What is the best treatment for removing penile warts?

Best Treatment Options for Penile Warts

Cryotherapy with liquid nitrogen is the most effective first-line treatment for penile warts, with efficacy rates of 63-88% in randomized trials and relatively low recurrence rates of 21-39%. 1

First-Line Treatment Options

Provider-Administered Treatments

1. Cryotherapy with liquid nitrogen

   • Apply every 1-2 weeks until warts resolve
   • Relatively inexpensive and does not result in scarring if performed properly
   • Patients experience moderate pain during and after the procedure
   • Special equipment required
   • Efficacy: 63-88% with recurrence in 21-39% of patients 1, 2

2. Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90%

   • Apply only to warts; powder with talc or sodium bicarbonate to remove unreacted acid
   • Repeat weekly if necessary
   • One randomized trial showed 81% efficacy with 36% recurrence rate 1
   • Must be applied sparingly to avoid damage to adjacent tissues 1

Patient-Applied Treatments

1. Podofilox 0.5% solution

   • Self-applied twice daily for 3 days, followed by 4 days of no therapy
   • Can repeat for up to 4 cycles
   • Total wart area treated should not exceed 10 cm² and volume should not exceed 0.5 mL per day
   • Efficacy: 45-88% with recurrence in 33-60% of patients 1
   • Contraindicated during pregnancy 3
   • More effective than podophyllin in comparative studies 4

2. Imiquimod 5% cream

   • Apply once daily at bedtime, three times a week for up to 16 weeks
   • Wash treatment area with soap and water 6-10 hours after application
   • Works by stimulating immune response
   • May weaken condoms and vaginal diaphragms
   • Contraindicated during pregnancy 5

Second-Line Treatment Options

1. Surgical removal

   • Options include tangential scissor excision, tangential shave excision, curettage, or electrosurgery
   • Most beneficial for patients with large or numerous warts
   • Can eliminate warts in a single visit
   • Efficacy: 93% with recurrence in 29% of patients 1, 2

2. Podophyllin 10%-25% in compound tincture of benzoin

   • Apply only to warts, limiting application to ≤0.5 mL or ≤10 cm² per session
   • Wash off in 1-4 hours
   • Repeat weekly if necessary
   • If warts persist after six applications, consider other treatments
   • Efficacy: 32-79% with recurrence in 27-65% of patients 1
   • Contraindicated during pregnancy

3. CO₂ laser therapy

   • Studies show higher clearance rates compared to cryotherapy (95% vs 46.2%)
   • Lower recurrence rates (0.05% vs 0.18%) 6
   • Typically requires only one treatment session
   • More expensive and requires specialized equipment

Treatment Algorithm

1. For few, small warts:

   • Start with cryotherapy or offer patient-applied podofilox if patient prefers self-treatment
   • If no response after 3 treatments, switch to TCA/BCA or imiquimod

2. For numerous or large warts:

   • Consider surgical removal or CO₂ laser therapy
   • These methods can clear warts in fewer sessions

3. For recurrent warts:

   • Try a different treatment modality than previously used
   • Consider combination therapy (though some specialists believe this may increase complications without improving efficacy) 1

Important Considerations

• Approximately one-third of penile warts regress spontaneously within 9 months 7

• No treatment completely eliminates HPV infection, only removes visible warts 2

• Treatment should be continued until complete clearance or for maximum duration specified for each treatment

• Patients should be warned about potential side effects:

  • Hypopigmentation or hyperpigmentation (may be permanent)
  • Local irritation, pain, or discomfort
  • Scarring (rare with proper technique)

• Recurrence is common with all treatment methods (at least 25% within 3 months) 2

Remember that the goal of treatment is to remove visible warts rather than eradicate the virus, as no current treatment completely eliminates HPV infection.