eMedicine Specialties > Dermatology > Viral Infections
Warts, Genital: Treatment & Medication
Updated: Oct 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Treatment is aimed at destruction of the warty growths rather than elimination of the virus.
- Subclinical infection probably is lifelong, and no cure is available.
- Most partners are likely to be subclinically infected with human papillomavirus (HPV), even if they do not have exophytic lesions.
- Use of condoms may reduce transmission of the virus to uninfected partners.
- Standard therapies for genital warts can remove most warts; however, no ideal treatment is available for all warts and all patients.11
- Caustics/acids - 80-90% bichloracetic acid (BCA) or trichloroacetic acid (TCA)
- Podophyllin resin - 10-25% or 0.5% podofilox solution or gel (Condylox)
- Imiquimod 5% cream (Aldara) - 3 times per week, up to 4 months (A recent article reported that the optimal duration of use for women's genital warts may be 1 month.)12
- Interferon, intramuscular or intralesional injection - 3 million units, 3 times per week for 3 weeks
- A vaccine against HPV types 6, 11, 16, and 18 (Gardasil, Merck) was approved in June 2006. It is recommended for girls and women aged 9-26 years and is given in a series of 3 shots (day 1, month 2, month 6). The US Food and Drug Administration (FDA) also approved it for boys and men aged 9-26 years. Another vaccine against HPV types 16 and 18 (Cervarix, GlaxoSmithKline) has just been approved for girls and women aged 10-25 years.
Surgical Care
- Cryosurgery is very effective for treating multiple, small, genital warts.
- Warts on the shaft of the penis and vulva respond very well to cryotherapy.
- Cryotherapy of the rectum is painful and less successful.
- Cryotherapy is effective and safe for the mother and fetus when used during the second and third trimesters of pregnancy.
- Electrosurgery is quite effective for a limited number of lesions on the shaft of the penis.
- Large, unresponsive lesions around the rectum or vulva can be treated with scissor excision of the bulk of the mass followed by electrocautery of the remaining tissue down to the skin surface.
- Loop electrocautery excisional procedure (LEEP) after colposcopic biopsy has become a standard procedure for cervical lesions particularly for the ones with neoplastic features.
- Removal of a very large mass of warts is a painful procedure, best performed under either general or spinal anesthesia.
- Carbon dioxide laser is an efficient method of treating primary and recurrent anogenital warts because of its precision and rapid healing without scarring.
- Primary cure rates as high as 91% have been reported.
- Carbon dioxide laser is the treatment of choice for pregnant women with extensive lesions or lesions that do not respond to TCA.
- Pulsed-dye laser and other new lasers have been used by some with various successful rates.
- Surgery is indicated particularly for large genital warts or malignant lesions.
- For recurrent carcinoma, Mohs surgery is a good choice.
Consultations
- Dermatologist
- Gynecologist
- Surgeon
Medication
Historically, medical treatments have been destructive in nature, although recently immunomodulators have been introduced.
Keratolytic agents
Cause cornified epithelium to swell, soften, macerate, and then desquamate.
Podofilox (Condylox)
Topical antimitotic that can be chemically synthesized or purified from plant families Coniferae and Berberidaceae (eg, species of Juniperus and Podophyllum). Treatment of anogenital warts results in necrosis of visible wart tissue. Exact mechanism of action is unknown. Genital warts are epidemiologically associated with cervical carcinoma.
Adult
Apply 0.5% solution to external genital warts with drug-dampened applicator bid for 3 d, followed by 4 d without treatment; repeat cycle for maximum of 4 wk
Pediatric
Not established
Coadministration with other keratolytic agents may cause increased skin irritation
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid >10 cm2/d or 0.5 mL/d of solution; about 15% of patients report severe local reactions to treatment area after first cycle, which reduces to 5% by last treatment cycle; local effects include pain, burning, inflammation, and erosion; avoid contact with eyes (If eye contact, immediately flush eye with copious quantities of water); not for use on mucous membranes of genital area including urethra, rectum, and vagina; do not exceed frequency of application or duration of usage
Podophyllum resin (Podocon-25)
Topical treatment for benign growths, including external genital and perianal warts, papillomas, and fibroids. Arrests mitosis in metaphase; active agent is podophyllotoxin; type of podophyllum resin used determines strength. American podophyllum contains one-fourth the amount of Indian source.
Although procedure is simple, home treatment should be avoided in most cases because patients tend to overtreat and cause excessive inflammation.
Adult
20% podophyllin resin in compound tincture of benzoin; apply to lesion and allow to dry, then remove by washing 1 h later; treat again in 1 wk
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; diabetes; impaired peripheral circulation; avoid use on mucous membranes, eyes, bleeding warts, moles, birthmarks, or unusual warts with hair; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Powerful caustic and severe irritant; do not use if surrounding tissue is swollen or irritated; 25% solution should not be applied near mucous membranes; do not use large amounts; avoid contact with cornea; systemic toxicity from absorption of podophyllin; polyneuritis, paralytic ileus, leukopenia, thrombocytopenia, coma, and death have occurred when large quantities absorbed (large surface area and long contact time); can produce bizarre forms of squamous cells, which can be mistaken for SCC; inform pathologist if previously treated wart is sent for biopsy
Trichloroacetic acid (TCA, Tri-Chlor)
Cauterizes skin, keratin, and other tissues. Although caustic, causes less local irritation and systemic toxicity than other drugs in the same class. However, response is often incomplete, and recurrence occurs frequently. Most clinicians use 25-50% TCA, although some use as high as 85% and then neutralize with either water or bicarbonate; tissue sloughs and subsequently heals in 7-10 d. Less destructive than laser surgery, electrocautery, or cryotherapy.
Adult
Paint onto lesions, avoid uninvolved skin; can be used in anal areas; repeat q1-2wk prn
Pediatric
Not established
None reported
Documented hypersensitivity; not for use on premalignant or malignant lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
External use only; restrict use to treatment areas only
Immunomodulators
Stimulate the release of key factors that regulate the immune system.
Imiquimod (Aldara)
Induces secretion of interferon alpha and other cytokines; mechanism of action is unknown. May be more effective in women than in men.
Adult
Apply 3 times/wk prior hs; leave on skin for 6-10 h
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal human papilloma infection; following surgery or drug treatment, do not use topical imiquimod until genital/perianal tissue is healed
Interferons
Are naturally produced proteins with antiviral, antitumor, and immunomodulatory actions. Alpha, beta, and gamma interferons may be given topically, systemically, and intralesionally.
Interferon alfa-2b (Intron A)
Protein product manufactured by recombinant DNA technology. Mechanism of antitumor activity is not clearly understood; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles. For patients >18 y with genital warts refractory to other forms of treatment.
Adult
Inject 0.1 mL of 10 million IU Intron A in 1 mL of diluent into each lesion 3 times/wk qod for 3 wk
Pediatric
Not established
Theophylline may increase interferon alpha toxicity; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity of interferon alpha
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Influenzalike symptoms usually clear in 24 h; pulmonary infiltrates, elevated liver enzymes, and mild leukopenia (all rare); caution in brain metastases, severe hepatic or renal insufficiencies, seizure disorders, multiple sclerosis, or compromised CNS
Antimetabolites
Inhibit cell growth and proliferation.
5-Fluorouracil or 5-FU (Efudex, Adrucil, Fluoroplex)
For management of superficial basal cell carcinomas. Interferes with DNA synthesis by blocking the methylation of deoxyuridylic acid and inhibits thymidylate synthetase, which subsequently reduces cell proliferation. For use on warts resistant to other forms of treatment.
Adult
Alternative for vaginal warts: Insert a special applicator that is one-third full with 5% 5-FU cream deeply into vagina, 1-2 times/wk for up to 10 consecutive wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; potentially serious infections
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Protect vulva and urethra with petrolatum and place tampon just inside introitus; if twice a week dosing is used, then protect vulva with either zinc oxide or hydrocortisone ointments (in one study there was no evidence of disease in 85% of cases after 3 mo of treatment); incidence of inflammatory reactions may occur with occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction
Vaccines
An HPV vaccine is now available for prevention of HPV-associated dysplasias and neoplasia, including cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions. Immunization series should be completed in girls and young women aged 11-26 y. Also indicated for boys and men aged 9-26 years for prevention of condyloma acuminata caused by HPV types 6 and 11.
Papillomavirus vaccine (Gardasil)
Quadrivalent HPV recombinant vaccine.
First vaccine indicated to prevent cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions (eg, cervical adenocarcinoma in situ; cervical intraepithelial neoplasia grades 1, 2, and 3; vulvar intraepithelial neoplasia grades 2 and 3; vaginal intraepithelial neoplasia grades 2 and 3) due to HPV types 6, 11, 16, and 18. Vaccine efficacy mediated by humoral immune responses following immunization series.
FDA-approved for females aged 9-26 years. Currently under FDA priority review to evaluate efficacy in women aged 27-45 years. Indicated for boys and men aged 9-26 years for prevention of condyloma acuminata caused by HPV types 6 and 11.
Adult
<26 years: 0.5 mL IM administered as 3 separate doses; administer second and third doses 2 and 6 mo after first dose, respectively
>26 years: Not established
Pediatric
<9 years: Not established
>9 years: Administer as in adults
Immunosuppressive therapies (eg, irradiation, antineoplastic agents, corticosteroids) may decrease immune response to vaccine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Shake well before administering; administer in deltoid region of upper arm or in higher anterolateral thigh; individuals with impaired immune responsiveness (eg, HIV infection, neoplastic disease, currently taking immunosuppressive drugs) may not elicit antibody response; because of IM administration, do not administer to individuals with bleeding disorders (eg, thrombocytopenia, coagulation disorders, anticoagulant therapy); common adverse effects include pain, swelling, erythema, and/or pruritus at injection site and fever
Miscellaneous topical ointments
Topical product that has gained FDA approval for genital warts.
Sinecatechins (Veregen)
Botanical drug product for topical use consisting of extract from green tea leaves. Mode of action unknown but does elicit antioxidant activity in vitro. Indicated for topical treatment of external genital and perianal warts (condylomata acuminatum) in immunocompetent patients. Ointment containing 15% sinecatechins, available in 15- and 30-g tubes.
Adult
Apply tid; use approximately a 0.5-cm strand of ointment topically for each external genital or perianal wart; continue treatment until complete clearance of all warts, but not to exceed 16 wk
Pediatric
<18 years: Not recommended
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not evaluated for urethral, intravaginal, cervical, rectal, or intra-anal HPV disease and should not be used to treat these conditions; avoid application to open wounds, eyes, and nose; wash hands before and after application; avoid sexual contact while ointment is on skin; may cause application site reactions, phimosis, inguinal lymphadenitis, urethral meatal stenosis, dysuria, genital herpes simplex, vulvitis, hypersensitivity, pruritus, pyodermitis, skin ulcer, erosions in the urethral meatus, and superinfection of warts and ulcers
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| Overview: Warts, Genital |
| Differential Diagnoses & Workup: Warts, Genital |
 Treatment & Medication: Warts, Genital |
| Follow-up: Warts, Genital |
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References
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Further Reading
Keywords
condyloma acuminatum, GW, genital warts, syphilis, gonorrhea, papillomas, benign proliferations of the anogenital skin, benign proliferations of the anogenital mucosa, human papillomavirus, HPV, anogenital cancer, sexually transmitted diseases, STDs, anogenital warts, papillomatous papules, papillomatous nodules, cauliflower like masses
epidermodysplasia verruciformis, squamous cell carcinoma, actinic keratosis, keratoacanthoma, Bowen disease, melanoma, oral focal epithelial hyperplasia, oral papilloma, laryngeal papilloma, recurrent respiratory papillomatosis, conjunctival papillomas, epidermal cyst, giant condyloma of Buschke and Löwenstein, verrucous carcinoma, bowenoid papulosis, vulvar intraepithelial neoplasia
cervical squamous intraepithelial lesions, low-grade squamous intraepithelial lesions, LGSIL, high-grade squamous intraepitheliallesions, HGSIL, cervical cancer
