Condyloma Acuminatum Treatment & Management

  • Author: Robert V Higgins, MD; Chief Editor: David Chelmow, MD   more...
 
Updated: Jun 3, 2010
 

Medical Care

A variety of medical treatments are available to remove condyloma acuminata; no single treatment regimen is superior. Patients should be informed that genital warts resolve spontaneously in 20-30% of women within 3 months.[12]

  • The treatment strategy is to eliminate as many of the visible lesions as possible until the host immune system can control viral replication.
  • Treatment is reserved for patients with visible vulvar condyloma.
  • The type of treatment is influenced by previous therapies, pregnancy status, sexual behavior, immune status, and the patient's willingness to comply with therapy.
  • Development of a therapeutic vaccine against HPV is currently being investigated. Two published trials demonstrated either a clinical complete response or a clinical partial response in women with vulvar or vaginal dysplasia.[42, 43]
  • Patients who are HIV positive or immunosuppressed due to immunosuppressive drugs usually require more than 1 treatment method. Often, the condyloma in these patients is refractory to therapy.
  • Regardless of the mode of therapy chosen, recurrence rates are high for any patient with condyloma acuminata. This can result in a high level of frustration for the patient and the physician.

Medical therapy should be the first option for most patients. The authors' prefer the following 4 options for patient-applied therapy.[44]

  • Podofilox: Our first choice, in a nonpregnant patient, is Podofilox gel or solution. This agent is applied twice daily for 3 consecutive days and repeated for up to 4 weeks. Side effects are minimal.
  • Imiquimod: This is our second choice in a nonpregnant woman with vulvar condyloma. Application is 3 times weekly at bedtime for up to 16 weeks. Imiquimod should be washed off 8 hours after application.[45] Several randomized trials have demonstrated that application of imiquimod 5% cream can result in complete resolution of genital warts in up to 50% of patients. Recurrence rates range from 19-23% at 6 months.[46] The primary side effect is erythema, itching, and burning. This drug is expensive and is often not a treatment option in many health insurance plans.
  • Sinecatechins (Veregen): A third option is Veregen ointment for medical treatment of anogenital warts. Several randomized, double-blind, placebo-controlled trials demonstrated a 58% clearance of external genital warts. A trial of 502 male and female patients with anogenital warts were treated 3 times per week for a maximum of 16 weeks. Complete clearance of all baseline and newly occurring warts was obtained in 57% of patients treated with 15% sinecatechins ointment.[47] The primary side effects were erythema, pruritus, and pain.[48]
  • 5-fluorouracil: Another option is 5-fluorouracil (Efudex) cream. This agent is applied to genital warts to cause a chemical desquamation. A meta-analysis of 6 trials involving 645 women concluded that topical treatment with 5-fluorouracil has a therapeutic effect. The data were unclear on the risks and benefits and further studies were recommended.[49] Protection of the normal surrounding skin is imperative to prevent pain, burning, and ulceration. This therapy is often not tolerated by patients. Use of this agent should be limited.

Other options include the following:

  • Podophyllin: Podophyllin is applied directly to warts but no more than 0.5 mL should be used with one treatment. Systemic absorption, ulceration, and pain are potential side effects of this therapy. Podophyllin is contraindicated in pregnancy. The authors of this article prefer Podofilox to podophyllin. Podofilox results in less toxicity and can be self-administered by the patient.
  • Interferon: Intralesional injection of interferon has been used to treat condyloma. Locally-injected interferon appears to be more effective than systemic injection of interferon. A meta-analysis of 7 randomized controlled trials comparing interferon and placebo for the treatment of genital warts reported complete response rate of 45% and 16%, respectively. Recurrence rates were 21% for interferon and 34% for patients in the placebo group.[50] Side effects including flu-like symptoms, fatigue, and pain. Interferon is contraindicated in pregnancy.
  • Trichloroacetic acid (TCA): TCA, using 80-90% concentration, is the author's first choice to treat vulvar/vaginal condyloma in pregnant women. TCA should be applied to the condyloma after pretreatment of the surrounding normal skin with petroleum jelly. This treatment usually requires weekly application for 4-6 weeks. The principle side effect is pain and burning if the TCA comes in contact with the normal skin.
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Surgical Care

Surgical removal of warts is appropriate if the condyloma do not respond to medical therapy, if there are numerous, bulky condyloma, or if the condyloma are associated with vulvar dysplasia. Several options are available.

  • Simple excision
    • Simple excision is usually performed in an outpatient surgical suite.
    • The individual lesions are removed with a knife after general or regional anesthesia is administered.
    • This procedure is reserved for refractory cases or extensive disease. The surgical specimen should be submitted for microscopic analysis.
    • Reports in the literature indicate that within one year of surgery, complete wart clearance occurs in 35-72% of individuals treated with surgical excision. One report found surgical excision as effective as laser surgery.[51]
  • Patients with a few small lesions can have vulvar condyloma removed in the office. The underlying skin should be anesthetized with 1% Xylocaine and the condyloma removed with a #15 knife blade. One or 2 sutures may be needed to reapproximate the healthy skin.
  • Carbon-dioxide laser therapy[51, 52, 53]
    • Laser treatment of vulvar condyloma acuminata effectively destroys the condyloma while sparing adjacent healthy tissue.
    • This procedure is performed in outpatient surgery with general or regional anesthesia.
    • The amount of energy needed to remove a condylomatous lesion with the laser depends on parameters controlled by the surgeon. These parameters include the amount of wattage, the length of time the beam is fired, and the spot size on the tissue. Some researchers calculate the power density, which equals the power (watts)/area (cm2). No exact power density is needed to remove vulvar or vaginal condyloma. The surgeon needs to be flexible in the application of the laser for each patient. If the laser is calibrated to 20 watts, continuous mode, the spot size can be adjusted easily to provide the proper power density.[54]
    • Most patients experience significant discomfort beginning 24 hours after surgery and require narcotic analgesia.
    • Laser therapy should be reserved for recalcitrant cases of condyloma or extensive disease.
    • Complete wart clearance after laser surgery has been reported to occur in 23-52% of patients within 3 years of surgery.
    • The recurrence rates are similar to surgical excision.
  • Electrosurgery[55]
    • For isolated lesions unresponsive to topical therapy, electrosurgical techniques can be performed in the office with local anesthesia.
    • The most popular method is to use a loop electrode that removes the lesion or lesions.
    • Pain after surgery is common and can be treated with narcotic analgesics. Topical analgesics, such as lidocaine jelly, can be beneficial to some patients.
    • A recurrence rate in one trial was 22% compared with 44% for podophyllin resin.
  • Cryotherapy[56, 57]
    • Cryotherapy is our treatment of choice for pregnant women when TCA fails to eliminate vulvar condyloma. This therapy is most effective for small lesions that can be treated with a small cryoprobe.
    • Data from several clinical trials report a 63-88% clearance 3 months after therapy. A trial comparing cryotherapy to cryotherapy combined with podophyllotoxin failed to demonstrate an improved outcome with the combination therapy.[58]
    • The recurrence rate of 22% is similar to electrosurgery.
    • The primary drawbacks are discomfort, ulceration, or scabbing at the treatment site.
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Next

Activity

  • The patient should refrain from sexual contact after any surgical procedure for condyloma acuminata.
  • Soaking the genital area in warm water or sitz baths usually offers excellent pain relief.
  • The genital area should be dried gently with a towel or a hair dryer.
  • Loose fitting cotton underwear is helpful to avoid chafing.
  • No other activity restrictions exist, although patients often have trouble sitting for long periods of time in the first week after surgery.
  • Patients who have condyloma removed from the periurethral area may experience dysuria. Sitz baths and topical analgesics are beneficial.
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Contributor Information and Disclosures
Author

Robert V Higgins, MD  Clinical Associate Professor, Department of Obstetrics/Gynecology, University of North Carolina School of Medicine; Residency Program Director, Vice-Chairman of Academic Affairs, Associate Director of Gynecologic Oncology, Department of Obstetrics/Gynecology, Carolinas Medical Center

Robert V Higgins, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, North Carolina Medical Society, and Society of Gynecologist Oncologists

Disclosure: Nothing to disclose.

Coauthor(s)

R Wendel Naumann, MD  Clinical Assistant Professor of Obstetrics and Gynecology, University of North Carolina at Chapel Hill; Director, Minimally Invasive Surgery in Gynecologic Oncology; Associate Director, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Carolinas Medical Center

R Wendel Naumann, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American College of Surgeons

Disclosure: Nothing to disclose.

James Hall, MD  Director, Division of Gynecologic Oncology, Blumenthal Cancer Center, Carolinas Medical Center; Clinical Professor, Department of Obstetrics and Gynecology, University of North Carolina

James Hall, MD is a member of the following medical societies: American Cancer Society, American College of Obstetricians and Gynecologists, and Society of Gynecologist Oncologists

Disclosure: merck Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; orthobiotek Honoraria Speaking and teaching

Specialty Editor Board

Steven David Spandorfer, MD  Assistant Professor, Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Cornell Medical College

Steven David Spandorfer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

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