What are the treatment options for genital warts?

Treatment Options for Genital Warts

The most effective treatment approach for genital warts includes patient-applied therapies such as podofilox 0.5% solution or gel and provider-administered therapies such as 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: Apply twice daily for 3 days, followed by 4 days of no therapy; cycle may be repeated up to 4 times until warts clear 3, 2

  • Treatment area should not exceed 10 cm², with total volume not exceeding 0.5 mL per day 3
  • Relatively inexpensive, easy to use, and safe for self-application 2
  • Contraindicated during pregnancy 2

• Imiquimod 5% cream: Apply three times weekly at bedtime for up to 16 weeks 4, 2

  • Treatment area should be washed with mild soap and water 6-10 hours after application 4
  • Works as an immune enhancer that stimulates production of interferon and other cytokines 2, 5
  • May weaken condoms and vaginal diaphragms 4
  • Not recommended during pregnancy 4

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, 6
  • Repeat applications every 1-2 weeks as necessary 6
  • Efficacy ranges from 63-88% in clinical trials 6

• Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90%: Apply only to warts; powder with talc or sodium bicarbonate to remove unreacted acid 6

  • Destroys warts by chemical coagulation of proteins 1
  • Can be neutralized with soap or sodium bicarbonate if pain is intense 1
  • Repeat weekly if necessary 6

• Podophyllin 10-25% in compound tincture of benzoin: Apply only to warts; wash off in 1-4 hours 6

  • Application should be limited to ≤0.5 mL or ≤10 cm² per session 6
  • Contraindicated during pregnancy 6
  • Consider alternative treatments if warts persist after six applications 6

• Surgical removal options for extensive or refractory warts 6:

  • Electrodesiccation or electrocautery (contraindicated for patients with cardiac pacemakers) 6
  • Carbon dioxide laser therapy 6
  • Surgical excision 6

Treatment Selection Considerations

• Factors influencing treatment choice include 1, 6:

  • Wart size, number, and anatomic location
  • Patient preference and ability to comply with treatment
  • Cost and convenience
  • Potential for adverse effects

• Warts on moist surfaces or intertriginous areas respond better to topical treatments than warts on drier surfaces 2, 6

• Treatment should be changed if 6:

  • Patient has not improved substantially after three provider-administered treatments
  • Warts have not completely cleared after six treatments

Important Caveats

• Treatment removes visible warts but does not eradicate HPV infection or affect its natural history 1, 6

• Recurrence rates are high (approximately 25-30%) with all treatment modalities 1, 7

• Untreated warts may resolve spontaneously (20-30% within 3 months), remain unchanged, or increase in size/number 1, 6

• Treatment complications may include 6:

  • Persistent hypopigmentation or hyperpigmentation (common with ablative methods)
  • Depressed or hypertrophic scars (rare)
  • Chronic pain syndromes (rare)

• Special considerations for specific anatomic sites 6:

  • Cervical warts: Require biopsy to exclude high-grade lesions before treatment; consult specialist
  • Vaginal warts: Use cryotherapy or TCA/BCA (avoid cryoprobe due to perforation risk)
  • Urethral meatus warts: Use cryotherapy or podophyllin
  • Anal warts: Use cryotherapy, TCA/BCA, or surgical removal; consult specialist for intra-anal warts