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, though surgical removal offers the highest single-visit efficacy at 93% when immediate clearance is the priority. 1, 2

Treatment Selection Algorithm

The choice between patient-applied versus provider-administered therapy depends on several key factors:

• Patient ability to identify and reach warts is fundamental to determining feasibility of self-treatment 1
• Wart characteristics: Most patients have <10 warts with total area of 0.5-1.0 cm², which influences treatment intensity 1
• Anatomic location: Warts on moist surfaces and intertriginous areas respond better to topical treatments than those on dry surfaces 1, 3
• Patient preference for self-treatment versus office visits, along with cost and convenience considerations 1

Patient-Applied Treatment Options

First-Line: Podofilox 0.5% Solution or Gel

Podofilox is the most effective patient-administered therapy and should be the initial choice for patients capable of self-application 2, 4:

• Apply twice daily (every 12 hours) for 3 consecutive days, then withhold for 4 consecutive days 5
• This one-week cycle may be repeated up to 4 times until warts clear 5
• Treatment should be limited to <10 cm² of wart tissue and ≤0.5 mL per day 3, 5
• Relatively inexpensive, easy to use, and safe, with common side effects of mild to moderate pain or local irritation 1, 3
• Contraindicated in pregnancy 2, 5, 4

Alternative: Imiquimod 5% Cream

• Apply three times weekly at bedtime for up to 16 weeks 2, 6
• Works as an immune enhancer stimulating interferon and cytokine production 1
• Wash treatment area with mild soap and water 6-10 hours after application 6
• Many patients achieve clearance by 8-10 weeks 1
• Contraindicated in pregnancy and may weaken condoms and diaphragms 2, 6, 4
• More frequent application (daily or multiple times daily) does not improve clearance and increases adverse events 7

Third Option: Sinecatechins 15% Ointment

• Apply three times daily for up to 16 weeks 2, 3
• Green tea extract with catechins as active ingredient 1, 3
• May weaken condoms and diaphragms 3
• Not recommended for HIV-infected or immunocompromised persons, or during pregnancy 1, 3, 4

Provider-Administered Treatment Options

Highest Efficacy: Surgical Removal

Surgical removal offers 93% efficacy with single-visit wart elimination, making it the strongest option when immediate clearance is the priority 2:

• Particularly beneficial for patients with large numbers or extensive wart areas 2
• Recurrence rate of 29% 2

Most Common: Cryotherapy with Liquid Nitrogen

• Efficacy ranges from 63-88% 1, 2
• Repeat every 1-2 weeks as necessary 3
• Requires substantial training for proper technique to avoid complications 1, 2
• Does not require anesthesia and does not result in scarring if performed properly 3

Safe in Pregnancy: Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA) 80-90%

TCA/BCA can be used in pregnancy, unlike other topical agents 1, 2, 3:

• Apply weekly as necessary 2
• Destroys warts by chemical coagulation of proteins 1
• Can be neutralized with soap or sodium bicarbonate if pain is intense 3

Alternative: Podophyllin Resin 10-25%

• Application limited to ≤0.5 mL or ≤10 cm² per session to avoid systemic toxicity 1, 3
• Contraindicated in pregnancy 1, 3

Treatment Monitoring and Modification

Change treatment modality if there is no substantial improvement after 3 provider-administered treatments or 8 weeks of patient-applied therapy 1, 2:

• For podofilox specifically, if incomplete response after 4 treatment weeks, consider alternative treatment 5
• Routine follow-up is not required for self-administered therapy, but a follow-up visit after several weeks can assess response 1

Critical Warnings and Pitfalls

Common Complications

• Persistent hypopigmentation or hyperpigmentation may occur and can be permanent 1, 2, 6
• Depressed or hypertrophic scars 1, 2

Rare but Serious Complications

• Disabling chronic pain syndromes such as vulvodynia or hyperesthesia of the treatment site 1

Important Limitations

Treatment removes visible warts but does not eradicate HPV infection 1, 2, 3:

• Recurrence rates are high with all treatment modalities 1, 2
• The effect on future transmission remains unclear 1
• New warts may develop during therapy 6
• Untreated warts may resolve spontaneously, remain unchanged, or increase in size/number 3

Special Precautions

• Female patients should take special care if applying cream at the vaginal opening, as local reactions can cause difficulty passing urine 6
• Uncircumcised males treating warts under the foreskin should retract the foreskin and clean the area daily 6
• Sexual contact should be avoided while cream is on the skin 6
• Application inside the vagina should be avoided 6