What are the treatment options for Human Papillomavirus (HPV) infection?

Treatment Options for Human Papillomavirus (HPV) Infection

There is no specific treatment for HPV infection itself, but treatments are available for the conditions caused by HPV, with options varying based on the type and location of lesions. 1

Treatment of Genital Warts

First-Line Treatment Options

1. Patient-Applied Therapies:

   • Podofilox 0.5% solution or gel: Apply twice daily for 3 days, followed by 4 days without treatment. Maximum area of 10 cm² and maximum volume of 0.5 ml per day. Contraindicated during pregnancy. 2
   • Imiquimod cream: Acts by stimulating the local immune response. 2
   • Sinecatechins 15% ointment: Apply three times daily to all external genital and perianal warts. Not for use on open wounds or urethral, intravaginal, cervical, rectal, or intra-anal warts. 3

2. Provider-Applied Therapies:

   • Cryotherapy with liquid nitrogen: Recommended for small, well-defined lesions. Can be repeated weekly if necessary. 1, 2
   • Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90%: Apply only to warts and allow to dry until a white frosting develops. Excess acid should be neutralized with talc, sodium bicarbonate, or liquid soap. Can be repeated weekly if necessary. 1, 2
   • Podophyllin 10%-25% in compound tincture of benzoin: Limited to ≤0.5 ml or ≤10 cm² per session to avoid systemic toxicity. Contraindicated during pregnancy. 1, 2

Second-Line Treatment Options

1. Surgical removal: Has higher efficacy (93%) with lower recurrence rate (29%) compared to other methods. 2
2. Carbon dioxide laser therapy: Useful for extensive warts, particularly for patients who have not responded to other regimens. Efficacy of 43% but high recurrence rate (95%). 2

Treatment Based on Anatomical Location

1. Vaginal Warts:

   • Cryotherapy with liquid nitrogen (avoid cryoprobe due to risk of perforation)
   • TCA or BCA 80%-90% 1

2. Urethral Meatus Warts:

   • Cryotherapy with liquid nitrogen
   • Podophyllin 10%-25% in compound tincture of benzoin 1

3. Anal Warts:

   • Cryotherapy with liquid nitrogen
   • TCA or BCA 80%-90%
   • Surgical removal 1

4. Intra-anal Warts:

   • Should be managed in consultation with a specialist
   • Patients may benefit from inspection of the rectal mucosa by digital examination, standard anoscopy, or high-resolution anoscopy 1

Important Clinical Considerations

1. Treatment Efficacy and Recurrence:

   • Available treatments have efficacy rates of 22%-94% for eliminating external genital warts 2
   • Recurrence rates are high (at least 25% within 3 months) with all treatment modalities 2
   • Treatment is more successful for warts that are small and have been present for less than 1 year 2

2. Natural History:

   • If left untreated, genital warts may resolve spontaneously (20-30% in 3 months), remain unchanged, or increase in size/number 1, 2
   • Active surveillance may be appropriate for certain types of lesions 2

3. Special Populations:

   • Individuals with HIV may not respond to HPV therapy as well as those without HIV 2
   • For pregnant women, avoid podophyllin and podofilox 1

Prevention of HPV Infection

1. HPV Vaccination:

   • Recommended for girls and boys aged 9-26 years 1, 2
   • Two vaccines are available: bivalent (HPV types 16,18) and quadrivalent (HPV types 6,11,16,18) 1
   • The nonavalent vaccine covers HPV types 6,11,16,18,31,33,45,52, and 58 1
   • Most effective when administered before sexual contact 1
   • Consider vaccination for high-risk populations including:
     • HIV-infected patients
     • Men who have sex with men (MSM)
     • Immunocompromised patients 1

2. Safe Sexual Practices:

   • Correct and consistent condom use may reduce transmission, but is not fully protective 1, 2
   • Limiting number of sexual partners 1
   • Abstinence is the surest way to prevent infection 2

Patient Counseling Points

1. HPV infection is very common, with most sexually active adults contracting it at some point 1
2. Most HPV infections clear spontaneously without causing health problems 1, 4
3. The types of HPV that cause genital warts are different from those that cause cancer 1
4. Within ongoing sexual relationships, both partners are usually infected when one person is diagnosed 1
5. HPV diagnosis in one partner does not indicate infidelity 1
6. HPV does not affect fertility or ability to carry a pregnancy 1

Treatment Pitfalls to Avoid

1. Do not use podophyllin or podofilox during pregnancy 1, 2
2. Avoid using cryoprobe in the vagina due to risk of perforation 1
3. Do not use sinecatechins on open wounds or for urethral, intravaginal, cervical, rectal, or intra-anal warts 3
4. Do not exceed recommended treatment areas or volumes for podophyllin to avoid systemic toxicity 2
5. Remember that no treatment completely eliminates HPV from the body 1, 5