What are the treatment options for genital penile warts caused by Human Papillomavirus (HPV)?

Treatment Options for Genital Penile Warts

The primary treatments for genital penile warts include patient-applied therapies (podofilox, imiquimod, and sinecatechins) and provider-administered therapies (cryotherapy, TCA/BCA application, and surgical removal), with selection based on wart characteristics, location, and patient preference. 1

Diagnosis

• Diagnosis of genital warts is primarily clinical, made through visual inspection 1, 2
• Biopsy is indicated only in specific circumstances: uncertain diagnosis, lesions unresponsive to standard therapy, worsening during therapy, atypical lesions, immunocompromised patients, or pigmented/indurated/fixed/bleeding/ulcerated warts 1, 2
• Acetic acid application is not recommended as a specific test for HPV infection 1, 2

Patient-Applied Treatment Options

Podofilox 0.5% Solution or Gel

• Applied by patient twice daily for 3 days, followed by 4 days of no therapy; cycle may be repeated up to 4 cycles 1, 3
• Total treatment area should not exceed 10 cm², with total volume not exceeding 0.5 mL per day 1, 3
• Contraindicated during pregnancy 3
• Common side effects include mild to moderate pain or local irritation 3

Imiquimod 5% Cream

• Immune enhancer that stimulates production of interferon and other cytokines 4, 5
• Applied three times weekly for up to 16 weeks 3, 5
• May weaken condoms and vaginal diaphragms 3
• Not recommended during pregnancy 3
• Complete clearance occurs in 37-50% of immunocompetent patients, with higher success rates in women than men 5

Sinecatechins 15% Ointment

• Green tea extract with catechins as active ingredients 3, 6
• Applied three times daily until complete clearance, but not longer than 16 weeks 3, 6
• May weaken condoms and diaphragms 6
• Not recommended for HIV-infected or immunocompromised persons, or during pregnancy 3, 6
• Complete clearance rates of 53.6% overall (47.3% in males, 60.4% in females) 6

Provider-Administered Treatment Options

Cryotherapy with Liquid Nitrogen

• Destroys warts by thermal-induced cytolysis 1
• Relatively inexpensive, does not require anesthesia, and does not result in scarring if performed properly 1
• Local anesthesia may be needed if warts are present in many areas or if the area is large 1
• Common side effects include pain, necrosis, and sometimes blistering 1

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

• Caustic agents that destroy warts by chemical coagulation of proteins 1
• Apply small amount only to warts and allow to dry until white frosting develops 1
• Can be neutralized with soap or sodium bicarbonate if pain is intense 1
• If excess acid is applied, powder with talc, sodium bicarbonate, or liquid soap to remove unreacted acid 1
• Treatment can be repeated weekly if necessary 1

Surgical Removal

• Advantages include usually eliminating warts in a single visit 1
• Requires substantial clinical training, additional equipment, and longer office visit 1
• Options include electrocautery, tangential excision with scissors or scalpel, laser, or curettage 1
• Most beneficial for patients with large number or area of genital warts 1
• Carbon dioxide laser and surgery might be useful for extensive warts or intraurethral warts 1

Treatment Selection Considerations

• Factors influencing treatment choice include wart size, number, anatomic site, morphology, patient preference, cost, convenience, adverse effects, and provider experience 1, 3
• Warts on moist surfaces or intertriginous areas respond better to topical treatment than warts on drier surfaces 1, 3
• No single treatment is ideal for all patients or all warts 1, 7
• First-line destructive treatment is typically cryotherapy, though surgery and electrodesiccation may be more effective 8
• First-line topical treatments are generally considered to be podofilox and imiquimod 8

Important Caveats

• Treatment removes visible warts but does not eradicate HPV infection or affect its natural history 1, 3
• Recurrence rates are high (approximately 25-30%) with all treatment modalities 1, 3
• Untreated warts may resolve spontaneously (20-30% within 3 months), remain unchanged, or increase in size/number 1
• Treatment complications are rare when properly administered but may include persistent hypopigmentation or hyperpigmentation, depressed or hypertrophic scars, or rare chronic pain syndromes 1, 3
• Special considerations apply to immunocompromised patients, who may have larger or more numerous warts, poorer response to therapy, higher recurrence rates, and increased risk of malignancy 2