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Genital Warts in Emergency Medicine Medication

  • Author: Delaram Ghadishah, MD; Chief Editor: William D James, MD  more...
 
Updated: Apr 26, 2016
 

Medication Summary

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.

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 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. 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).[9]

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Keratolytics

Class Summary

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

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

 

Podophyllum resin is a powdered mixture of resins removed from the May apple (mandrake) (Podophyllum peltatum linne). It is 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 sources. 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)

 

Podofilox is a 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. The 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-Chlor)

 

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

5-Fluorouracil (Efudex, Fluoroplex)

 

5-Fluorouracil has antimetabolic, antineoplastic, and immunostimulative activity. It is useful to prevent recurrence in patients who are immunocompromised if started within 4 weeks of condyloma ablation. Mild local discomfort can be treated with cortisol cream.

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Miscellaneous topical ointment

Class Summary

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

Kunecatechins (Veregen)

 

Kunecatechins is a botanical drug product for topical use consisting of extract from green tea leaves. Its mode of action is unknown, but it does elicit antioxidant activity in vitro. It is indicated for topical treatment of external genital and perianal warts (condylomata acuminatum) in immunocompetent patients.

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Interferons

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)

 

Interferon alfa-n3 is 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.

The recurrence rate is 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.

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Immune response modifiers

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.

Imiquimod (Aldara) 5% cream

 

Imiquimod induces secretion of interferon alpha and other cytokines; the mechanisms of action are unknown.

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Vaccines

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.

Papillomavirus vaccine (Gardasil)

 

Papillomavirus vaccine is a quadrivalent HPV recombinant vaccine. It is the 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 is mediated by humoral immune responses following immunization series. It is indicated for prevention of condyloma acuminata caused by HPV types 6 and 11 in boys, men, girls, and women aged 9-26 years.

It is recommended as part of routine vaccination in girls and boys aged 11-12 years.

Papillomavirus vaccine, bivalent (Cervarix)

 

Papillomavirus vaccine, bivalent, is a recombinant human papillomavirus (HPV) vaccine prepared from L1 protein of HPV types 16 and 18. It is 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).

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Contributor Information and Disclosures
Author

Delaram Ghadishah, MD Physician, Emergency Department, Kaiser Permanente West Los Angeles Medical Center

Delaram Ghadishah, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Acknowledgements

Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center

Disclosure: Nothing to disclose.

Rasha A Hindiyeh, MD, MBA Physician, Department of Internal Medicine, University of California Irvine School of Medicine

Disclosure: Nothing to disclose.

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, 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.

Elizabeth Rubano, MD Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center

Elizabeth Rubano, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Binita R Shah, MD, FAAP Professor of Clinical Pediatrics and Emergency Medicine, SUNY Health Sciences Center at Brooklyn; Director of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Kings County Hospital Center

Binita R Shah, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

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

  2. [Guideline] Centers for Disease Control and Prevention, Workowski KA, Berman SM. Genital Warts. Sexually Transmitted Diseases Treatment Guidelines 2010. Available at http://www.cdc.gov/std/treatment/2010/genital-warts.htm. Accessed: November 4, 2014.

  3. [Guideline] American College of Obstetricians and Gynecologists. Human Papillomavirus Vaccination. Available at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Human-Papillomavirus-Vaccination. Accessed: November 4, 2014.

  4. [Guideline] FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010 May 28. 59(20):626-9. [Medline]. [Full Text].

  5. [Guideline] FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010 May 28. 59(20):630-2. [Medline]. [Full Text].

  6. Mandic A. Primary prevention of cervical cancer: prophylactic human papillomavirus vaccines. J BUON. 2012 Jul-Sep. 17(3):422-7. [Medline].

  7. [Guideline] Centers for Disease Control and Prevention. HPV Vaccines. Available at http://www.cdc.gov/hpv/vaccine.html. Accessed: November 4, 2014.

  8. Food and Drug Administration. FDA Approves New Vaccine for Prevention of Cervical Cancer. Oct 16, 2009. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm187048.htm. Accessed: January 5, 2010.

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

  10. American Academy of Dermatology. Genital Warts. Available at https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/e---h/genital-warts. Accessed: April 26, 2016.

 
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Genital wart in pubic area.
Genital wart in pubic area.
Genital wart in pubic area.
Genital wart in pubic area (close-up). Note the pearly appearance.
Genital warts. Condyloma acuminatum. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. Small papilloma of the vulva. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. "Cauliflower" condyloma of the penis. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. Small papilloma on the shaft of penis. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. Small papilloma of the anus. Courtesy of Tsu-Yi Chuang, MD, MPH.
 
 
 
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