Brief overview
- Course and prognosis: No classical course of the disease, often unnoticed and healing without consequences, wart formation possible (especially skin warts, genital warts), very rarely cancer (such as cervical cancer, oral pharyngeal cancer, anal cancer)
- Treatment: Depending on the clinical picture, icing, laser therapy, electrocautery, medication, surgical procedures
- Causes and risk factors: Infection with human papillomavirus (HPV) primarily through direct skin or mucosal contact; risk factors: unprotected sexual intercourse, smoking, suppressed immune system, many births, other infections
- Symptoms: Depending on the clinical picture; e.g., in the case of genital warts, reddish, brownish or whitish papules in the genital and anal regions, possibly with a feeling of wetness and itching; in the case of cervical cancer, vaginal discharge and unexplained vaginal bleeding
- Examination and diagnosis: Physical examination, cell smear (Pap test), colposcopy (extended reflection of the vagina), HPV test, biopsy (analysis of a tissue sample)
- Prevention: safer sex (condoms), vaccination, hygiene, regular examination recommended for women by gynecologist
What is HPV?
HPV infection can lead to the development of various types of warts, but also cancer (for example, cervical cancer). Human papillomaviruses are divided into low-risk groups (including types 6, 11) and high-risk groups (including types 16, 18). Long-term infection with a high-risk HPV type increases the risk of developing cancer. In most cases, however, HPV infection heals without therapy or negative consequences.
HPV infection is treatable only in the case of genital warts (genital warts) or carcinomas (malignant tissue changes). For the pure infection with HPV there is no medication, so it often takes some time to get rid of the virus. Accordingly, an HPV infection is also contagious for a relatively long time.
During the acute and longer lasting (usually up to two years maximum) infection, it is possible to infect one’s sexual partners with HPV. Since a symptom-free HPV infection is not even noticed, the infection often occurs unknowingly.
How does HPV progress in men and women?
The human papillomavirus (HPV) does not distinguish between women and men. It is possible for both to become infected during unprotected sexual intercourse (including oral sex). The classic course of an HPV infection does not exist. It often goes unnoticed and heals without consequences. If HPV symptoms occur, spontaneous healing is also possible.
In general, most HPV infections heal within a few months. After two years, about 90 percent of all HPV infections are cured.
Rarely, after an incubation period of a few weeks to eight months after infection with HPV, genital warts (genital warts) develop in the genital (vagina, vulva, penis, scrotum) and/or anal area. Initially, small papules (nodules or vesicles) form, which sometimes spread over a large area. Only in a few patients do certain HPV viruses persist longer and even lead to cancer. Years or decades often pass before cancer develops due to HPV.
A healed HPV infection offers no protection against a renewed infection with the pathogens.
In most cases, HPV infections heal spontaneously, as the immune cells fight and kill the HPV viruses. Sometimes, however, existing diseases weaken the immune system and thus the natural fight against HPV. Therefore, these must be treated to defeat HPV as well.
In general, the choice of HPV therapy depends on the type and extent of HPV symptoms. Symptoms such as condylomas or skin warts are treated in different ways. The HPV viruses themselves are rarely completely eliminated. Therefore, relapses often occur.
If the doctor has tested a patient positive for HPV, it makes sense to also inform the sexual partner about this in order to avoid infecting other people if possible.
Icing (cryotherapy)
Electrocautery
The doctor uses electrocautery like icing for genital warts and skin warts. The tissue changed by HPV is destroyed by electric current. However, the HPV virus remains in the body and sometimes triggers new skin changes.
The electrocautery is also used after surgical wart removal: the doctor burns the directly adjacent skin layers and their vessels. This reduces the risk of recurrence, but there is a high probability that a scar will form.
Surgical procedures
It is possible to address an HPV symptom in surgery. This involves the use of various instruments. First, the affected area of the body is anesthetized locally. Then the growths are cut out with a sharp spoon (curettage), an electric loop (loop electrosurgical excisional procedure, LEEP) or surgical scissors (scissor punch) (excision).
However, if the patient is pregnant, they try to delay the surgery until after the birth. Depending on the stage of the cancer, the surgeon will extend the operation accordingly. For example, in the case of advanced cervical cancer, the entire uterus is usually removed (radical hysterectomy).
In some cancer patients, radiation therapy and/or chemotherapy is performed as an alternative or in addition to surgery.
Laser therapy
This option for treating HPV disease is also one of the surgical procedures. Laser (for example CO2 or Nd:YAG laser) is used for HPV warts of any kind. Under local anesthesia, the growths are cut out and vaporized. However, caution is advised: The HPV viruses spread easily due to the smoke development. Therefore, adequate protection by means of extractors and filters is particularly important.
Medication against HPV warts
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Drug |
User |
Notes |
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Podophyllotoxin-0.15% cream |
Patient |
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Imiquimod 5% cream |
Patient |
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Trichloroacetic acid |
Physician |
In principle, HPV infections are associated with a high risk of recurrence (relapse). Therefore, it is advisable to monitor the treated areas carefully and to visit the doctor at regular intervals.
Causes and risk factors
The human papillomaviruses (HPV) belong to the DNA viruses. Like the human genome, their genetic information is stored on a DNA strand. To reproduce, HPV viruses require human cells. Infection works like this:
HPV viruses introduce their genetic material into a human host cell (skin or mucous membrane cell) and force it to continuously produce new viruses. At some point, the host cell bursts (and dies in the process), releasing the many new viruses. They then in turn infect new human cells.
Transmission
Many HPV viruses are transmitted by mere skin contact. This is especially true for those pathogens that cause harmless skin warts (papillomas).
HPV types that infect the genital organs and cause genital warts or cervical cancer, for example, are mainly transmitted through sexual intercourse. Genital HPV infections are therefore classified as sexually transmitted diseases (STDs).
Infection with HPV is also possible through oral sex if the oral mucosa comes into contact with HPV-infected skin sites (such as the labia or penis).
In general, it is also possible to become infected with HPV in a committed partnership, i.e. during sexual intercourse with the same partner.
The same applies to physical contact when bathing together, although this is a much rarer route of infection. At least theoretically possible is also an HPV virus infection via infected objects such as sex toys, towels or the toilet.
Another possibility is the transmission of the pathogen from mother to child during birth, whereby benign tumors in the larynx area (laryngeal papilloma) rarely occur.
According to current knowledge, there is no risk of infection through breastfeeding, normal kissing or donating blood.
If genital warts are found in the genital-anus area of children, special attention is required. Here it is important that the doctor examines each individual case to rule out sexual abuse.
Risk factors
Probably the most significant risk factor for genital infection results from the mechanism of HPV transmission: frequent and especially unprotected sexual intercourse. Other risk factors for HPV infection include:
- First sexual contact before age 16: This risk factor is especially true for girls.
- Smoking: Cigarettes & Co. not only increase the risk of HPV infection, but also the risk that the cells will degenerate and develop into cancer cells.
- Inconsistent use of condoms: Condoms do not always prevent HPV infection 100 percent, but if they are used consistently during sexual contact, the risk of infection is reduced.
- Suppressed immune system: If the immune system is impaired in its function due to a disease (such as HIV) or due to medication (immune suppressants), the risk of HPV infection increases.
- Other genital infections: Chlamydia, genital herpes, and similar infections also appear to promote HPV transmission.
In addition, some factors increase the risk of HPV-infected cells becoming cancer cells. These include smoking, many pregnancies, HIV infection, and use of the contraceptive pill for five years or longer.
Consequential diseases
The secondary diseases that may result from an HPV infection depend on the type of virus. Most do not cause any symptoms at all or only cause harmless skin warts. Some HPV types specifically infect the genital mucosa. They are divided into groups according to how likely they are to cause cancer:
High-risk types (high-risk HPV) cause tissue changes (dysplasia, neoplasia) from which, in rare cases, a malignant tumor develops over a period of years. Cervical cancer (cervical carcinoma) is particularly common. However, HPV infection also increases the risk of other cancers such as penile cancer or laryngeal cancer. The two main high-risk HPV types are HPV 16 and 18, and other high-risk types are listed in the table below.
Some papillomaviruses such as HPV 26, 53, and 66 are more likely to be detected in precancerous lesions. Some authors refer to these as intermediate HPV (medium-high risk). The cancer risk for these HPV types is between that of the low- and high-risk types. HPV viruses 5 and 8, for example, are also classified as intermediate HPV. They are actually only really dangerous in two cases: in the case of immune deficiency and in the case of the rare hereditary skin disease epidermodysplasia verruciformis.
In the following table, the most common HPV types are classified according to risk classes:
| Classification Risk Class | HPV types |
| Low risk | 6, 11, 40, 42, 43, 44, 54, 61, 62, 70, 71, 72, 74, 81, 83, CP6108 |
| High risk | |
| Medium high risk | 5, 8, 26, 53, 66 |
The table of HPV types is not complete. It concerns here the HPV types, whose classification into the different risk groups is at present sufficiently supported by studies. However, there are other HPV types, some of which also lead to secondary diseases.
Genital warts (Condylomata acuminata)
Genital warts (pointed condylomas) are benign tissue growths in the genital area and at the anus. They are transmitted through unprotected sexual intercourse and the low-risk types HPV 6 and 11 are usually responsible, but sometimes other representatives of HPV are also responsible. Men and women are equally affected by genital warts.
From infection with the HPV virus to the appearance of the genital warts (incubation period) sometimes takes up to eight months. Condylomas are the most common benign tumors of the external genital and anal area. They usually heal spontaneously, but sometimes persist for months or years.
Condylomata plana
- Cervical intraepithelial neoplasia (CIN): on the cervix (= cervix)
- Vulvar intraepithelial neoplasia (VIN): on the vulva (= labia, clitoris and mons veneris)
- Vaginal intraepithelial neoplasia (VAIN): in the vagina (= vagina)
- Penile intraepithelial neoplasia (PIN): on the penis
- Perianal intraepithelial neoplasia (PAIN): in the anus region
- Anal intraepithelial neoplasia (AIN): in the anus (anus) region
If you want to know more about the development and treatment of condylomas, read the article Genital Warts.
Cancer of the cervix (cervical carcinoma).
When mucosal cells on the cervix (neck of the womb) are chronically infected with high-risk HPV types, there is a chance that they will degenerate over time and form a malignant tumor. However, this does not happen with every infection, but relatively rarely: According to statistics, less than one in 100 women infected with a high-risk HPV type develops cervical cancer – and this happens on average 15 years after HPV infection.
Read more about the development, symptoms, treatment and prognosis of cervical cancer in the text Cervical Cancer.
Other cancer diseases
In the case of cervical cancer, the connection with the HPV virus has been clearly proven. However, the development of cancer by HPV is also being investigated in other places. For example, HPV infection through oral sex may increase the risk of malignant growths in the throat (such as laryngeal cancer), but also in the mouth (lips). In addition, there are studies showing a link between HPV infection and lung cancer.
Some high-risk HPV types promote cancerous growths in the genital and anal areas, such as vaginal cancer, vulvar cancer, penile cancer, and anal cancer. However, these cancers are all much less common than cervical cancer.
A 2021 study showed that infection with high-risk HPV type 16 increases the likelihood of developing cancer of the tongue, palate, gums, and base of the oral cavity.
Skin warts
If an infection with HPV causes warts on the sole of the foot, these are usually plantar warts (verrucae plantares). If plantar warts occur in larger numbers in the form of wart fields, dermatologists refer to them as mosaic warts.
The flat warts that often occur in children are triggered by HPV 3 or 10. Their technical term is verrucae planae juveniles.
Warts in the mouth
Sometimes individual warts can be seen in the mouth with HPV infection. They are called oral papillomas.
If warts or wart-like structures appear in the mouth, it may be Heck disease (Heck’s disease or focal epithelial hyperplasia). These benign skin growths always occur in clusters and not individually. Their development is associated with HPV 13 or 32. Heck’s disease is rare among the European population, but is common in other populations, such as the indigenous peoples of Central and South America.
Epidermodysplasia verruciformis
Symptoms
The human immune system fights an infection with HPV viruses quite well in many cases, so that no or hardly any HPV symptoms occur. Generally, symptoms occur in men and women, for example, on the genital organs or in the mouth/throat area.
In the case of a latent HPV infection (one is infected but has no symptoms), the human papillomaviruses can only be detected in the laboratory. In the case of a subclinical HPV infection (without visible symptoms), it is only possible to visualize the virus-related skin/mucous membrane changes using special techniques.
In contrast, when HPV symptoms are visible to the naked eye, medical professionals refer to this as a clinical HPV infection. The signs HPV viruses cause depend on the type of virus and the particular disease.
Symptoms of genital warts (condylomata acuminata)
In women, such HPV signs are found mainly in the labia, at the posterior junction of the two labia majora (posterior commissure) and in the anal region. However, genital warts sometimes develop in the vagina and cervix. In men, these signs of infection with HPV affect the penis and anal region.
Genital warts hardly cause any discomfort. Sometimes, however, a feeling of wetness and itching, burning and bleeding after sexual intercourse are possible symptoms of genital warts caused by HPV. Pain occurs only occasionally.
In rare cases, genital warts that have existed for years develop into so-called Buschke-Löwenstein giant condylomas (Condylomata gigantea). These cauliflower-like growths displace and destroy the surrounding tissue. It is possible for the cells to degenerate and form cancerous cells (verrucous carcinoma).
Symptoms of condylomata plana
Symptoms of intraepithelial neoplasia
In many affected individuals, cell changes caused by HPV (intraepithelial neoplasia) do not cause any symptoms. This applies, for example, to cervical intraepithelial neoplasia (CIN, cell changes in the area of the cervix). In other cases, symptoms are sometimes more or less obvious. For example, intraepithelial neoplasia in the vulva (VIN) is sometimes accompanied by itching, burning and pain during sexual intercourse (dyspareunia) or remains asymptomatic.
Anal or perianal intraepithelial neoplasia (AIN and PAIN) causes itching in the anal area and discrete bleeding from the anus and pain during defecation. Penile cellular lesions (PIN) sometimes cause a velvety, irregular, shiny redness in the glans or foreskin area.
Symptoms of HPV-associated cancer
In advanced stages of cervical cancer, women often report pain in the lower back or pelvic area, during urination or bowel movements. Accumulation of fluid in the tissues (lymphatic congestion) in the legs also sometimes occurs.
Sometimes other cancers are also associated with HPV. Symptoms depend on the location of the tumor and the stage of the disease. In the case of penile cancer, for example, skin changes such as swelling or hardening of the glans or foreskin, easily bleeding skin on the penis and sometimes foul-smelling discharge occur. Vaginal cancer only becomes noticeable at an advanced stage with symptoms such as bloody discharge or vaginal bleeding (for example after sex).
Symptoms of skin warts
Skin warts are usually easy to detect. They usually do not cause any discomfort, apart from occasional itching, a feeling of pressure or tension. Warts on the sole of the foot often cause pain. Sometimes warts (like plantar warts) have small black spots. These are clotted blood from tiny skin capillaries.
Plantar warts on the soles of the feet are pressed inward like nails by body weight when walking or standing. This sometimes causes such pain that walking is very difficult.
Mosaic warts are about the size of a pinhead and white. They grow especially on the balls of the feet or under the toes. In some patients, they also cover the entire bottom of the foot. Because they are flatter than plantar warts, they usually do not cause pain when walking or standing.
Verrucae planae juveniles, which occur mainly in children, are flat, skin-colored warts. They form especially on the face and the backs of the hands. When children scratch them, they spread the HPV viruses in a dash-like pattern, so the warts are often also arranged in a dash-like pattern.
Symptoms of warts in the mouth
Oral papillomas caused by HPV infection are solitary, cauliflower-like warts in the mouth. They are found preferentially on the hard or soft palate or on the uvula.
In Heck’s disease, several round or oval papules appear on the oral mucosa. Children and adolescents are mainly affected.
Symptoms of epidermodysplasia verruciformis
Diagnosis and examination
In most cases, no HPV symptoms can be found in an infection. In most cases, the infection remains unnoticed. However, if the HPV viruses cause signs of disease, these are usually typical changes in the skin or mucous membrane.
However, some manifestations are so inconspicuous that it is only possible to make them visible by special procedures. The necessary examinations are usually performed by specialists, i.e. depending on the clinical picture, either dermatologists, gynecologists, urologists or ear, nose and throat specialists. A classic blood test is not performed for HPV diagnosis.
Medical history
First, the doctor asks the patient about any symptoms that may be consistent with HPV infection, for example:
- Where exactly are the complaints or skin changes?
- Is there genital itching or burning?
- Has there been any bleeding that cannot be explained?
The doctor also notes general risk factors such as smoking or medication. He will also ask about any known pre-existing conditions. These may weaken the immune system and thus favor an HPV infection.
Physical examination
The doctor usually examines the whole body. Most HPV symptoms, namely warts on the skin, are easily recognized. Further examinations are then usually not necessary. If a skin wart appears suspicious, the doctor removes it and sends it to a laboratory for further examination.
Changes in the female genital area are usually discovered during preventive examinations. The vagina is palpated and then examined with a speculum (“mirror”). Palpation is important because sometimes specula cover up deep-seated growths, which are rarely caused by HPV viruses.
HPV is sometimes also found in the anal area. Since tumors triggered by HPV sometimes extend into the anal canal, some physicians perform an endoscopy of the anal canal (proctoscopy).
Cell smear
For women 20 years of age and older, gynecologists regularly swab the cervix for early detection of cervical cancer. Using circular movements, the doctor first swabs the surface of the cervix with a type of brush. The second smear is taken from the cervical canal. The smears are then consolidated on a glass plate with the help of a high-percentage alcohol solution, and then stained and examined with the help of a microscope.
This is not a special HPV smear to detect the viruses, but an examination for suspicious changes in the cells resulting from HPV infection (or from other causes).
Read more about the different stages as a result of the Pap test here: Pap test.
Colposcopy
Colposcopy is to be understood as an extended reflection of the vagina. During this examination, the gynecologist also uses a so-called colposcope (colpo = vagina; skopie = observation), i.e. a kind of microscope. With a magnification of up to 40 times, the doctor can detect the smallest changes or bleeding on the cervix, cervix, vaginal walls and vulva.
In extended colposcopy, the doctor dabs two to three percent acetic acid onto the mucous membrane. This causes altered upper covering layers to swell and stand out whitish from the rest of the mucosa.
A further step is the so-called Schiller iodine test. The vaginal mucosa is dabbed with an iodine solution (four percent Lugol’s iodine solution). The healthy mucosa then turns brown-red due to the starch (glycogen) it contains. In contrast, cell layers that are altered by HPV, for example, remain unstained.
Biopsy
HPV test
This test is used to detect HPV infection and identify the type of virus. Its use on the cervix is best tested: the test result helps to diagnose the malignant tumor or its precursors. Much less suitable is the test for detecting HPV infection on other parts of the body.
The HPV test is available in different variants. For the early detection of cervical cancer, it is currently only recommended for women over the age of 30 together with the Pap test. If a conspicuous Pap test is already available at a younger age, a test for human papilloma viruses is usually also useful. It also helps to monitor the success of treatment for precancerous lesions on the cervix.
If you would like to know more about the procedure, significance and costs of this examination, please read the article HPV test.
Prevention
If you are HPV positive and wish to have a child, it is important that you contact your gynecologist about this.
In general, it makes sense to pay attention to thorough hygiene and to strengthen the immune system. To reduce the risk of infection with normal skin warts, it is also a good idea not to walk around barefoot in swimming pools, sauna facilities, public changing rooms and hotel rooms. If someone in the environment has warts, do not share a towel, washcloth, or socks (for warts on the feet) with that person, for example.
To prevent HPV infections in the genital and anal area, it is best to always use a condom, especially if you frequently change sexual partners. Safer sex does not offer 100 percent protection against HPV, because the HPV virus is sometimes transmitted by smear infection. However, condoms reduce the risk of infection.
It is considered certain that the risk of HPV is lower in men who are circumcised than in non-circumcised men.
A very good way to prevent is HPV vaccination for young men and women.
HPV vaccination
It is not yet known exactly how long the vaccination protection lasts. Study results indicate that vaccinated girls/women are still effectively protected against HPV infection twelve years after vaccination. However, it is not yet possible to say whether the vaccination protection will need to be refreshed at some point.
You can read more about the implementation, effectiveness and costs of this vaccination against HPV in the article HPV vaccination.
Self-help groups
- Cancer Information Service – Cancer support groups and patient associations: www.krebsinformationsdienst.de/wegweiser/adressen/selbsthilfe.php
