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

HPV Treatment

For visible genital warts, treatment focuses on removing the warts to alleviate symptoms and cosmetic concerns, not on eradicating HPV, which cannot be eliminated with current therapies. 1, 2

Key Treatment Principle

Treatment targets visible warts only and does not eliminate the underlying virus or prevent future transmission. 1, 3 Approximately 20-30% of untreated warts resolve spontaneously within 3 months, making observation a reasonable option for asymptomatic patients. 1, 4

First-Line Treatment Options

Patient-Applied Therapies

• Podofilox 0.5% solution or gel: Apply twice daily for 3 consecutive days, followed by 4 days off therapy; repeat cycle up to 4 times. 1, 4 Limit treatment area to ≤10 cm² and volume to ≤0.5 mL per day. 4
• Imiquimod 5% cream: Applied by patient at bedtime 3 times per week for up to 16 weeks. 1
• Sinecatechins 15% ointment: Apply three times daily to all warts using approximately 0.5 cm strand per wart, continuing until complete clearance for up to 16 weeks. 5

Provider-Administered Therapies

• Cryotherapy with liquid nitrogen: Apply every 1-2 weeks until warts clear; efficacy 63-88% with recurrence rates of 21-39%. 1, 2 This is relatively inexpensive, requires no anesthesia, and causes no scarring when performed correctly. 4
• Trichloroacetic acid (TCA) 80-90%: Apply only to warts, powder with talc or sodium bicarbonate to neutralize unreacted acid, repeat weekly as needed. 1, 2 Can be neutralized with soap if pain is intense. 4
• Surgical excision: Use tangential scissor excision, shave excision, or electrosurgery for extensive disease; efficacy 93% with 29% recurrence rate. 2

Anatomic Site-Specific Recommendations

• Vaginal warts: Use cryotherapy with liquid nitrogen (avoid cryoprobe due to perforation risk) or TCA/BCA 80-90%. 3
• Urethral meatus warts: Use cryotherapy with liquid nitrogen or podophyllin 10-25% in compound tincture of benzoin. 3
• Anal warts: Use cryotherapy or TCA/BCA 80-90%; consult specialist for intra-anal warts. 3

Critical Management Considerations

When Active Infection is Present

Never treat warts in the presence of active purulent infection or drainage. 2 First initiate empiric antibiotic coverage targeting Staphylococcus aureus and Streptococcus species, obtain wound cultures, and assess for abscess requiring incision and drainage. 2 Only proceed with wart-directed therapy after infection resolution. 2

Pregnancy Modifications

Avoid podofilox, podophyllin, and imiquimod during pregnancy. 2, 3 Use only cryotherapy and TCA as safer alternatives. 2 Many experts recommend removing genital warts during pregnancy as they can proliferate and become friable. 2, 3

Immunocompromised Patients

Immunosuppressed patients may not respond as well to therapy, have more frequent recurrences, and are at higher risk for squamous cell carcinomas arising in or resembling genital warts. 3 These patients require biopsy more frequently to confirm diagnosis. 1

Expected Outcomes and Follow-Up

Most genital warts respond within 3 months of therapy. 1 Change treatment modality if no substantial improvement occurs after a complete course or if side effects are severe. 1 Recurrence is common (approximately 25-30%) regardless of treatment method, primarily due to reactivation of subclinical infection rather than reinfection. 1, 3, 4

Important Pitfalls to Avoid

• Never use extensive or aggressive treatment that may result in scarring, chronic pain syndromes (vulvodynia, hyperesthesia), painful defecation, or fistulas. 1, 2
• Do not use acetic acid soaks as a screening test for subclinical HPV infection due to high false-positive rates and lack of specificity. 1, 3
• Do not treat subclinical HPV infection diagnosed by Pap smear, colposcopy, or HPV DNA testing in the absence of dysplasia. 1
• Avoid treating urethral, intravaginal, cervical, rectal, or intra-anal HPV disease with topical agents designed for external warts. 5

Patient Counseling Points

Inform patients that HPV types 6 and 11 cause over 90% of genital warts and are low-risk types that do not cause cancer. 2 Treatment removes visible warts but does not eliminate the virus or affect its natural history. 2, 4 The virus can remain dormant for long periods, so new warts do not necessarily indicate recent exposure or partner infidelity. 3

Cervical Cancer Screening

All women with HPV infection should undergo cervical cancer screening following standard age-appropriate guidelines. 3 Women with abnormal Pap test results require referral for colposcopy and directed biopsy. 3