Genital warts medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Genital warts may disappear without treatment, but sometimes eventually develop a fleshy, small raised growth. There is no way to predict whether they will grow or disappear.

Medical Treatment

• The primary reason for treating genital warts is the amelioration of symptoms (including relieving cosmetic concerns) and ultimately, removal of the warts. In most patients, treatment can induce wart-free periods.

• If left untreated, visible genital warts can resolve on their own, remain unchanged, or increase in size or number. Available therapies for genital warts likely reduce, but probably do not eradicate, HPV infectivity.

• Whether the reduction in HPV viral DNA resulting from treatment reduces future transmission remains unclear. No evidence indicates that the presence of genital warts or their treatment is associated with the development of cervical cancer.

• Factors that influence selection of treatment include wart size, wart number, anatomic site of the wart, wart morphology, patient preference, cost of treatment, convenience, adverse effects, and provider experience.

• The treatment modality should be changed if a patient has not improved substantially after a complete course of treatment or if side effects are severe. Most genital warts respond within 3 months of therapy.

Genital Warts Treatment Preferred Regimen External genital warts(Patient applied) ▸ Podofilox (0.5% solution or gel): apply 2x/day x 3 days, 4th day no therapy, repeat cycle 4x OR ▸ Imiquimod 5% cream: apply once daily at bedtime 3x/week x up to 16 weeks OR ▸ Sinecatechins 15% ointment External genital warts(Provider administered) ▸ Cryotherapy with liquid nitrogen; repeat q1-2 weeks OR ▸ Podophyllin resin 10-25% in tincture of benzoin. Repeat weekly as needed OR ▸ Trichloroacetic acid(TCA): repeat weekly as needed OR ▸ Surgical removal Vaginal warts ▸ Cryotherapywith liquid nitrogen OR ▸ Trichloroacetic acid Urethral warts ▸ Cryotherapy with liquid nitrogen OR ▸ Podophyllin resin 10-25% in tincture of benzoin. Anal warts ▸ Cryotherapy with liquid nitrogen OR ▸ Trichloroacetic acid OR ▸ surgical removal. Advise anoscopy to look for rectal warts Skin Papillomas ▸ Topical α-lactalbumin. Oleic acid (from human milk) applied 1x/day for 3 weeks

• Imiquimod (Aldara) a topical immune response cream, applied to the affected area
• A 20% podophyllin anti-mitotic solution, applied to the affected area and later washed off
• A 0.5% podofilox solution, applied to the affected area but not to be washed off
• A 5% 5-fluorouracil (5-FU) cream
• Trichloroacetic acid (TCA)
• Pulsed dye laser
• Liquid nitrogen cryosurgery
• Electric or laser cauterization
• Condylox
• Sinecatechins (Veregen) also Polyphenon E: ointment made of several green-tea-extracted catechines and other components. Mode of action is undetermined. It is FDA-approved but very expensive

• Podophyllin and podofilox should not be used during pregnancy, as they are absorbed by the skin and may cause birth defects in the fetus. 5-fluorouracil cream should not be used while trying to become pregnant or if there is a possibility of pregnancy.

Some doctors inject the antiviral drug interferon-alpha directly into the warts, to treat warts that have returned after removal by traditional means. The drug is expensive, and does not reduce the rate that the warts return.

• In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment.

• Patients should be warned that persistent hypopigmentation or hyperpigmentation occurs commonly with ablative modalities and has also been described with immune modulating therapies (imiquimod).