Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Possible anogenital malignancy or obstructive disease
Ulceration, induration, fixation, bleeding, rapid growth, diagnostic uncertainty, immunosuppression or lesions obstructing the urethra, vagina or anus require prompt specialist assessment.
Action: Document the lesion carefully, avoid repeated blind destruction, arrange biopsy or urgent anogenital specialist review, and address pain, bleeding, urinary or bowel compromise.
Synopsis
Recognise typical anogenital warts, distinguish atypical or malignant lesions, choose patient-applied or clinician-applied treatment, and connect HPV vaccination with site-specific cancer prevention.
Typical external anogenital warts are soft papillomatous, filiform or flat-topped papules and are usually diagnosed by inspection.
Routine HPV typing does not confirm that a visible lesion is a wart, choose treatment or reliably predict its future behaviour.
Biopsy atypical, pigmented, indurated, ulcerated, bleeding or treatment-resistant lesions, especially with immunosuppression.
Key red flags
A pigmented, indurated, fixed, ulcerated or spontaneously bleeding lesion may represent intraepithelial neoplasia or invasive cancer rather than a simple wart.
Failure after an adequate, correctly used treatment course requires diagnostic review; repeating destructive therapy indefinitely can delay biopsy.
Extensive, unusually large or rapidly recurrent lesions in an immunosuppressed person need HIV assessment and specialist management.
Urethral, vaginal, cervical or intra-anal lesions may not be fully visible and can require anoscopy, colposcopy, urology or gynaecology expertise.
Anogenital lesions in a child require a careful paediatric and safeguarding assessment that does not infer sexual transmission from appearance alone.
Atypical lesion
Pigmentation, ulceration, induration, fixation or bleeding is not a routine wart phenotype and prompts biopsy.
Internal disease
Symptoms such as bleeding, discharge, altered urine stream or anal discomfort can indicate lesions beyond external inspection.
Investigation priorities
01
Careful anogenital examinationFirst step
Define morphology, distribution and whether lesions extend into an internal site.
Management branches
Worked caseClassify before treating
An adult presents with new external anogenital papules and requests immediate removal.
Inspect all reported sites with consent and identify whether morphology is typical or contains biopsy features.
Explain that diagnosis is usually clinical, HPV typing is not useful for wart treatment, and latency prevents reliable dating of acquisition.
Key medicines
Podophyllotoxin for suitable external wartsApply the licensed preparation to visible suitable external lesions exactly according to its product cycle and maximum treated area.Avoid in pregnancy, internal sites and uncertain lesions; protect normal skin and stop for severe ulceration or systemic symptoms.
Imiquimod for suitable external wartsApply the licensed cream on its formulation-specific schedule, wash off after the specified contact period, and continue only to its maximum course.No self-applied topical agent is licensed during pregnancy or breastfeeding. Do not routinely use imiquimod when safe ablative options are available; BASHH lists cryotherapy, laser, electrosurgery, excision and TCAA as options that may be used safely in pregnant or breastfeeding adults.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 13 Sept 2026; clinical approval remains outstanding.