What is a recommended topical treatment for genital warts?

Topical Genital Wart Treatment Options

The CDC recommends three patient-applied topical treatments for genital warts: podofilox 0.5% solution or gel, imiquimod 5% cream, and sinecatechins 15% ointment. 1

First-Line Patient-Applied Treatments

Podofilox 0.5%

• Podofilox is an antimitotic drug that destroys warts through direct cytotoxic effects and is relatively inexpensive, easy to use, and safe for self-application. 1
• Apply with a cotton swab (solution) or finger (gel) to visible genital warts, limiting treatment area to ≤10 cm² of wart tissue. 1
• Common side effects include mild to moderate pain or local irritation. 1
• Contraindicated in pregnancy as safety has not been established. 1

Imiquimod 5% Cream

• Imiquimod is a topically active immune enhancer that stimulates production of interferon and other cytokines. 1
• Apply with a finger at bedtime three times per week for up to 16 weeks, washing the treatment area with mild soap and water 6-10 hours after application. 2, 3
• Many patients achieve clearance by 8-10 weeks or sooner. 2
• May weaken condoms and vaginal diaphragms, so concurrent use is not recommended. 3
• Not recommended during pregnancy as safety has not been established. 1, 2
• Local skin reactions (erythema, erosion, excoriation/flaking, edema) are common but typically mild to moderate. 3

Sinecatechins 15% Ointment

• Green tea extract with catechins as the active ingredient. 1
• Apply three times daily until complete clearance of warts, but not longer than 16 weeks. 1
• May weaken condoms and diaphragms. 1
• Not recommended for HIV-infected or immunocompromised persons, or during pregnancy. 1

Treatment Selection Algorithm

Choose based on the following hierarchy: 4

1. Wart location: Moist surfaces and intertriginous areas respond better to topical treatments than dry surfaces. 1, 4
2. Patient ability: Can the patient identify and reach the warts for self-application? 4
3. Pregnancy status: If pregnant, avoid all patient-applied options and use provider-administered TCA/BCA instead. 1, 4
4. Immunocompromised status: Avoid sinecatechins in HIV-infected or immunocompromised patients. 1
5. Patient preference: Between podofilox (faster acting, more irritation) versus imiquimod (immune-based, longer duration). 4

Critical Treatment Monitoring

• Change treatment if no substantial improvement after 8 weeks of patient-applied therapy. 4
• Follow-up visit after several weeks can assess response and address concerns, though routine follow-up is not required for self-administered therapy. 4, 2

Essential Caveats

• Treatment removes visible warts but does not eradicate HPV infection or affect its natural history. 1
• Recurrence rates are high with all treatment modalities. 4
• Untreated warts may resolve spontaneously, remain unchanged, or increase in size/number. 1
• Treatment complications may include persistent hypopigmentation or hyperpigmentation, depressed or hypertrophic scars, or rare chronic pain syndromes. 1, 4
• The effect on future HPV transmission remains unclear. 4