Genital Warts Treatment & Management

Updated: Oct 16, 2018
  • Author: Delaram Ghadishah, MD; Chief Editor: William D James, MD  more...
  • Print
Treatment

Approach Considerations

Symptomatic treatment may be warranted in emergency situations. Use pressure to stop bleeding, if present. Relieve urethral obstruction (rare). Search for evidence of coexistent STDs; treat them if found and indicated. Further treatment, screening, and vaccination guidelines from the American College of Obstetricians and Gynecologists and Centers for Disease Control and Prevention are available. [2, 3, 4]  Also see Human Papillomavirus.

Untreated

If visible genital warts are left untreated, they can undergo spontaneous resolution, increase in size, increase in number, or remain unchanged. Complete resolution of lesions after 2 years occurs in 75% of individuals without intervention.

Ablative therapy

Cryotherapy [3] can be used. 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, clearance occurs about 75% of the time 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) and curettage have been used.

Surgical excision [3] has the highest success rate and lowest recurrence rate. Initial cure rates are 63-91%.

Carbon dioxide laser treatment is used for extensive or recurrent genital warts. The procedure requires local, regional, or general anesthesia. (A eutectic mixture of local anesthetics [EMLA] cream may be used as an alternative anesthetic.) Clearance rates are more than 90%, but reoccurrence can be up to 40%. HPV-6 DNA has been detected in the carbon dioxide laser plume; therefore, the laser operator is at risk of developing mucosal warts.

With infrared coagulation, a beam of infrared light is delivered to the affected lesions, causing tissue coagulation and necrosis. Treatment is successful in about 80% of cases.

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).

Vaccination  [5, 6]

The 9-valent HPV vaccine (Gardasil 9 [9vHPV]) is available in the United States to decrease the risk of certain cancers and precancerous lesions in males and females. The 9vHPV vaccine covers HPV subtypes 6, 11, 16, 18, 31, 33, 45, 52, and 58. Cervarix (2vHPV) and Gardasil (4vHPV) were discontinued in the United States in October 2016. Children and adolescents aged 15 years and younger need two, not three, doses of the 9vHPV vaccine; this Advisory Committee on Immunization Practices (ACIP) recommendation stems from the vaccine’s enhanced immunogenicity in preteens and adolescents aged 9-14 years. The schedule for older adolescents and young adults aged 15-45 years is three inoculations within 6 months.

Approval for adults up to age 45 years was based on a study of approximately 3200 women aged 27-45 years followed for an average of 3.5 years. The 9vHPV vaccine was 88% effective in preventing the combined endpoint of persistent infection, genital warts, vulvar and vaginal precancerous lesions, cervical precancerous lesions, and cervical cancer related to HPV types covered by the vaccine. [7, 8]

The effectiveness of 9vHPV in men aged 27-45 years is inferred from the data described above in women, as well as from efficacy data in younger men (aged 16-26 y) and immunogenicity data from a clinical trial in which 150 men, aged 27-45 years, received a three-dose regimen over 6 months. [8]

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. The 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.

Next:

Consultations

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

Previous
Next:

Prevention

The 9-valent HPV vaccine (Gardasil 9 [9vHPV]) is available in the United States to decrease the risk of certain cancers and precancerous lesions in males and females. 9vHPV vaccine covers HPV subtypes 6, 11, 16, 18, 31, 33, 45, 52, and 58. Cervarix (2vHPV) and Gardasil (4vHPV) were discontinued in the United States in October 2016. Children and adolescents aged 15 years and younger need two, not three, doses of the 9vHPV 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 young adults aged 15 through 45 years is three inoculations within 6 months.

Approval for adults up to 45 years old was based on a study of approximately 3200 women aged between 27 through 45 years followed for an average of 3.5 years. 9vHPV vaccine was 88% effective in preventing the combined endpoint of persistent infection, genital warts, vulvar and vaginal precancerous lesions, cervical precancerous lesions, and cervical cancer related to HPV types covered by the vaccine. [7, 8]

Effectiveness of 9vHPV in men aged 27 through 45 years is inferred from the data described above in women, as well as efficacy data in younger men (aged 16 through 26 years) and immunogenicity data from a clinical trial in which 150 men, aged 27 through 45 years, received a 3-dose regimen over 6 months. [8]

Previous
Next:

Long-Term Monitoring

Ensure follow-up with a dermatologist, OB/GYN (females), or urologist (males) within 1 week. Perform a workup for human papillomavirus (HPV) and other sexually transmitted diseases (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.

Previous