How can I differentiate between genital warts and other similar lesions during a clinical examination?

During clinical examination, genital warts (condylomata acuminata) can be differentiated from other similar lesions by their characteristic appearance and clinical context. Genital warts typically present as soft, flesh-coloured or grey, papillomatous, cauliflower-like growths that may be keratinised or non-keratinised and are often multiple. They are usually found on the external genitalia, perianal area, or adjacent skin and mucosa. The lesions are generally painless but may cause discomfort or pruritus. The diagnosis is primarily clinical, based on the typical morphology and distribution of the lesions ¹.

Other lesions that may mimic genital warts include molluscum contagiosum, seborrhoeic keratoses, pearly penile papules, angiokeratomas, and benign papillomas. Molluscum contagiosum presents as small, firm, dome-shaped, umbilicated papules that are usually smooth and waxy, differing from the rough, papillomatous surface of warts ¹,². Pearly penile papules are small, dome-shaped, and symmetrically arranged around the corona of the glans penis and are benign anatomical variants, not infectious lesions ¹.

Histories of lesion onset, sexual activity, and risk factors for human papillomavirus (HPV) infection support the clinical diagnosis. Genital warts have a long latency period (3 weeks to 8 months), so recent partner infidelity is not necessarily implied ¹. In children, genital warts may raise concerns about sexual abuse, but non-sexual transmission and autoinoculation are also possible; referral for safeguarding assessment is advised if abuse is suspected ²,³.

Additional clinical clues include lesion texture: soft, non-keratinised warts respond well to topical treatments like podophyllotoxin, whereas keratinised lesions may require ablative methods, indicating their more hyperkeratotic nature ¹. Differential diagnosis should also consider rare conditions such as genital benign chronic pemphigus (Hailey-Hailey disease), which can mimic condylomas but usually has a different clinical course and histopathology (Langenberg et al., 1992). Papillomas in the genital area may require histological examination to distinguish from warts, especially if atypical features are present (Heinrich and Heinrich, 1993).

In summary, differentiation relies on careful inspection of lesion morphology, distribution, and patient history, supported by awareness of common mimics and consideration of patient age and risk factors. Referral to sexual health specialists is recommended if diagnosis is uncertain or if there are concerns about co-existing sexually transmitted infections or safeguarding ¹[(Imbernón-Moya and Ballesteros, 2017)].