What is the treatment for penile warts?

Treatment of Penile Warts

The first-line treatment for penile warts is patient-applied podofilox 0.5% solution or gel applied twice daily for 3 days followed by 4 days of no therapy, for up to 4 cycles, or imiquimod 5% cream applied three times weekly at bedtime for up to 16 weeks. 1

Treatment Options

Patient-Applied Treatments

1. Podofilox 0.5% solution or gel

   • Application: Twice daily for 3 consecutive days, followed by 4 days without treatment
   • Duration: Up to 4 weekly cycles
   • Maximum area: Limited to less than 10 cm² of wart tissue
   • Maximum volume: 0.5 mL per day
   • Efficacy: 45-88% clearance rate
   • Mechanism: Antimitotic drug that destroys warts
   • Contraindications: Not established as safe during pregnancy
   • Common side effects: Mild to moderate pain or local irritation 2, 3

2. Imiquimod 5% cream

   • Application: Three times weekly at bedtime
   • Duration: Up to 16 weeks
   • Technique: Apply, then wash off with mild soap and water 6-10 hours later
   • Efficacy: Complete clearance in approximately 35% of men with penile warts
   • Mechanism: Immune enhancer that stimulates production of interferon and cytokines
   • Contraindications: Not established as safe during pregnancy
   • Common side effects: Local inflammatory reactions including redness, irritation
   • Note: May weaken condoms and vaginal diaphragms 2, 4, 5

Provider-Administered Treatments

1. Cryotherapy with liquid nitrogen

   • Frequency: Every 1-2 weeks
   • Efficacy: 63-88% clearance rate
   • Recurrence rate: 21-39%
   • Requires proper training to avoid over/under-treatment 1

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

   • Application: Weekly as needed
   • Technique: Apply until white "frosting" develops; neutralize excess with talc/sodium bicarbonate
   • Efficacy: 81% clearance rate
   • Recurrence rate: 36% 1

3. Surgical removal options

   • Methods: Tangential scissor excision, tangential shave excision, curettage, or electrosurgery
   • Efficacy: 93% clearance rate
   • Recurrence rate: 29% 1

Treatment Algorithm Based on Wart Characteristics

For small, few warts on dry surfaces:

1. First choice: Podofilox 0.5% solution/gel
2. Alternative: Imiquimod 5% cream

For warts on moist surfaces or intertriginous areas:

1. First choice: TCA/BCA 80-90% or imiquimod
2. Alternative: Provider-administered cryotherapy

For extensive warts:

1. First choice: Provider-administered cryotherapy or surgical removal
2. Alternative: Combination of methods

Special Considerations

• Uncircumcised men: Retract foreskin and clean area daily when using topical treatments 4
• Pregnancy: Podofilox and imiquimod are contraindicated; TCA/BCA or cryotherapy are preferred 1
• Immunosuppressed patients: Lower response rates to imiquimod (32% clearance in HIV+ patients on HAART) 6
• Treatment monitoring: Change treatment if no substantial improvement after three provider-administered treatments or if warts haven't cleared after six treatments 2

Important Caveats

• All treatments have recurrence rates of at least 25% within 3 months
• Treatment removes warts but does not eradicate HPV infection
• Scarring in the form of persistent hypopigmentation or hyperpigmentation is common with ablative modalities
• More frequent application of imiquimod (beyond three times weekly) does not improve clearance rates and increases adverse events 5
• Approximately one-third of penile warts regress without treatment within approximately 9 months 7

Practical Application Tips

• For patient-applied treatments, patients must be able to identify and reach warts to be treated
• The initial application should be demonstrated by the healthcare provider to ensure proper technique
• Respect the 10 cm² limit for podofilox to prevent systemic absorption
• Evaluate risk-benefit ratio throughout therapy to avoid overtreatment
• Sexual contact should be avoided while topical treatments are on the skin

By following this treatment approach, most patients with penile warts can achieve clearance, though recurrence remains a common challenge requiring patient education and possibly repeated treatment courses.