Replacement for Zyclara (Imiquimod 3.75%) Pump
The standard replacement for Zyclara pump is Aldara (imiquimod 5% cream), which is the original formulation of imiquimod and remains the most established topical immune response modifier for treating genital warts and other HPV-related lesions. 1, 2, 3
Primary Alternative: Aldara (Imiquimod 5%)
Aldara is the direct replacement and gold standard formulation, offering the same mechanism of action as Zyclara but at a higher concentration. 3, 4
Application Protocol for Genital Warts:
- Apply with a clean finger at bedtime, three times per week (not daily) for up to 16 weeks 1, 2
- Wash treatment area with mild soap and water 6-10 hours after application (typically morning) 1, 2
- Most patients achieve clearance by 8-10 weeks or sooner 2
- Have the provider demonstrate proper application technique at first visit to identify which warts require treatment 1, 2
Efficacy Data:
- Complete clearance rates of 37-50% in immunocompetent patients 5
- Partial clearance (≥50% reduction) in 76% of patients 5
- Recurrence rates of only 13-19% after complete clearance 5
- Superior to vehicle placebo with 84% clearance when used up to three times weekly for 12 weeks 1
Other Patient-Applied Alternatives
If imiquimod is contraindicated or not tolerated, consider these CDC-recommended patient-applied options: 1
Podofilox (Podophyllotoxin)
- Antimitotic agent that destroys warts through cell cycle arrest 1
- Apply with cotton swab (solution) or finger (gel) twice daily for 3 days, then 4 days off 1
- Repeat cycle up to four times 1
- Limit treatment to ≤10 cm² total area and ≤0.5 mL per day 1
- More affordable than imiquimod but requires more frequent application 1
Sinecatechins 15% Ointment
- Green tea extract with catechins applied three times daily until complete clearance 1
- Maximum duration 16 weeks 1
- Do not wash off after application 1
- Avoid in HIV-infected or immunocompromised patients (safety not established) 1
- Also contraindicated with active genital herpes 1
Provider-Applied Alternatives
When patient-applied therapy is not appropriate: 1
Cryotherapy with Liquid Nitrogen
- Repeat applications every 1-2 weeks until clearance 1
- Highly effective for visible warts 1
- Requires office visits but provides immediate treatment 1
Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA) 80-90%
- Applied by provider and allowed to air-dry 1
- Can be repeated weekly as needed 1
- Effective for smaller lesions 1
Surgical Removal
- Options include tangential scissor excision, shave excision, curettage, or electrosurgery 1
- Immediate removal but invasive 1
Critical Considerations
Safety in Pregnancy:
The safety of imiquimod during pregnancy has not been established - this applies to both Zyclara and Aldara formulations. 1, 2 Consider provider-applied cryotherapy or TCA/BCA instead for pregnant patients. 1
Condom Compatibility:
Both imiquimod formulations may weaken condoms and vaginal diaphragms - counsel patients accordingly. 1
Local Reactions:
Expect mild to moderate local inflammatory reactions including erythema, irritation, induration, and possible ulceration/erosions with imiquimod. 1 These reactions correlate with therapeutic response. 1
Follow-up Strategy:
While routine follow-up is not required for self-administered therapy, schedule a visit after several weeks to assess response, address side effects, and reinforce proper technique. 1, 2 If no substantial improvement by 8 weeks, consider switching treatment modalities. 2
Immunosuppressed Patients:
Imiquimod shows reduced but still meaningful efficacy in HIV-infected and immunosuppressed patients, though clearance rates are lower than in immunocompetent individuals. 1, 5