What is the treatment for genital warts caused by Human Papillomavirus (HPV)?

Treatment of Genital Warts Caused by HPV

The primary goal of treating genital warts is removal of visible lesions to ameliorate symptoms and cosmetic concerns, not HPV eradication—treatment should be guided by patient preference, with first-line options being patient-applied podofilox or imiquimod, or provider-administered cryotherapy. 1

Understanding Treatment Goals and Limitations

• Treatment removes visible warts but does NOT eradicate HPV infection and does not affect the natural history of the virus 1
• No evidence indicates that treating genital warts reduces the risk of cervical cancer development 1
• Recurrence rates are high (approximately 25-30%) with ALL treatment modalities, regardless of which therapy is chosen 1, 2, 3
• Spontaneous resolution occurs in 20-30% of untreated cases within 3 months, making observation an acceptable alternative for some patients 1

Diagnosis

• Diagnosis is clinical, made by visual inspection alone—no additional testing is routinely needed 1, 2
• Biopsy is indicated ONLY when: diagnosis is uncertain, lesions don't respond to standard therapy, disease worsens during treatment, lesions are atypical/pigmented/indurated/fixed/bleeding/ulcerated, or the patient is immunocompromised 1, 2
• HPV DNA testing is NOT recommended for diagnosis or management of visible genital warts 1, 4

Treatment Selection Algorithm

Choose treatment based on:

• Wart size, number, and anatomic location 1, 2
• Patient preference and ability to apply medication correctly 1
• Cost and convenience considerations 1
• Warts on moist surfaces or intertriginous areas respond best to topical treatments 1, 3

First-Line Patient-Applied Therapies

Podofilox 0.5% Solution or Gel

• Apply twice daily for 3 consecutive days, followed by 4 days of no therapy—repeat cycle up to 4 times 1, 2, 4
• Total treatment area must not exceed 10 cm², and total volume must not exceed 0.5 mL per day 1, 2, 4
• Provider should demonstrate proper application technique and identify which warts to treat at initial visit 1
• Contraindicated in pregnancy 1
• Cost-effective at approximately $200-300 per treatment course 5

Imiquimod Cream

• Immune response modifier that induces interferon and other cytokines at the treatment site 6, 7
• Good clearance rates with generally tolerable side effects in controlled trials 7
• Can cause hypopigmentation or hyperpigmentation 1
• Contraindicated in pregnancy 1

First-Line Provider-Administered Therapies

Cryotherapy with Liquid Nitrogen

• Destroys warts by thermal-induced cytolysis 2
• Relatively inexpensive, requires no anesthesia, and does not cause scarring when performed properly 2
• Repeat applications every 1-2 weeks 1
• Cost approximately $200-300 per successful treatment course 5

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

• Destroys warts by chemical coagulation of proteins 2
• Can be neutralized with soap or sodium bicarbonate if pain is intense 2
• Less consistent results compared to other modalities 8

Surgical Removal

• Options include tangential scissor excision, tangential shave excision, curettage, or electrosurgery 1
• More effective than cryotherapy (93% efficacy with 29% recurrence in randomized trials) 1
• Useful for extensive warts or treatment failures 1

Alternative Provider-Administered Therapy

Podophyllin Resin 10-25%

• Applied by provider in compound tincture of benzoin 1
• Contraindicated in pregnancy 1

Therapies NOT Recommended

• Interferon (systemic or intralesional): No more effective than placebo, expensive, high frequency of adverse effects 1
• 5-Fluorouracil cream: Not evaluated in controlled studies, frequently causes local irritation 1

Treatment Response Monitoring

• Most genital warts respond within 3 months of therapy 1
• Change treatment modality if no substantial improvement after a complete course or if severe side effects occur 1
• Small warts present less than 1 year respond better to treatment 1

Special Populations

Pregnancy

• Imiquimod, sinecatechins, podophyllin, and podofilox are contraindicated 1
• Warts can proliferate and become friable during pregnancy 1
• Resolution may be incomplete until pregnancy is complete 1
• Cesarean delivery should NOT be performed solely to prevent HPV transmission to newborn 1

HIV-Infected/Immunosuppressed Patients

• May have larger, more numerous warts that are more recalcitrant to treatment 1, 3
• More frequent recurrences after treatment 1
• Same treatment modalities should be used, but may require more aggressive or prolonged therapy 1
• Higher risk of squamous cell carcinoma—biopsy atypical lesions 1

Common Pitfalls to Avoid

• Avoid expensive therapies, toxic therapies, and procedures causing scarring for limited disease 1
• Do not use laser or conventional surgery for limited lesions—reserve for extensive or refractory disease 1
• Ensure adequate healing time between treatments to prevent hypertrophic or depressed scars 1
• Persistent hypopigmentation or hyperpigmentation commonly occurs with ablative modalities 1