Medication Summary
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). [1]
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.
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.
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.
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.
Vaccines
Class Summary
The 9-valent HPV vaccine is indicated for prevention of HPV-associated dysplasias and neoplasia, including cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions.
Children and adolescents aged 15 years and younger need two, not three, doses of the HPV vaccine; this ACIP recommendation stems from the vaccine’s enhanced immunogenicity in preteens and adolescents aged 9-14 years. The schedule for older adolescents and adults aged 15-45 years is three inoculations within 6 months.
Human papillomavirus vaccine, nonavalent (Gardasil 9)
This vaccine induces a humoral immune response to 9 HPV subtypes: 6, 11, 16, 18, 31, 33, 45, 52, and 58. It is indicated in males and females aged 9-45 years to prevent HPV-associated diseases.
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Genital wart in pubic area.
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Genital wart in pubic area.
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Genital wart in pubic area.
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Genital wart in pubic area (close-up). Note the pearly appearance.
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Genital warts. Condyloma acuminatum. Courtesy of Tsu-Yi Chuang, MD, MPH.
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Genital warts. Small papilloma of the vulva. Courtesy of Tsu-Yi Chuang, MD, MPH.
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Genital warts. "Cauliflower" condyloma of the penis. Courtesy of Tsu-Yi Chuang, MD, MPH.
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Genital warts. Small papilloma on the shaft of penis. Courtesy of Tsu-Yi Chuang, MD, MPH.
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Genital warts. Small papilloma of the anus. Courtesy of Tsu-Yi Chuang, MD, MPH.
