eMedicine Specialties > Emergency Medicine > Dermatology

Warts, Genital: Follow-up

Author: A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
Coauthor(s): Rasha A Hindiyeh, MD, MBA, Researcher, Department of Dermatology, University of California, Irvine, School of Medicine
Contributor Information and Disclosures

Updated: Aug 17, 2009

Follow-up

Further Outpatient Care

  • Ensure follow-up with a dermatologist, OB/GYN (females), or urologist (males) within 1 week.
  • Perform a workup for HPV and other STDs as indicated.
  • Treat the patient using medications; if medications are ineffective, treat with cryotherapy, curettage, electrodesiccation, surgical excision, carbon dioxide laser treatment, or combination therapy.
  • Evaluate and treat sexual partner(s).
  • Search for immunosuppression in patients with treatment failures and recurrences.
  • Perform a tissue biopsy if recurrences or treatment failures occur.

Inpatient & Outpatient Medications

  • Podofilox (purified podophyllotoxin) is available for home use by the patient.
    • A 0.5% solution is applied twice daily for 3 consecutive days followed by 4 days of no therapy. The cycle can be repeated up to 4 times.
    • Slightly higher cure rates are expected than with podophyllin.
    • Podofilox is useful for prophylaxis.
    • Podofilox is not recommended as the sole treatment for recurrent warts.
  • Imiquimod (Aldara) 5% cream: The cream is applied qhs, 3 times a week for a treatment period of 16 weeks. The treatment area should be washed with soap and water 6-10 hours after application.

Deterrence/Prevention

  • No treatment is 100% effective.
    • The FDA has approved a vaccine for HPV.3
    • Sexual abstinence and monogamy are protective.
    • Condoms may discourage transmission.

Complications

  • Local disfigurement
  • Transformation to genitourinary malignancies in both males and females
  • Transmission to neonate or partners
  • Recurrence: According to Diamantis et al, recurrence rates for anogenital warts ranged from 19% at 3 months to 23% at 6 months.4

Prognosis

  • Many cases fail to respond to treatment or recur after adequate response.
  • Recurrence rate of cervical dysplasia in women is not altered by treatment of their sex partners.
  • Recurrence rates exceed 50% after 1 year and have been attributed to the following:
    • Recurrent infection from sexual contact
    • Long incubation period of HPV
    • Location of the virus in superficial skin layers away from lymphatics
    • Persistence of the virus in the surrounding skin, in the hair follicle, or in sites inadequately reached by the intervention
    • Missed or deep lesions
    • Subclinical lesions
    • Underlying immunosuppression

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to inform patients of potential risk of malignant transformation of lesions
  • Failure to indicate necessity for follow-up, even after treatment eradicates lesions
  • Failure to recognize the possibility of subclinical and intravaginal or cervical lesions and failure to search for them
  • Failure to indicate treatment availability and follow-up
  • Failure to inform patients of the risk of HPV transmission to sex partners and neonates
  • Failure to inform patient of necessity to treat partners
  • Failure to search for immunosuppression in patients with treatment failures and recurrences

Special Concerns

  • Pregnancy
    • Latent infections may become activated with numerous large lesions.
    • Lesions often present or increase during pregnancy.
    • Lesions may make vaginal delivery difficult if they are in the cervix, vagina, or vulva.
    • Lesions tend to bleed easily.
    • Lesions often regress spontaneously after delivery.
  • Pediatrics
    • Neonates may become infected during passage through an infected birth canal.
    • Incidence of perinatal transmission to the infant pharynx may be as high as 50%; transmission occurs most frequently with HPV-6 and HPV-11.
    • Incidence of genital infection in neonates is 4%, although the American College of Obstetrics and Gynecology currently does not recommend cesarean delivery due solely to positive HPV status.
 
Acknowledgments




More on Warts, Genital

Overview: Warts, Genital
Differential Diagnoses & Workup: Warts, Genital
Treatment & Medication: Warts, Genital
Follow-up: Warts, Genital
Multimedia: Warts, Genital
References

References

  1. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Human papillomavirus. Washington (DC): American College of Obstetricians and Gynecologists (ACOG). Apr 2005;ACOG practice bulletin; no. 61. [Full Text].

  2. [Guideline] Centers for Disease Control and Prevention, Workowski KA, Berman SM. HPV infection and genital warts. Sexually transmitted diseases treatment guidelines 2006. MMWR Morb Mortal Wkly Rep. Aug 4 2006;55(RR-11):62-7. [Full Text].

  3. [Guideline] Centers for Disease Control and Prevention. ACIP Provisional Recommendations for the Use of Quadrivalent HPV Vaccine. 2006. Accessed August 18, 2006. [Full Text].

  4. Diamantis ML, Bartlett BL, Tyring SK. Safety, efficacy & recurrence rates of imiquimod cream 5% for treatment of anogenital warts. Skin Therapy Lett. Jun 2009;14(5):1-3, 5. [Medline].

  5. American Academy of Dermatology. Genital Warts. 2006. Accessed June 6, 2006. 2006. [Full Text].

  6. [Guideline] Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines. 2002. Accessed June 6, 2006. [Full Text].

  7. Chan PD, Winkle PJ, Winkle CR. Condyloma acuminata. Current Clinical Strategies - Family Medicine. 2nd ed. 1995: 209-10.

  8. Congilosi SM, Madoff RD. Current therapy for recurrent and extensive anal warts. Dis Colon Rectum. Oct 1995;38(10):1101-7. [Medline].

  9. Garrido JL. Human papilloma virus--H.P.V. condyloma. Current studies in diagnosis, treatment and prognosis. Clin Exp Obstet Gynecol. 1996;23(2):99-102. [Medline].

  10. Kresge KJ. Cervical cancer vaccines. Introduction of vaccines that prevent cervical cancer and genital warts may fore-shadow implementation and acceptability issues for a future AIDS vaccines. IAVI Rep. Nov-Dec 2005;9(5):1-5. [Medline].

  11. Mayeaux EJ, Harper MB, Barksdale W, Pope JB. Noncervical human papillomavirus genital infections. Am Fam Physician. Sep 15 1995;52(4):1137-46, 1149-50. [Medline].

  12. Prasad CJ. Pathobiology of human papillomavirus. Clin Lab Med. Sep 1995;15(3):685-704. [Medline].

  13. Rosen T. Sexually transmitted diseases 2006: a dermatologist's view. Cleve Clin J Med. Jun 2006;73(6):537-8, 542, 544-5 passim. [Medline].

  14. Sykes NL Jr. Condyloma acuminatum. Int J Dermatol. May 1995;34(5):297-302. [Medline].

  15. Vandepapeliere P, Barrasso R, Meijer CJ, et al. Randomized controlled trial of an adjuvanted human papillomavirus (HPV) type 6 L2E7 vaccine: infection of external anogenital warts with multiple HPV types and failure of therapeutic vaccination. J Infect Dis. Dec 15 2005;192(12):2099-107. [Medline].

Further Reading

Keywords

human papillomavirus, HPV, sexually transmitted disease, STD, condyloma acuminatum, papilloma acuminatum, papilloma venereum, pointed condyloma, pointed wart, venereal wart, verruca acuminata, genital warts, papovaviruses, HPV infection

Contributor Information and Disclosures

Author

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Rasha A Hindiyeh, MD, MBA, Researcher, Department of Dermatology, University of California, Irvine, School of Medicine
Rasha A Hindiyeh, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, and American Medical Women's Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.