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

HPV Wart Treatment

Treatment should be guided by patient preference, with cryotherapy or patient-applied podofilox/imiquimod as first-line options, recognizing that all treatments remove visible warts but do not eradicate HPV, and recurrence occurs in approximately 25-30% of cases regardless of modality. 1

Treatment Goals and Expectations

The primary goal is removal of symptomatic visible warts, not HPV eradication. 1 No currently available treatment eliminates the virus from surrounding tissue or affects the natural history of HPV infection. 1 Treatment may or may not decrease infectivity, and there is no evidence that treating visible warts affects cervical cancer development. 1

Untreated warts spontaneously resolve in 20-30% of patients within 3 months, remain unchanged, or increase in size/number. 1

Patient-Applied Therapies (First-Line Options)

Podofilox 0.5% Solution or Gel

• Apply twice daily for 3 consecutive days, followed by 4 days of no therapy; repeat cycle up to 4 times. 1, 2
• Limit treatment to less than 10 cm² of wart tissue and no more than 0.5 mL per day. 1, 2
• Allow solution to dry before opposing skin surfaces return to normal position. 2
• Contraindicated in pregnancy. 3

Imiquimod Cream

• Available as patient-applied immunomodulator therapy. 1, 4
• Works better on moist surfaces and intertriginous areas than dry surfaces. 1
• Contraindicated in pregnancy. 3

Provider-Administered Therapies (First-Line Options)

Cryotherapy with Liquid Nitrogen

• Preferred first-line provider-administered treatment with efficacy of 63-88% and recurrence rates of 21-39%. 3
• Apply every 1-2 weeks as needed. 3
• Relatively inexpensive, requires no anesthesia, and produces no scarring if performed properly. 5, 6
• Destroys warts through thermal-induced cytolysis. 5

Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA) 80-90%

• Apply only to warts, powder with talc or sodium bicarbonate to remove unreacted acid. 3
• Repeat weekly if necessary. 3
• Can be neutralized with soap or sodium bicarbonate if pain is intense. 5
• Works better on moist surfaces than dry surfaces. 1
• Safe in pregnancy. 3

Treatment Selection Algorithm

Change treatment modality if the patient has not improved substantially after 3 provider-administered treatments or if warts have not completely cleared after 6 treatments. 1

Factors Influencing Treatment Choice:

• Wart size, number, and anatomic location 1, 5
• Wart morphology (moist vs. dry surfaces) 1
• Patient preference and ability to attend office visits 1
• Cost, convenience, and provider experience 1, 5
• Pregnancy status 3

Treatment Success Predictors:

• Small warts present less than 1 year respond better to treatment. 1
• Warts on moist/intertriginous areas respond better to topical treatments. 1

Second-Line and Specialized Treatments

Surgical Excision

• Reserved for extensive or refractory disease not responding to other regimens. 1, 3
• Efficacy of 93% with recurrence rate of 29%. 1, 3
• Methods include tangential scissor excision, shave excision, or electrosurgery. 3

CO2 Laser

• Reserved for extensive warts in patients who have not responded to other treatments. 1, 7
• Not appropriate for limited lesions. 1, 7
• Recurrence occurs in approximately 28-30% of patients within 3 months to 3 years. 7

Interferon Therapy

• Not recommended due to high cost, frequent adverse effects, and efficacy no greater than other available therapies. 1

5-Fluorouracil Cream

• Not recommended as it has not been evaluated in controlled studies and frequently causes local irritation. 1

Critical Pitfalls to Avoid

Never treat warts in the presence of active purulent infection, as this increases risk of treatment failure, scarring, and systemic complications. 3 If secondary bacterial infection is present, initiate empiric antibiotic coverage targeting Staphylococcus aureus and Streptococcus species before wart-directed therapy. 3

Avoid expensive therapies, toxic therapies, and procedures that result in scarring. 1 Avoid extensive or aggressive treatment that may cause scarring, chronic pain syndromes, or painful defecation. 3

Evaluate the risk-benefit ratio throughout treatment to avoid overtreatment. 1 Scarring in the form of persistent hypopigmentation or hyperpigmentation is common with ablative modalities. 1

Special Populations

Pregnancy

• Use only cryotherapy and TCA as safer alternatives. 3
• Avoid podofilox, podophyllin, and imiquimod. 3
• Consider removal of genital warts during pregnancy as they can proliferate and become friable. 3

Immunocompromised Patients

• Biopsy indicated if diagnosis uncertain or lesions atypical. 1, 5

Patient Counseling

Inform patients that HPV types 6 and 11 cause over 90% of genital warts and are low-risk types that do not cause cancer. 3 Treatment targets visible warts but does not eliminate the underlying virus. 3 Recurrence is common (approximately 30%) regardless of treatment method due to reactivation of subclinical infection, not reinfection by a partner. 1, 3, 7