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




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References
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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].

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Further Reading

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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

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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

 
 
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