What are the treatment options for Human Papillomavirus (HPV)?

HPV Treatment

There is no cure for HPV infection itself—treatment focuses exclusively on removing visible genital warts to alleviate symptoms and cosmetic concerns, not on eradicating the virus. 1, 2, 3

Critical Understanding: Treatment Goals vs. Viral Eradication

The primary goal is removal of visible warts and symptom relief, NOT HPV eradication. 1, 2 No therapy has been shown to eradicate HPV, as the virus persists in adjacent tissue even after aggressive laser vaporization or surgical excision. 1 Treatment does not reduce cervical cancer risk and has uncertain effects on transmission. 1, 2

Natural History Without Treatment

• 20-30% of genital warts resolve spontaneously within 3 months without any intervention. 1, 2
• Untreated warts may remain unchanged or grow in size/number. 2
• Most recurrences result from reactivation of subclinical infection rather than reinfection by partners. 1, 2

Treatment Selection Algorithm

Treatment should be guided by patient preference, wart characteristics (size, number, location), cost, convenience, and potential adverse effects. 1, 2 Avoid expensive therapies, toxic treatments, and procedures causing scarring. 1

First-Line Topical Therapies (Patient-Applied)

• Podofilox 0.5% solution: Apply twice daily for 3 days, followed by 4 days off therapy, repeat for up to 4 cycles. 2
• Imiquimod 5% cream: Apply 3 times weekly for up to 16 weeks until warts clear or maximum duration reached. 2
• Sinecatechins 15% ointment: Apply three times daily to all warts using approximately 0.5 cm strand per wart for up to 16 weeks (FDA-approved for immunocompetent patients ≥18 years). 4

Provider-Applied Therapies

• Cryotherapy with liquid nitrogen: First-line option applied every 1-2 weeks with 63-88% efficacy and 21-39% recurrence rates. 5, 2
• Trichloroacetic acid (TCA) 80-90%: Apply only to warts, powder with talc or sodium bicarbonate to remove unreacted acid, repeat weekly as needed. 5, 2

Surgical Options for Extensive/Refractory Disease

• Surgical excision (tangential scissor, shave excision, electrosurgery): 93% efficacy with 29% recurrence rate. 5
• Carbon dioxide laser and conventional surgery: Reserved for extensive warts or treatment failures, though one trial showed only 43% efficacy with 95% recurrence. 1

Treatment Efficacy and Expectations

• Current therapeutic methods demonstrate 22-94% effectiveness in clearing warts. 1
• Recurrence rates are high (at least 25% within 3 months) with ALL modalities. 1, 2
• Treatment is more successful for small warts present less than 1 year. 1
• Most warts respond within 3 months of therapy. 2
• Change treatment modality if no substantial improvement after complete course or if severe side effects occur. 2

Special Populations

Pregnancy

• Avoid podofilox, podophyllin, and imiquimod during pregnancy. 5
• Use cryotherapy and TCA as safer alternatives. 5
• Consider wart removal as they can proliferate and become friable during pregnancy. 5

HIV-Infected Patients

• May have larger, more numerous warts with poorer treatment response and more frequent recurrences. 2
• Higher risk for squamous cell carcinomas arising in warts. 2

Purulent Drainage/Secondary Infection

• Never treat warts in the presence of active purulent infection—this increases treatment failure, scarring, and systemic complications. 5
• Initiate empiric antibiotic coverage targeting Staphylococcus aureus and Streptococcus species. 5
• Obtain wound culture if infection doesn't respond to empiric treatment. 5
• Assess for abscess requiring incision and drainage before wart-directed therapy. 5

Critical Pitfalls to Avoid

• Do not use Veregen (sinecatechins) for urethral, intravaginal, cervical, rectal, or intra-anal HPV disease. 4
• Avoid use on open wounds. 4
• Avoid sun/UV-light exposure to treated areas. 4
• Avoid extensive or aggressive treatment causing scarring, chronic pain, or painful defecation. 5

Prevention

• Quadrivalent HPV vaccine (Gardasil) prevents infection with HPV types 6 and 11, which cause 90% of genital warts. 2
• Recommended for males and females aged 9-26 years, even if already diagnosed with HPV. 2
• Consistent condom use may reduce but not eliminate transmission risk, as HPV infects areas not covered by condoms. 2

Patient Counseling Essentials

• HPV types 6 and 11 cause over 90% of genital warts and are low-risk types that do not cause cancer. 5
• Treatment targets visible warts but does not eliminate the underlying virus. 5
• Recurrence is common (approximately 30%) regardless of treatment method due to reactivation of subclinical infection. 5, 2
• HPV diagnosis does not necessarily indicate sexual infidelity in a relationship. 2
• Most common adverse reactions include erythema, pruritus, burning, pain/discomfort, erosion/ulceration, edema, induration, and vesicular rash (incidence ≥20%). 4