Genital Warts Treatment & Management

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.^[15] Various treatment methods are as follows:

• Caustics/acids - Eighty to ninety percent bichloracetic acid (BCA) or trichloroacetic acid (TCA)
• Podophyllin resin (20-25% solution) - Applied by healthcare providers twice a week for 6 weeks
• Podophyllotoxin 0.5% gel, cream, or solution (Condylox) - Twice a day, 3 days a week for 4 weeks; lower recurrence rate than podophyllin resin
• Fluorouracil (5%) cream or solution(Efudex) - Approximately 1-3 days a week for 4 weeks
• Imiquimod 5% cream (Aldara) - Three nights per week for up to 4 months (A recent article reported that the optimal duration of use for women's genital warts may be 1 mo.)^[16]
• Sinecatechins (15%) ointment (Veregen) - Three times a day for up to 16 weeks; cheaper than imiquimod^[17] ; recurrence rate as low as 5%
• Interferon, intramuscular or intralesional injection - 3 million units, 3 times per week for 3 weeks

The HPV vaccine Gardasil (against HPV types 6, 11, 16, and 18 infection) is recommended for males and females aged 9-26 years. The vaccine is given at day 1, at month 2, and at month 6. The vaccine has been highly effective. In Australia, there was a dramatic decline and near disappearance of genital warts in women and men younger than 21 years 4 years after commencing a free quadrivalent HPV vaccine program.^[18] Another vaccine against HPV types 16 and 18, Cervarix, has been approved by the US Food and Drug Administration (FDA) for females aged 10-25 years (administrated in a similar manner: given at day 1, at month 1, and at month 6). Of note, Gardasil also provides cross-protection against nonvaccine HPV types (ie, HPV types 31, 33, 45, 52, and 58 in 30-40% of recipients. The latter HPVs are responsible for greater than 20% of cervical cancers.^[19]

Note the following clinical guideline summaries:

• Centers for Disease Control and Prevention -HPV infection and genital warts. Sexually transmitted diseases treatment guidelines 2006
• Society of Obstetricians and Gynaecologists of Canada -Treatment of external genital warts and pre-invasive neoplasia of the lower tract. In: Canadian consensus guidelines on human papillomavirus
• American Cancer Society -American Cancer Society guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors

Also see the following clinical trials:

• Phase 3 Study of Imiquimod Creams in the Treatment of External Genital Warts
• Human Papillomavirus (HPV) Genotypes in Genital Warts in Colombian Population
• Safety and Effectiveness Study of Imiquimod Creams in the Treatment of External Genital Warts
• Safety and Effectiveness Study of an Experimental Topical Ointment (GS-9191) for the Treatment of Genital Warts
• Low Dose Cyclophosphamide Treats Genital Warts

Physical destruction or excision has been more effective in eradicating genital warts than medical therapeutic regimens, but it carries a relatively high recurrence rate of 25-55%.

• 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.

• Dermatologist
• Gynecologist
• Surgeon