What are the treatment options for genital warts?

Treatment of Genital Warts

Treatment should be guided by patient preference between patient-applied and provider-administered options, as no single treatment has proven superior to others, and both categories offer effective wart clearance. 1

Treatment Decision Framework

Choose between patient-applied or provider-administered therapy based on:

• Patient ability to identify and reach warts 1
• Number and size of warts (most patients have <10 warts with total area 0.5-1.0 cm²) 1
• Anatomic location (moist surfaces and intertriginous areas respond better to topical treatments than dry surfaces) 1
• Patient preference for self-treatment versus office visits 1
• Cost and convenience considerations 1

Important principle: Observation without treatment is acceptable, as spontaneous resolution can occur. 1

Patient-Applied Options (Home Treatment)

Podofilox 0.5% Solution or Gel

• Most effective patient-administered therapy for wart removal 2
• Apply twice daily for 3 consecutive days, then withhold for 4 consecutive days 1, 3
• Repeat this weekly cycle up to 4 times 1, 3
• Limit treatment to <10 cm² total wart area and ≤0.5 mL volume per day 1, 3
• Apply with cotton swab (solution) or finger (gel) 1, 3
• Provider should demonstrate initial application technique 1, 3
• Relatively inexpensive, easy to use, and safe 1
• Common side effects: mild to moderate pain or local irritation 1, 4
• Contraindicated in pregnancy 1, 4, 2

Imiquimod 5% Cream

• Apply once daily at bedtime, 3 times per week for up to 16 weeks 1, 5
• Wash treatment area with mild soap and water 6-10 hours after application 1, 5
• Many patients achieve clearance by 8-10 weeks 1, 6
• Works as immune enhancer stimulating interferon and cytokine production 1, 4
• More frequent application (daily or multiple times daily) does not improve clearance and increases adverse events 7
• Common side effects: mild to moderate local inflammatory reactions (erythema, erosion, edema) 5
• May weaken condoms and vaginal diaphragms 4, 5
• Contraindicated in pregnancy 1, 4, 2

Sinecatechins 15% Ointment

• Apply 3 times daily until complete clearance, maximum 16 weeks 4
• Green tea extract with catechins as active ingredient 4
• May weaken condoms and diaphragms 4
• Not recommended for HIV-infected or immunocompromised persons 4
• Contraindicated in pregnancy 4, 2

Provider-Administered Options

Cryotherapy with Liquid Nitrogen

• Most commonly used provider-administered treatment with 63-88% efficacy 4
• Repeat applications every 1-2 weeks 1, 4
• Destroys warts by thermal-induced cytolysis 1, 4
• Does not result in scarring if performed properly 4
• Requires substantial training for proper technique 1
• Common side effects: pain after application, necrosis, sometimes blistering 1
• Local anesthesia may facilitate treatment for numerous or large warts 1

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

• Apply small amount only to warts until white "frosting" develops 1, 4
• Neutralize excess with talc, sodium bicarbonate, or soap 1, 4
• Repeat weekly if necessary 1, 4
• Destroys warts by chemical coagulation of proteins 1, 4
• Can be used in pregnancy (unlike other topical agents) 1

Podophyllin Resin 10-25% in Compound Tincture of Benzoin

• Apply to each wart and allow to air dry 1
• Limit to ≤0.5 mL or ≤10 cm² per session to avoid systemic toxicity 1, 4
• Wash off thoroughly 1-4 hours after application 1
• Repeat weekly if necessary 1
• Contraindicated in pregnancy 1, 4

Surgical Removal

• Most effective for wart removal at end of treatment (along with CO₂ laser and electrosurgery) 2
• Options include tangential scissor excision, tangential shave excision, curettage, or electrosurgery 1

Alternative Regimens

• Intralesional interferon 1
• Laser surgery 1
• CO₂ laser therapy (most effective for wart removal) 2

Treatment Monitoring and Modification

Change treatment modality if: 1

• No substantial improvement after 3 provider-administered treatments
• Warts not completely cleared after 6 treatments
• No improvement after 8 weeks of patient-applied therapy 6

Follow-up considerations: 6

• Routine follow-up not required for self-administered therapy
• Follow-up visit after several weeks can assess response and address concerns

Critical Warnings and Complications

Common complications with ablative treatments: 1

• Persistent hypopigmentation or hyperpigmentation (common)
• Depressed or hypertrophic scars (uncommon, especially with insufficient healing time between treatments)

Rare but serious complications: 1

• Disabling chronic pain syndromes (vulvodynia or hyperesthesia of treatment site)

Important limitations of all treatments: 4

• Treatment removes visible warts but does not eradicate HPV infection
• Does not affect natural history of HPV
• Recurrence rates are high with all treatment modalities 4
• Effect on future transmission remains unclear 1

Special precautions for women: 5

• Avoid application inside vagina (considered internal use)
• Local reactions on moist surfaces can cause pain, swelling, and urinary difficulties
• Take special care when applying at vaginal opening

Special precautions for uncircumcised males: 5

• Retract foreskin and clean area daily when treating warts under foreskin