Genital Warts in Emergency Medicine Medication

Do not administer the following medications in the ED. These agents are listed strictly for educational purposes and to help readers understand and manage potential complications.

Warts generally regress spontaneously within months or years. Remove genital or laryngeal warts, however, because of the possibility of malignant transformation.

The CDC recommends keratolytic agents, antimitotic agents, and immune-response modifiers as alternative regimens to cryotherapy to treat external genital/perianal warts, vaginal warts, and urethral meatus warts.

Class Summary

These agents cause the cornified epithelium to swell, soften, macerate, and then desquamate.

Podophyllum resin (Podocon-25, Podo-Ben-25, Podofin)

Powdered mixture of resins removed from the May apple (mandrake) (Podophyllum peltatum linne). Cytotoxic agent used topically to treat genital warts. Arrests mitosis in metaphase, an effect it shares with other cytotoxic agents (eg, vinca alkaloids). Podophyllotoxin is the active agent, and its strength varies with the type of podophyllum resin used. American podophyllum contains a fourth the amount of Indian source. A cure rate of 20-50% can be expected if used as a single agent. Clearance rates are much higher if cryotherapy is used simultaneously.

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. Slightly higher cure rates can be expected with podofilox than with podophyllin. Additionally, this agent is useful for prophylaxis.

Trichloroacetic acid topical (Tri-Clor), Dichloroacetic (Bichloracetic) acids

Cauterizes skin, keratin, and other tissues. Although caustic, causes less local irritation and systemic toxicity than other agents in the same class. However, response is often incomplete and recurrences are frequent.

5-Fluorouracil (Efudex, Fluoroplex)

Has antimetabolic, antineoplastic, and immunostimulative activity. Useful to prevent recurrence in patients who are immunocompromised if started within 4 wk of condyloma ablation.

Mild local discomfort can be treated with cortisol cream.

Class Summary

Another topical product that has gained FDA approval for genital warts includes kunecatechins.

Kunecatechins (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.

Class Summary

These agents are naturally produced proteins with antiviral, antitumor, and immunomodulatory actions. Alpha-, beta-, and gamma-interferons exist and may be administered topically, systemically, and intralesionally.

Interferon alfa-n3 (Alferon N)

Approved by the FDA for injection in refractory condyloma acuminata. The mechanism by which interferons exert antitumor activity is poorly understood. Direct antiproliferative action against tumor cells and modulation of the host immune response may play important roles.

Recurrence rate of 20-40%, but the recurrence rate after successful treatment is lower than with other treatment modalities. Nevertheless, intralesional interferon is expensive and requires repeated office visits.

Class Summary

These agents are indicated for treatment of genital warts. Induces secretion of interferon alpha and other cytokines; mechanisms of action are unknown. They may be more effective in women than in men.

Diamantis et al note that complete clearance of warts occurred in 50% of patients treated with imiquimod 5% cream (administered once-daily, 3 times/wk, up to 16 wk).^[5]

Imiquimod (Aldara) 5% cream

Induces secretion of interferon alpha and other cytokines; mechanisms of action are unknown.

Class Summary

HPV vaccines are now available for prevention of HPV-associated dysplasias and neoplasia including cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions. The immunization series should be completed in girls and women aged 9-26 years.^[6] Considered optional for males but considered routine for high-risk males (eg, homosexuals).^[7]

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. Indicated for prevention of condyloma acuminata caused by HPV types 6 and 11 in boys, men, girls, and women aged 9-26 years.

Recommended as part of routine vaccination in girls aged 11-12 years. Optional immunization for males but should be administered for high-risk males (eg, homosexuals).

Papillomavirus vaccine, bivalent (Cervarix)

Recombinant human papillomavirus (HPV) vaccine prepared from L1 protein of HPV types 16 and 18. Indicated in girls and women (aged 10-25 y) for prevention of diseases caused by oncogenic HPV types 16 and 18 (ie, cervical cancer, cervical intraepithelial neoplasia grade 2 or higher, adenocarcinoma in situ, cervical intraepithelial grade 1.