What are the treatment options for anogenital warts?

Treatment Options for Anogenital Warts

Multiple effective treatment options are available for anogenital warts, with provider-administered treatments like TCA/BCA 80-90% and cryotherapy offering the highest efficacy rates, while patient-applied treatments like podofilox and imiquimod provide convenient alternatives with moderate efficacy. 1, 2

First-Line Treatment Options

Patient-Applied Treatments

1. Podofilox 0.5% solution or gel

   • Apply twice daily for 3 days, followed by 4 days without treatment
   • Repeat for up to 4 cycles (total 4 weeks)
   • Efficacy: 45-88% clearance rate
   • Limitations: Not for use in pregnancy, on open lesions, or areas >10 cm²
   • Total volume should not exceed 0.5 mL per day 1, 3

2. Imiquimod 5% cream

   • Apply once daily at bedtime, three times weekly for up to 16 weeks
   • Wash off after 6-10 hours
   • Efficacy: ~35% clearance rate
   • Common side effects: Local inflammatory reactions (erythema, irritation)
   • Limitations: May weaken condoms and diaphragms; not established for use in pregnancy 1, 4, 5
   • Recurrence rates: 13-23% at 3-6 months 5, 6

3. Sinecatechin 15% ointment (green tea extract)

   • Apply three times daily for up to 16 weeks
   • Do not wash off after application
   • Avoid sexual contact while ointment is on skin
   • Common side effects: Erythema, pruritus/burning, pain
   • Limitations: Not recommended for HIV-infected or immunocompromised patients 1

Provider-Administered Treatments

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

   • Applied by provider weekly as needed
   • Apply small amount only to warts until white "frosting" develops
   • Neutralize excess with talc, sodium bicarbonate, or liquid soap
   • Efficacy: 81% clearance rate 1, 2

2. Cryotherapy with liquid nitrogen

   • Applied every 1-2 weeks
   • Efficacy: 63-88% clearance rate
   • Common side effects: Pain, necrosis, blistering
   • Safe to use during pregnancy 1, 2

3. Surgical removal

   • Options: Tangential scissor excision, shave excision, curettage, or electrosurgery
   • Efficacy: 93% clearance rate
   • Recurrence rate: 29% 1, 2

4. Podophyllin resin 10-25%

   • Applied by provider weekly
   • Allow to air-dry before contact with clothing
   • Wash off after 1-4 hours
   • Limitations: Application should be limited to <0.5 mL or area <10 cm²
   • Contraindicated in pregnancy 1

Treatment Algorithm Based on Wart Location

External Genital Warts

• First-line: Patient-applied treatments (podofilox, imiquimod, sinecatechin)
• Alternative: Provider-administered treatments (TCA/BCA, cryotherapy, surgical removal)

Urethral Meatus Warts

• First-line: Cryotherapy with liquid nitrogen
• Alternative: Surgical removal
• Limited data on podofilox and imiquimod for this location 1

Anal Warts

• First-line: Cryotherapy with liquid nitrogen
• Alternative: TCA/BCA 80-90% or surgical removal
• Consult specialist for intra-anal warts 1

Oral Warts

• First-line: Cryotherapy with liquid nitrogen
• Alternative: Surgical removal or electrocautery 1

Special Populations

Pregnancy

• Avoid: Podofilox, podophyllin, imiquimod, sinecatechin
• Preferred options: TCA/BCA or cryotherapy 1, 2

HIV-Infected/Immunocompromised Patients

• May have lower response rates to standard treatments
• Avoid sinecatechin
• May require more aggressive or prolonged therapy 1, 2

Treatment Monitoring and Follow-up

• Change treatment if no substantial improvement after three provider-administered treatments
• Consider alternative approach if warts haven't cleared after six treatments or after completing recommended cycles for patient-applied treatments 2
• No follow-up needed after warts have responded to therapy 1
• Annual cervical cytologic screening recommended for women with or without genital warts 1

Common Pitfalls and Caveats

1. Overtreatment: Excessive application of caustic agents like TCA/BCA can damage surrounding healthy tissue
2. Undertreatment: Inadequate treatment cycles may lead to persistence of warts
3. Recurrence: Warts may recur even after successful treatment (recurrence rates 13-39% depending on treatment)
4. Partner management: Examination of sex partners is not necessary for management of genital warts, though partners may benefit from counseling 1
5. Patient expectations: Counsel patients that treatments target the warts but not the underlying HPV infection, which may persist 1
6. Spontaneous resolution: 20-30% of warts resolve without treatment within 3 months, making watchful waiting an acceptable option in some cases 2