted Diseases Treatment Guidelines 2015. . Accessed: January 6, 2020.
  10. Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019; 68 (32): p.698-702.doi: 10.15585/mmwr.mm6832a3 . | Open in Read by QxMD
  11. Supplemental information and guidance for vaccination providers regarding use of 9-valent HPV. Updated: November 29, 2016. Accessed: April 18, 2023.
  12. Sinclair KA, Woods CR, Kirse DJ, Sinal SH. Anogenital and respiratory tract human papillomavirus infections among children: age, gender, and potential transmission through sexual abuse.. Pediatrics. 2005; 116 (4): p.815-25.doi: 10.1542/peds.2005-0652 . | Open in Read by QxMD
  13. Allen AL, Siegfried EC. The natural history of condyloma in children.. J Am Acad Dermatol. 1998; 39 (6): p.951-5.doi: 10.1016/s0190-9622(98)70268-3 . | Open in Read by QxMD

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