Sandbox mona

• 1.Preferred regimen for External Anogenital Warts (i.e., penis, groin, scrotum, vulva, perineum, external anus, and perianus)

• 1.1Patient-Applied::Imiquimod 3.75% or 5% cream ORPodofilox 0.5% solution or gel OR Sinecatechins 15% ointment
• 1.2Provider-Administered:Cryotherapy with liquid nitrogen or cryoprobe OR Surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser,or electrosurgery 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

• 2.1 Urethral Meatus Warts
• Regimens :Cryotherapy with liquid nitrogen OR Surgical removal
• 2.2Vaginal Warts
• Regimens:Cryotherapy with liquid nitrogen. OR Surgical removal 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
• Regimen: Cryotherapy with liquid nitrogen OR Surgical removal 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
• Regimens :Cryotherapy with liquid nitrogen OR Surgical removalOR TCA or BCA 80%–90% solution
• Note:Management of intra-anal warts should include consultation with a specialist.

• 3. Specific considerations

• 3.1. 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.

• 3.2 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.

• 3.3 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).

• 3.4 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

• 3.5 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.

• Granuloma Inguinale (Donovanosis)

• Preferred regimen:Azithromycin 1 g PO once per week OR 500 mg PO qd for 3 weeks
• Alternative regimen:Doxycycline 100 mg PO bid for 3 weeks ORCiprofloxacin 750 mg PO bid for 3 weeks ORErythromycin base 500 mg PO qid for 3 weeks OR Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) PO bid for 3 weeks
• Note:continue treatment until all lesions have completely healed

• Pregnant and lactating women

• Preferred regimen:treated with a macrolide regimen (erythromycin or azithromycin). The addition of an aminoglycoside (gentamicin 1 mg/kg IV every 8 hours) can be considered if improvement is not evident within the first few days of therapy.

• HIV Infection

• Preferred regimen:Azithromycin 1 g PO once per week OR 500 mg PO qd for 3 weeks and until all lesions have completely healed
• Alternative regimen:Doxycycline 100 mg PO bid for 3 weeks ORCiprofloxacin 750 mg PO bid for 3 weeks OR Erythromycin base 500 mg PO qid for 3 weeks OR Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) PO bid for 3 weeks
• Note:The addition of an aminoglycoside (gentamicin 1 mg/kg IV every 8 hours) can be considered if improvement is not evident within the first few days of therapy.