MKSAP Quiz: Slow-growing genital lesions

A 34-year-old man is evaluated for several slow-growing, wart-like penile lesions that have progressively enlarged over 3 years. Repeated topical cryotherapy and topical imiquimod have yielded no improvement. The patient has HIV infection and is taking tenofovir, emtricitabine, and efavirenz. There are no other skin findings, and vital signs and the remainder of the physical examination are normal. After obtaining laboratory studies, what is the most appropriate management?

A 34-year-old man is evaluated for several slow-growing lesions on his penis. He first noticed the wart-like growths 3 years ago, and they have progressively enlarged. He was treated with topical cryotherapy six times and topical imiquimod over the past year without improvement; the lesions have continued to enlarge. Medical history is significant for HIV infection. Medications are tenofovir, emtricitabine, and efavirenz.

On physical examination, vital signs are normal. Multiple red to brown verrucous papules with underlying induration and focal erosions are present on the penile shaft.

There is no lymphadenopathy. There are no other skin findings, and the remainder of the physical examination is normal.

Laboratory studies are significant for a CD4 cell count of 875/μL (0.875 × 109/L) and an undetectable viral load.

Which of the following is the most appropriate management?

A. Biopsy
B. Cryotherapy
C. Human papillomavirus (HPV) vaccination
D. Topical triamcinolone cream

MKSAP Answer and Critique

The correct answer is A. Biopsy. This item is available to MKSAP 17 subscribers as item 1 in the Dermatology section. More information on MKSAP 17 is available online.

This patient has condylomata acuminata, and his lesions should be biopsied. This is especially important in a patient with underlying HIV infection. These lesions have been refractory to therapy, and the incidence is continuing to grow. Condyloma acuminatum is a form of human papillomavirus (HPV) infection in the genital area, most often secondary to HPV 6 and HPV 11. Therapy for condylomata acuminata includes destructive techniques such as cryotherapy, cantharidin, podophyllin, laser therapy, and topical application of salicylic acid. Immune modulators such as imiquimod also can be used. When these lesions are recalcitrant to therapy or large and atypical in appearance, biopsy is essential to establish the diagnosis and rule out verrucous carcinoma or squamous cell carcinoma.

Although use of cryotherapy for condylomata acuminata and other verruca vulgaris is standard care, repeat cryotherapy is not appropriate in this setting since the lesion has been previously treated multiple times without improvement and with worsening.

HPV vaccination is currently recommended for routine vaccination in males and females at 11 to 12 years of age, with catch-up vaccination up to age 21 years in men and up to age 26 years in women and men who have sex with men or are immunocompromised or have HIV infection.

However, its use outside of these risk groups, and particularly in those who already have the infection, is unknown at this time. This vaccine is used to help prevent cervical and anal cancer, and whether the vaccine prevents development of condylomata is not known yet. The quadrivalent vaccine against four types of HPV is currently recommended for men and provides additional protection; a bivalent vaccine also is available.

Topical triamcinolone can be effective in the treatment of dermatitis and multiple inflammatory disorders but does not have a role in the treatment of condylomata or potential cancers.

Key Point

  • Condylomata acuminata that is recalcitrant to therapy should be biopsied to rule out premalignant or malignant transformation of lesions.