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==Overview==
==Overview==
Some warts will disappear without treatment, although it can sometimes take a couple of years. Treated or not, warts that go away often reappear. All warts can spread from one part of the body to another. Unsightly or painful warts can be treated. Warts around and under the nails are much more difficult to cure than warts in other places.
Medical therapies for human papillomavirus infection include either [[imiquimod]], [[sinecatechins]], or [[podofilox]].<ref name=CDC>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
 
==Medical Therapy==
==Treatment==
===Medical Therapy===
===Medical Therapy===
Treatments that may be prescribed by a medical professional include:
*'''Human papillomavirus therapy'''<ref name=CDC>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
*[[Treatment of warts by keratolysis|Keratolysis]], removal of dead surface skin cells usually using [[salicylic acid]], blistering agents, immune system modifiers ("immunomodulators"), or [[formaldehyde]].
:* ''' Anogenital warts'''<ref name=CDC>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
*[[Cryosurgery]], which involves freezing the wart (generally with [[liquid nitrogen]]), after which the wart and surrounding dead skin falls off by itself.
::* 1.'''Preferred regimen for External Anogenital Warts'''(i.e., penis, groin, scrotum, vulva, perineum, external anus, and perianus)
*Surgical [[curettage]] of the wart.
:::* 1.1 '''Patient-applied''': [[Imiquimod]] 3.75% or 5% cream {{or}} [[Podofilox]] 0.5% solution or gel {{or}} [[Sinecatechins]] 15% ointment
*[[Laser]] treatment.
:::* 1.2 '''Provider-administered''': Cryotherapy with liquid nitrogen or cryoprobe {{or}} [[Trichloroacetic acid]] (TCA) {{or}} Bichloroacetic acid (BCA) 80%-90% solution
*[[Imiquimod]], a topical cream that helps the body's immune system fight the wart virus by encouraging [[interferon]] production.
:::* Note (1): Many persons with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.
*[[Candida (genus)|Candida]] injections at the site of the wart, which also stimulate the body's immune system.<ref>[http://archderm.ama-assn.org/cgi/content/short/141/5/589 Horn TD, Johnson SM, Helm RM, Roberson PK (2005) Intralesional immunotherapy of warts with mumps, Candida, and Trichophyton skin test antigens. ''Arch Dermatol'' 141: 589–94]</ref>
:::* Note (2): Might weaken condoms and vaginal diaphragms.
*[[Cantharidin]], a chemical found naturally in many members of the beetle family [[Meloidae]] which causes dermal blistering.
::* 2.'''Alternative regimens for external genital warts'''<ref name=CDC>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
:::* 2.1 '''Urethral meatus warts'''
::::* Preferred regimen: Cryotherapy with liquid nitrogen
:::* 2.2 '''Vaginal warts'''
::::* Preferred regimen: Cryotherapy with liquid nitrogen  {{or}}  TCA {{or}} BCA 80%–90% solution
::::* Note: The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation
:::* 2.3 '''Cervical warts'''
::::* Preferred regimen: Cryotherapy with liquid nitrogen {{or}} TCA {{or}} BCA 80%–90% solution
::::* Note: Management of cervical warts should include consultation with a specialist.For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated.
:::* 2.4 '''Intra-anal warts'''
::::* Preferred regimen: Cryotherapy with liquid nitrogen {{or}} TCA {{or}} BCA 80%–90% solution
::::* Note: Management of intra-anal warts should include consultation with a specialist.


The wart often regrows after the skin has healed.
::* 3. '''Specific considerations'''<ref name=CDC>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>


One review of 52 clinical trials of various cutaneous wart treatments concluded that topical treatments containing salicylic acid were the best supported, with an average cure rate of 75% observed with salicylic acid compared with 48% for placebo in six placebo-controlled trials including a total of 376 participants.<ref name="Cochrane">[http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/rel0001/CD001781/pdf_fs.html Gibbs S, Harvey I, Sterling JC, Stark R. (2003) Local treatments for cutaneous warts. ''Cochrane Database of Systematic Reviews'' Issue 3]</ref> The reviewers also concluded that there was little evidence of a significant benefit of cryotherapy over [[placebo]] or no treatment.<ref name="Cochrane"/>
:::* 3.1 '''Management of sex partners'''
::::* Persons should inform current partner(s) about having genital warts because the types of HPV that cause warts can be passed on to partners. Partners should receive counseling messages that partners might already have HPV despite no visible signs of warts, so HPV testing of sex partners of persons with genital warts is not recommended.


====Over-the-counter====
:::* 3.2 '''Pregnancy'''
There are several [[over-the-counter drug|over-the-counter]] options. The most common ones involve [[salicylic acid]].  These products are readily available at [[drugstore]]s and [[supermarket]]s. There are typically two types of products: adhesive pads treated with salicylic acid or a bottle of concentrated salicylic acid. Removing a wart with salicylic acid requires a strict regimen of cleaning the area, applying the acid, and removing the dead skin with a [[pumice]] stone or [[emery board]]. It may take up to 12 weeks to remove a wart.
::::* [[Podofilox]] (podophyllotoxin), [[Podophyllin]], and [[Sinecatechins]] should not be used during pregnancy. Imiquimod appears to pose low risk but should be avoided until more data are available.
::::* Cesarean delivery is indicated for women with anogenital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding.  
::::* Pregnant women with anogenital warts should be counseled concerning the low risk for warts on the larynx of their infants or children (recurrent respiratory papillomatosis).


Another over-the-counter product that can aid in wart removal is [[silver nitrate]] in the form of a [[caustic pencil]], which is also available at drug stores. This method generally takes three to six daily treatments to be effective. The instructions must be followed to minimize staining of skin and clothing.
:::* 3.3 '''HIV infection'''
::::* Data do not support altered approaches to treatment for persons with HIV infection.
::::* Squamous cell carcinomas arising in or resembling anogenital warts might occur more frequently among immunosuppressed persons, therefore requiring biopsy for confirmation of diagnosis for suspicious cases


Over-the-counter cryosurgery kits are also available, however they can often cost three times as much as the previously named products.
:::* 3.4 '''High-grade squamous intraepithelial lesions'''
::::* Biopsy of an atypical wart might reveal HSIL or cancer of the anogenital tract. In this instance, referral to a specialist for treatment is recommended.


Like prescription treatments, over-the-counter treatments usually require multiple applications and are only necessary if the warts are problematic. Additionally, these treatments are capable of destroying healthy skin as well as warts, so caution must be exercised by those attempting them without medical supervision.
===Follow-up===
* Most anogenital warts respond within 3 months of therapy.
*Factors that might affect response to therapy include immunosuppression and treatment compliance.
*In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment.
*A new treatment modality should be selected when no substantial improvement is observed after a complete course of treatment or in the event of severe side effects; treatment response and therapy-associated side effects should be evaluated throughout the course of therapy.
----


====Household Remedies====
==References==
* [[Duct tape occlusion therapy]] involves placing a piece of [[duct tape]] (or medical tape) over the affected area for a week at a time.  The procedure is otherwise identical to that of using salicylic acid adhesive pads.
* One study by ''Focht et al.'' found that the duct tape method was 85% effective, compared to a 60% success rate in the study's cryotherapy group.<ref>[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12361440&query_hl=3&itool=pubmed_docsum Focht DR III, Spicer C, Fairchok MP (2002) The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris (the common wart). ''Archives of Pediatrics & Adolescent Medicine'' 156(10): 971-4] (reviewed in [http://www.aafp.org/afp/20030201/tips/8.html Miller KE (2003) Duct tape more effective than cryotherapy for warts. ''American Family Physician'' 67(3)] & [http://www.jyi.org/volumes/volume7/issue5/features/demichele.html DeMichele J (2003) A new medical breakthrough: wart to do when verruca vulgaris attacks. ''Journal of Young Investigators'' 7(5)])</ref>
* Another study by ''Wenner and coworkers'', however, found no statistically significant effect in a double-blind, randomized and controlled clinical trial in 90 adults when duct tape was compared to mole skin.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17372095&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Wenner et al. Duct tape for the treatment of common warts in adults: a double-blind randomized controlled trial. Arch Dermatol. 2007 Mar;143(3):309-13.]</ref>
* There was no statistically significant difference for resolution of the target wart between patients treated with moleskin versus patients treated with duct tape. Eight of 39 patients [21%] in the treatment group vs 9 of 41 patients in the control group [22%] had complete resolution of the target wart. Fewer of the patients achieving resolution of their wart in the moleskin group had recurrence of their wart. Of the patients who had complete resolution, 6 (75%) in the treatment group and 3 (33%) in the control group had recurrence of the target wart by the sixth month.  "Whether or not the standard type of duct tape is effective is up in the air," said co-author Dr. Rachel Wenner of the University of Minnesota, who started the new study as a medical student. "Theoretically, the rubber adhesive could somehow stimulate the immune system or irritate the skin in a different manner."<ref>[http://newsmax.com/archives/articles/2007/3/20/161113.shtml Study Casts Doubt on Duct Tape Wart Cure]. [[March 21]], [[2007]].</ref>
* Fig latex, the sap from a fig tree, is also a common treatment for warts. Studies on cows comparing treatment with fig latex to salicylic acid showed that fig latex worked equally well.
* An Iranian study compared fig latex treatment on humans to cryotherapy and found the fig latex to be only slightly less effective, but with the benefit of fewer side effects.
* Tempra paint serves as a successful treatment as well. Dabbed onto the surface of a wart and allowed to dry completely, it will noticably reduce the size of the wart over a period of days. Removal of the wart can take a week or more. Children who frequently fingerpaint with Tempra show it to be successful as a remedy. Caution and close observation is advised however, as infection and permanent scarring can occur.
* Other household remedies include the application of common household items, such as a bruised garlic (held in place with a bandage or duct tape), banana skin, vinegar <ref>{{cite web|url=http://www.cidervinegar.org/2007/07/apple-cider-vinegar-for-warts_02.html|title=Apple Cider Vinegar for Warts}}</ref>, hot water and washing liquid, aerosol sprays or compressed air, [[Thuja occidentalis]], [[tea tree oil]] and other natural oils, unskinned potatoes, potato or cauliflower or tomato juice, salt, or [[vegemite]] to the affected area.
* [[Milkweed]], [[dandelion]], and [[poison ivy]] sap have also been used. Accounts vary in regards to how long these remedies must be applied with each session and how long they take to work.
 
Without controlled studies for most household remedies, it is difficult to know whether the warts disappear because the remedies work, or if they disappear due to the individual's own immune system response to the virus (possibly augmented by a [[placebo effect]]).  The success of [[hypnosis]] in curing warts<ref>[http://www.internethealthlibrary.com/Health-problems/Warts%20-%20researchAltTherapies.htm Alternative & Complementary Therapies: Hypnotherapy & Warts]</ref> at least suggests that the condition may be cured by belief in a remedy, the placebo effect or other psychological means. 
 
Some household remedies are potentially dangerous.  These include attempts to cut or burn away the warts.  [[Incense]] is sometimes used in Asian countries to burn warts.  These methods are very [[Pain and nociception|painful]], and can lead to [[infection]] and/or permanent [[scar]]ring.


==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Disease]]


[[Category:Viruses]]
[[Category:Viral diseases]]
[[Category:Dermatology]]
[[Category:Gynecology]]
[[Category:Infectious disease]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Primary care]]


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Latest revision as of 19:10, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]

Overview

Medical therapies for human papillomavirus infection include either imiquimod, sinecatechins, or podofilox.[1]

Medical Therapy

Medical Therapy

  • Human papillomavirus therapy[1]
  • Anogenital warts[1]
  • 1.Preferred regimen for External Anogenital Warts(i.e., penis, groin, scrotum, vulva, perineum, external anus, and perianus)
  • 1.1 Patient-applied: Imiquimod 3.75% or 5% cream OR Podofilox 0.5% solution or gel OR Sinecatechins 15% ointment
  • 1.2 Provider-administered: Cryotherapy with liquid nitrogen or cryoprobe OR Trichloroacetic acid (TCA) OR Bichloroacetic acid (BCA) 80%-90% solution
  • Note (1): Many persons with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.
  • Note (2): Might weaken condoms and vaginal diaphragms.
  • 2.Alternative regimens for external genital warts[1]
  • 2.1 Urethral meatus warts
  • Preferred regimen: Cryotherapy with liquid nitrogen
  • 2.2 Vaginal warts
  • Preferred regimen: Cryotherapy with liquid nitrogen OR TCA OR BCA 80%–90% solution
  • Note: The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation
  • 2.3 Cervical warts
  • Preferred regimen: Cryotherapy with liquid nitrogen OR TCA OR BCA 80%–90% solution
  • Note: Management of cervical warts should include consultation with a specialist.For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated.
  • 2.4 Intra-anal warts
  • Preferred regimen: Cryotherapy with liquid nitrogen OR TCA OR BCA 80%–90% solution
  • Note: Management of intra-anal warts should include consultation with a specialist.
  • 3. Specific considerations[1]
  • 3.1 Management of sex partners
  • Persons should inform current partner(s) about having genital warts because the types of HPV that cause warts can be passed on to partners. Partners should receive counseling messages that partners might already have HPV despite no visible signs of warts, so HPV testing of sex partners of persons with genital warts is not recommended.
  • 3.2 Pregnancy
  • Podofilox (podophyllotoxin), Podophyllin, and Sinecatechins should not be used during pregnancy. Imiquimod appears to pose low risk but should be avoided until more data are available.
  • Cesarean delivery is indicated for women with anogenital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding.
  • Pregnant women with anogenital warts should be counseled concerning the low risk for warts on the larynx of their infants or children (recurrent respiratory papillomatosis).
  • 3.3 HIV infection
  • Data do not support altered approaches to treatment for persons with HIV infection.
  • Squamous cell carcinomas arising in or resembling anogenital warts might occur more frequently among immunosuppressed persons, therefore requiring biopsy for confirmation of diagnosis for suspicious cases
  • 3.4 High-grade squamous intraepithelial lesions
  • Biopsy of an atypical wart might reveal HSIL or cancer of the anogenital tract. In this instance, referral to a specialist for treatment is recommended.

Follow-up

  • Most anogenital warts respond within 3 months of therapy.
  • Factors that might affect response to therapy include immunosuppression and treatment compliance.
  • In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment.
  • A new treatment modality should be selected when no substantial improvement is observed after a complete course of treatment or in the event of severe side effects; treatment response and therapy-associated side effects should be evaluated throughout the course of therapy.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.

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