What is a recommended treatment for genital warts?

Treatment Options for Genital Warts

For genital warts, the recommended first-line treatments are patient-applied podofilox 0.5% solution/gel or imiquimod 5% cream, with provider-administered cryotherapy or trichloroacetic acid (TCA)/bichloroacetic acid (BCA) 80-90% as effective alternatives. 1

Patient-Applied Treatments

Podofilox 0.5% Solution or Gel

• Application: Twice daily for 3 days, followed by 4 days of no therapy
• Duration: Can be repeated for up to 4 cycles
• Efficacy: 45-88% clearance rate
• Limitations:
  • Total wart area treated should not exceed 10 cm²
  • Total volume should not exceed 0.5 mL per day
  • Contraindicated in pregnancy 2, 1

Imiquimod 5% Cream

• Application: Three times weekly at bedtime
• Duration: Up to 16 weeks
• Efficacy:
  • Complete clearance in approximately 50% of patients overall
  • Higher efficacy in women (72%) than men (33%) 3
• Mechanism: Stimulates immune response by inducing interferon and cytokines
• Limitations:
  • Contraindicated in pregnancy
  • May weaken condoms and vaginal diaphragms 1, 3
• Side effects: Local inflammatory reactions (redness, irritation) 3

Provider-Administered Treatments

Cryotherapy with Liquid Nitrogen

• Application: Every 1-2 weeks as needed
• Efficacy: 63-88% clearance
• Recurrence rate: 21-39% 1

Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA) 80-90%

• Application: Weekly as needed
• Technique: Apply small amount until white "frosting" develops
• Neutralization: Use talc or sodium bicarbonate to remove excess
• Efficacy: 81% clearance
• Recurrence rate: 36%
• Particularly effective for warts on moist surfaces or intertriginous areas 2, 1

Treatment Selection Algorithm

1. For small, few warts on dry surfaces:

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

2. For warts on moist surfaces or intertriginous areas:

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

3. For extensive warts:

   • First choice: Provider-administered cryotherapy
   • Alternative: Combination of methods 1

4. For pregnant patients:

   • Avoid podofilox and imiquimod
   • Use TCA/BCA or cryotherapy 1

Important Clinical Considerations

• Change treatment if no substantial improvement after three provider-administered treatments or if warts haven't cleared after six treatments 2, 1

• All treatments have recurrence rates of at least 25% within 3 months 1

• Treatment removes visible warts but does not eradicate HPV infection or prevent transmission 2, 1

• Spontaneous resolution occurs in 20-30% of cases within 3 months, making watchful waiting an acceptable alternative for some patients 1

• Female patients should take special care when applying treatments near the vaginal opening, as local skin reactions on delicate moist surfaces can result in pain, swelling, or urinary difficulties 3

• Uncircumcised males treating warts under the foreskin should retract the foreskin and clean the area daily 3