From the Guidelines
The most effective management of genital warts involves provider-administered cryotherapy with liquid nitrogen or cryoprobe, repeated every 1–2 weeks, as it offers a high clearance rate with minimal side effects. Management of genital warts involves several treatment approaches depending on the extent and location of the warts. First-line treatments include patient-applied therapies such as imiquimod 3.5% or 5% cream (applied at bedtime three times weekly for up to 16 weeks) 1, podofilox 0.5% solution or gel (applied twice daily for 3 days, followed by 4 days of no treatment, for up to 4 cycles) 1, or sinecatechins 15% ointment (applied three times daily for up to 16 weeks) 1.
Some key points to consider when managing genital warts include:
- Patient-applied therapies are convenient and relatively inexpensive, but may have lower clearance rates compared to provider-administered treatments 1
- Provider-administered treatments, such as cryotherapy, trichloroacetic acid (TCA) 80-90% applied weekly, and surgical removal through excision, electrocautery, or laser therapy, offer higher clearance rates but may require more frequent office visits 1
- Combination therapy may be necessary for extensive or resistant warts 1
- Treatment should continue until warts are completely cleared, but should be reassessed if no improvement occurs after 3 treatments or if warts haven't completely cleared after 6 treatments 1
- Patients should be advised that recurrence is common (approximately 30%) due to persistent HPV infection, and multiple treatment courses may be needed 1
- Sexual partners should be examined for warts, and patients should be counseled about condom use to reduce transmission risk 1
It is essential to note that these treatments work by either physically destroying the wart tissue or by stimulating the immune system to clear the HPV infection, though none completely eradicates the virus from the body 1.
From the FDA Drug Label
Podofilox Topical Solution 0.5% is indicated for the topical treatment of external genital warts (Condyloma acuminatum). Imiquimod Cream is indicated for the treatment of external genital and perianal warts/condyloma acuminata in patients 12 years old and older. Apply twice daily morning and evening (every 12 hours), for 3 consecutive days, then withhold use for 4 consecutive days This one week cycle of treatment may be repeated up to four times until there is no visible wart tissue.
The management of genital warts involves:
- Topical treatment with podofilox (TOP) or imiquimod (TOP)
- Application of podofilox twice daily for 3 consecutive days, then withholding use for 4 consecutive days, and repeating the cycle up to four times until there is no visible wart tissue 2 2
- Treatment of external genital and perianal warts with imiquimod cream in patients 12 years old and older 3
From the Research
Treatment Options for Genital Warts
- Topical treatments: podophyllin resin, imiquimod, trichloroacetic acid, and podophyllotoxin 4
- Surgical or destructive therapies: carbon dioxide laser, surgical excision, loop excision, cryotherapy, and electrodessication 4
- Interferon can be injected locally or administered systemically to treat genital warts 4, 5
- Patient-applied therapy: imiquimod cream or podofilox 6
- Photodynamic therapy combined with other destructive modalities might increase the cure rate for genital warts 7
Effectiveness of Treatment Options
- Podofilox 0.5% solution is the most effective patient-administered therapy 8
- Carbon dioxide laser therapy, surgery, and electrosurgery are the most effective for wart removal at the end of treatment 8
- Imiquimod 3.75% is a new agent with fewer side effects and perhaps a better dosing schedule than imiquimod 5% 7
- Sinecatechins/Polyphenon E 15% can be effective against genital warts but requires three times a day dosing and is not more effective than existing treatments 7
Considerations for Treatment Selection
- Number, size, and location of lesions 4, 6
- Patient preferences, cost, convenience, adverse effects, and clinician experience 4, 6
- Pregnancy: use of podofilox, imiquimod, and sinecatechins should be avoided 8
- Immune status, pregnancy, and ability to return for frequent injections for interferon therapy 5