HIV-Associated Condyloma Acuminatum

Of HIV-infected men, 90% have anal human papilloma virus (HPV) infection.
Of HIV-infected men, 73% with HPV have multiple subtypes.
The most common subtype is the oncogenic subtype HPV 16.
The increasing rate of anal cancer that has been seen in the United States over the last three decades is due to the increasing rate of HIV infection with HPV coinfection.
More than half of HIV-infected men with anal condyloma will develop anal intraepithelial neoplasia (AIN). HIV-infected patients with AIN are more likely to develop invasive cancer than nonimmunocompromised persons.
There have been fewer studies on HIV-infected women, but it is known that 49% of HIV-infected women have latent cervical HPV infection, with high oncogenic risk types, persistent infection, and an increased risk of cervical dysplasia and cancer.

Clinical Manifestations ⬆ ⬇

Four morphologic types of anogenital condyloma acuminata have been described.
The verrucous type (Fig. 33.12) is associated with coinfection with at least four subtypes, including HPV 16. These patients are at high risk for the development of high-grade AIN.
In the leukoplakic type, a majority of patients have HPV 16, but with fewer numbers of coinfecting subtypes, and a lower risk of high-grade AIN.
The other types are erythroplakic and bowenoid.
Lesions may occur anywhere on the anogenital skin.
Lesions may also occur on skin at the angles of the mouth, or on the intraoral, vaginal, or rectal mucous membranes. Rectal condylomata may be a cause of recurrent anal condyloma, and such patients should be referred for evaluation by a rectal surgeon.

Diagnosis ⬆

Diagnosis is made on clinical grounds.
Lesions that appear to be atypical (e.g., with ulcerations) that fail to respond to several treatments, or that grow in spite of treatment should be biopsied to evaluate for malignant degeneration.

Differential Diagnosis

Squamous Cell Carcinoma

This is the most important diagnosis to exclude. This can only be done by skin biopsy of atypical lesions, or of an atypical area within a lesion.

Inflammatory Conditions

Atypical, nonverrucous lesions may be confused with an inflammatory dermatosis such as perianal psoriasis, lichen planus, or lichen simplex chronicus. For a detailed discussion of the differential diagnosis of condyloma acuminatum, please refer to Chapter 28: Sexually Transmitted Diseases.

Management

The treatment of condyloma acuminata in HIV-infected patients is the same as that in HIV-negative patients, although it is more difficult to eradicate because intact cellular immunity is necessary to clear the skin of viral lesions.
Some experts advocate anal cytology smears in HIV-infected patients with anogenital HPV. This is not currently recommended by the Centers for Disease Control (CDC) because rate of progression of AIN to invasive cancer, the reliability of the screening method, and the safety and the effectiveness of treatment for AIN are all unknown.

Points to Remember

HIV-infected patients appear to have an increased susceptibility to malignant degeneration when they are infected with oncogenic subtypes of human papillomavirus, with the development of anal cancers in homosexual men and cervical cancer in women.
Condylomata that appear to be clinically atypical, do not respond to treatment, or enlarge in spite of treatment should be biopsied to evaluate for malignant degeneration.