eMedicine Specialties > Emergency Medicine > Dermatology

Warts, Genital: Treatment & Medication

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

Treatment

Emergency Department Care

  • Although an in-depth discussion of the treatment of genital warts (ie, type of workup, treatment regimens, necessary follow-up) is beyond the scope of ED practice, symptomatic treatment may be warranted.
    • Use pressure to stop bleeding, if present.
    • Relieve urethral obstruction (rare).
    • Search for evidence of coexistent STDs; treat them if found and indicated.
  • The following measures are beyond the scope of the ED and are presented for educational purposes only. Further treatment and screening guidelines from the American College of Obstetricians and Gynecologists and Centers for Disease Control and Prevention are available.1,2
    • Untreated: If visible genital warts are left untreated, they can undergo spontaneous resolution, increase in size, increase in number, or remain unchanged.
    • Ablative therapy
      • Cryotherapy2 : Use an open spray or cotton-tipped applicator for 10-15 seconds and repeat as needed. Lift away mobile skin from the underlying normal tissue before freezing. Response rates are high with few adverse sequelae. Adverse reactions include pain during treatment, erosion, ulceration, and postinflammatory hypopigmentation of skin. Cryotherapy is safe for use during pregnancy.
      • Electrodesiccation (smoke plume may be infective)
      • Curettage
      • Surgical excision2 : Excision has the highest success rate and lowest recurrence rate. Initial cure rates are 63-91%.
      • Carbon dioxide laser treatment: This treatment is used for extensive or recurrent genital warts. HPV-6 DNA has been detected in the carbon dioxide laser plume; therefore, treatment is potentially infectious. The procedure requires local, regional, or general anesthesia. (A eutectic mixture of local anesthetics [EMLA] cream may be used as an alternative anesthetic.)
    • Immune-based therapy
      • Physician administered treatments include acid applications (bichloroacetic acid or trichloroacetic acid) and interferon injections with antiviral mechanisms.
      • Medications for home use include imiquimod 5% cream, podofilox gel or solution, and antiproliferative compounds (5-fluorouracil).
      • HPV vaccines: Two HPV vaccine candidates have proven to be highly effective in clinical trials: Gardasil and Cervarix. Gardasil, Merck's HPV vaccine, was licensed by the Food and Drug Administration (FDA) in June 2006 for the prevention of cervical cancers and other diseases caused by HPV in females. It is composed of a viruslike particle consisting of recombinant L1 proteins from HPV types 6, 11, 16, and 18. It has been recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices to be routinely given to girls at age 11-12 years.3 It can be administered starting at age 9 years, with catch-up vaccinations recommended for females aged 13-26 years. The vaccine is not established as CDC policy until it is accepted by the director of the CDC.
      • HPV vaccines: Cervarix (not yet licensed in the US) is GlaxoSmithKline's HPV vaccine candidate and focuses on cancer prevention with L1 proteins from HPV types 16 and 18 only. The vaccines do not eliminate the need for other prevention strategies and screening.

Consultations

  • No emergent consultation is indicated.
  • Outpatient follow-up with a dermatologist, an OB/GYN, or a urologist is indicated.

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.

Keratolytics

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.

Adult

Sparingly apply 10-25% concentration onto lesions 1-2 times/wk; use 1 gtt at a time, allowing drying between gtt until area is covered
Treat only intact lesions; wash treatment area 1-2 h after first application; in subsequent treatments, patient can wait 4-6 h before washing off agent

Pediatric

Apply as in adults

Documented hypersensitivity; diabetes; impaired peripheral circulation; avoid use on mucous membranes, eyes, bleeding warts, moles, birthmarks, or unusual warts with hair

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Powerful caustic and severe irritant; do not use if surrounding tissue is swollen or irritated; do not apply 25% solution near mucous membranes; do not use large amounts; avoid contact with cornea


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.

Adult

0.5% solution applied bid for 3 d and discontinued for 4 d; repeat this on-and-off cycle for up to 4 wk
Use no more than 0.5 mL of solution or 0.5 g of gel qd; treat <10 cm2 of tissue qd
Thoroughly wash hands after each application

Pediatric

Not established

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid contact with eyes; if eye contact, immediately flush eye with copious quantities of water and seek medical advice; not for use on mucous membranes of genital area, including urethra, rectum, and vagina; do not exceed frequency of application or duration of usage; not recommended by itself for recurrent warts or perianal or genital mucous membranes (distinguishing between these conditions can be difficult); obtain histopathologic confirmation if the diagnosis is doubtful


Trichloroacetic (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.

Adult

Paint on to lesions, avoiding uninvolved skin; can be used in anal areas; repeat q1-2wk; 3-4 treatments may be necessary
Treated area requires no cleansing after several hours

Pediatric

Not established

Documented hypersensitivity; not for use on premalignant or malignant lesions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

External use only; restrict use to treatment areas only; if acid spilled on normal tissue or if too much applied, remove immediately and wash with water; sodium bicarbonate may be applied as a local antidote


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.

Adult

5% cream qd or periodically for 10 wk
1% cream bid for 2-6 wk

Pediatric

Not established

Documented hypersensitivity; pregnancy

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Incidence of inflammatory reactions may occur with occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction; avoid prolonged exposure to sunlight or UV radiation; increased absorption may occur through ulcerated or swollen skin; use care near eyes, nose, and mouth; wash hands immediately after application; prolonged use may result in erosive dermatitis and mucositis; additionally, there is a risk of developing vaginal adenosis and clear cell adenocarcinoma with this treatment; pain, pruritus, burning, irritation, inflammation, allergic contact dermatitis, and telangiectasia are possible adverse effects

Miscellaneous topical ointment

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.

Adult

Apply topically tid; use approximately a 0.5-cm strand of ointment topically for each external genital or perianal wart

Pediatric

<18 years: Not established

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not evaluated for urethral, intravaginal, cervical, rectal, or intra-anal human papilloma viral disease and should not be used to treat these conditions; avoid application to open wounds, eyes, and nose; wash hands before and after application; avoid sexual contact while ointment is on skin; may cause application site reactions, phimosis, inguinal lymphadenitis, urethral meatal stenosis, dysuria, genital herpes simplex, vulvitis, hypersensitivity, pruritus, pyodermitis, skin ulcer, erosions in the urethral meatus, and superinfection of warts and ulcers

Interferons

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.

Adult

250,000 U intralesionally twice weekly for a maximum of 8 wk; not to exceed 2.5 million U per treatment session

Pediatric

Not established

Potential risk of renal failure when administered concurrently with interleukin-2; theophylline may increase toxicity by reducing clearance; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity

Documented hypersensitivity to mouse immunoglobulin, egg protein, or neomycin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Numerous adverse reactions may occur with IM administration, including myalgias, fever and chills, GI symptoms, transient leukopenia, thrombocytopenia, LFT abnormalities, and serum lipid abnormalities, as well as a theoretical risk of viral transmission with natural interferon products; viral symptoms abate with time, and all adverse effects resolve once therapy is stopped; viral symptoms can be treated with acetaminophen or NSAIDs in the interim; monitor periodically to determine if the patient is responding to treatment; if patient does not respond within 6 mo, discontinue treatment; if a response to treatment is seen, continue treatment until either no further improvement is observed or the laboratory parameters have been stable for about 3 mo (not known whether continued treatment after that time is beneficial); caution in debilitating cardiovascular disease, severe pulmonary disease, diabetes mellitus with ketoacidosis, coagulation disorders, severe myelosuppression, or seizure disorders

Immune response modifiers

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).4


Imiquimod (Aldara) 5% cream

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

Adult

Apply 3 times/wk prior hs for 16 wk; leave on skin for 6-10 h, then wash treatment area with soap and water

Pediatric

<12 years: Not established
>12 years: Apply as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Genital use: Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal human papilloma infection; following surgery or drug treatment, do not use topical imiquimod until genital/perianal tissue is healed
Actinic keratosis: Avoid exposure to sunlight or artificial tanning; regular use of sunscreen is encouraged; avoid contact with lips, eyes, or nostrils; common adverse effects include erythema, edema, vesicles, erosion or ulceration, weeping, exudate, flaking, scaling, dryness, and scabbing or crusting
Basal cell carcinoma: Medical follow-up is essential to ensure cancer has responded adequately to treatment; may cause redness, swelling, and sore development at application site; may cause itching or burning

Vaccines

A HPV vaccine is 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 young women aged 9-26 years.


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.

Adult

<26 years: 0.5 mL IM administered as 3 separate doses; administer second and third doses 2 and 6 mo after first dose, respectively
>26 years: Not established

Pediatric

<9 years: Not established
>9 years: Administer as in adults

Immunosuppressive therapies (eg, irradiation, antineoplastic agents, corticosteroids) may decrease immune response to vaccine

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Shake well before administering; administer in deltoid region of upper arm or in higher anterolateral thigh; individuals with impaired immune responsiveness (eg, HIV infection, neoplastic disease, currently taking immunosuppressive drugs) may not elicit antibody response; because of IM administration, do not administer to individuals with bleeding disorders (eg, thrombocytopenia, coagulation disorders, anticoagulant therapy); common adverse effects include pain, swelling, erythema, and/or pruritus at injection site and fever

More on Warts, Genital

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