Treatment Options for Genital Warts
The most effective treatments for genital warts include patient-applied therapies such as podofilox 0.5% solution/gel and provider-administered therapies like cryotherapy with liquid nitrogen, with treatment selection based on wart characteristics, location, and patient preference. 1, 2
Patient-Applied Treatment Options
- Podofilox 0.5% solution or gel is applied twice daily for 3 days, followed by 4 days of no therapy; this cycle may be repeated up to 4 times 1, 3
- Total treatment area should not exceed 10 cm², with total volume not exceeding 0.5 mL per day 3
- Podofilox is relatively inexpensive, easy to use, and safe for self-application, with common side effects including mild to moderate pain or local irritation 2
- Imiquimod 5% cream is applied three times weekly at bedtime for up to 16 weeks, with the treatment area washed 6-10 hours after application 2, 4
- Imiquimod stimulates production of interferon and other cytokines to activate the immune response against the virus 5
- Both podofilox and imiquimod are contraindicated during pregnancy 2, 4
Provider-Administered Treatment Options
- Cryotherapy with liquid nitrogen destroys warts by thermal-induced cytolysis and is relatively inexpensive, does not require anesthesia, and doesn't result in scarring if performed properly 1
- Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90% are caustic agents that destroy warts by chemical coagulation of proteins 6
- Podophyllin resin 10-25% in compound tincture of benzoin can be applied by providers, but application should be limited to ≤0.5 mL or ≤10 cm² per session to avoid systemic absorption 6
- Surgical removal options include electrocautery, tangential excision with scissors or scalpel, laser therapy, or curettage for extensive warts or those unresponsive to other treatments 6
Treatment Selection Considerations
- Factors influencing treatment choice include wart size, number, anatomic site, morphology, patient preference, cost, convenience, adverse effects, and provider experience 1
- Warts on moist surfaces or intertriginous areas respond better to topical treatments than warts on drier surfaces 2
- The treatment modality should be changed if a patient has not improved substantially after three provider-administered treatments or if warts have not completely cleared after six treatments 6
- For women with exophytic cervical warts, high-grade squamous intraepithelial lesions must be excluded before treatment is initiated 6
Special Anatomic Site Considerations
- For vaginal warts: Cryotherapy with liquid nitrogen (avoiding cryoprobe due to perforation risk) or TCA/BCA 80-90% 6
- For urethral meatus warts: Cryotherapy with liquid nitrogen or podophyllin 10-25% in compound tincture of benzoin 6
- For anal warts: Cryotherapy with liquid nitrogen, TCA/BCA 80-90%, or surgical removal 6
- Intra-anal warts should be managed in consultation with a specialist 6
Important Caveats
- Treatment removes visible warts but does not eradicate HPV infection or affect its natural history 1, 2
- Untreated warts may resolve spontaneously (20-30% within 3 months), remain unchanged, or increase in size/number 6, 1
- Recurrence rates are high (approximately 25-30%) with all treatment modalities 2, 7
- Treatment can result in persistent hypopigmentation or hyperpigmentation, depressed or hypertrophic scars, or rare complications such as chronic pain syndromes 2
- Imiquimod and other topical treatments may weaken condoms and vaginal diaphragms 4
Treatment Efficacy
- Carbon dioxide laser therapy, surgery, and electrosurgery are the most effective for wart removal at the end of treatment 7
- Podofilox 0.5% solution is the most effective patient-administered therapy 7
- All treatment strategies are associated with some recurrence, but most successfully treated warts do not recur 7