What are the treatment options for genital warts?

Treatment for Genital Warts

For most patients with genital warts, start with patient-applied podofilox 0.5% solution/gel or imiquimod 5% cream, reserving provider-administered cryotherapy with liquid nitrogen for patients who prefer office-based treatment or have difficulty self-applying medication. 1, 2

Patient-Applied Treatment Options (First-Line for Motivated Patients)

Podofilox 0.5% Solution or Gel

• Apply twice daily for 3 consecutive days, followed by 4 days off therapy; repeat this cycle up to 4 times until warts clear 1, 3
• Total treatment area must not exceed 10 cm² of wart tissue, and total volume should not exceed 0.5 mL per day 1, 3
• Use a cotton swab for solution or finger for gel application 1
• This is relatively inexpensive, easy to use, and safe for self-application, with common side effects being mild to moderate pain or local irritation 1, 2
• Contraindicated in pregnancy 1
• Works through direct cytotoxic effects as an antimitotic drug 1

Imiquimod 5% Cream

• Apply 3 times per week (not on consecutive days) for up to 16 weeks until complete clearance 1, 4
• Wash treatment area with mild soap and water 6-10 hours after application 4
• Works as a topically active immune enhancer that stimulates interferon and cytokine production 1, 2
• Many patients achieve clearance by 8-10 weeks 2
• May weaken condoms and vaginal diaphragms; concurrent use not recommended 1, 4
• Contraindicated in pregnancy 1
• Common local reactions include erythema, erosion, excoriation/flaking, and edema 4

Sinecatechins 15% Ointment (Alternative Patient-Applied Option)

• Apply three times daily until complete clearance, but not longer than 16 weeks 1
• Green tea extract with catechins as active ingredient 1, 2
• May weaken condoms and diaphragms 1
• Not recommended for HIV-infected or immunocompromised persons 1
• Contraindicated in pregnancy 1

Provider-Administered Treatment Options

Cryotherapy with Liquid Nitrogen (Most Common Provider Treatment)

• Destroys warts by thermal-induced cytolysis with 63-88% efficacy 1, 2
• Repeat every 1-2 weeks as necessary 1
• Relatively inexpensive, does not require anesthesia, and does not result in scarring if performed properly 1, 2
• Pain after application followed by necrosis and sometimes blistering is common 5
• Local anesthesia (topical or injected) may facilitate therapy if warts are present in many areas or if the area is large 5

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

• Apply sparingly to warts only and allow to dry before patient sits or stands 5, 1
• Destroys warts by chemical coagulation of proteins 5, 2
• Can be neutralized with soap or sodium bicarbonate if pain is intense 5, 1
• Repeat applications weekly if necessary 1
• Can be used in pregnancy, unlike other topical agents 2
• TCA has low viscosity comparable to water and can spread rapidly if applied excessively, potentially damaging adjacent tissues 5

Podophyllin Resin 10-25% in Compound Tincture of Benzoin

• Apply thin layer only to warts and allow to air dry before treated area contacts clothing 5
• Application limited to ≤0.5 mL or ≤10 cm² per session to avoid systemic toxicity 1, 2
• Contraindicated in pregnancy 1, 2
• Over-application or failure to air dry can result in local irritation caused by spread to adjacent areas 5

Surgical Therapy (For Extensive Warts or Treatment Failures)

• Eliminates warts at a single visit but requires substantial clinical training, additional equipment, and longer office visit 5
• Options include electrocautery, tangential excision with scissors or scalpel, or curettage 5
• Most warts are exophytic and can be removed with wound extending only into upper dermis 5
• Carbon dioxide laser and surgery useful for extensive warts or intraurethral warts, particularly for patients who have not responded to other treatments 5

Treatment Selection Algorithm

Choose Based on These Factors:

• Wart location: Moist surfaces and intertriginous areas respond better to topical treatments than dry surfaces 1, 2
• Number and size: Most patients have <10 warts with total area of 0.5-1.0 cm² 2
• Patient ability: Can patient identify and reach warts for self-application? 2
• Patient preference: Self-treatment at home versus office visits 1, 2
• Pregnancy status: Only TCA/BCA can be used in pregnancy 2
• Cost and convenience 2

When to Change Treatment

Switch treatment modality if: 2

• No substantial improvement after 3 provider-administered treatments 1, 2
• No substantial improvement after 8 weeks of patient-applied therapy 2
• Warts have not completely cleared after 6 provider-administered treatments 1

Critical Warnings and Limitations

Treatment Does Not Cure HPV

• Treatment removes visible warts but does not eradicate HPV infection or affect its natural history 1, 2
• Recurrence rates are high (approximately 25-30%) with all treatment modalities 6, 2
• Effect on future transmission remains unclear 2

Untreated Warts May:

• Resolve spontaneously (20-30% within 3 months) 6
• Remain unchanged 1, 2
• Increase in size or number 1, 2

Common Complications:

• Persistent hypopigmentation or hyperpigmentation (may be permanent) 2, 4
• Depressed or hypertrophic scars 1, 2
• Rare but serious: Disabling chronic pain syndromes such as vulvodynia or hyperesthesia of treatment site 2

Special Precautions:

• Cervical warts: Must exclude high-grade squamous intraepithelial lesions before treatment; requires specialist consultation 5
• Vaginal warts: Use cryotherapy with liquid nitrogen only; cryoprobe not recommended due to risk of vaginal perforation and fistula formation 5
• Female patients: Special care needed if applying cream at vaginal opening, as local reactions on delicate moist surfaces can cause pain, swelling, and difficulty urinating 4
• Uncircumcised males: Treating warts under foreskin requires daily retraction and cleaning of area 4
• Sexual contact: Avoid genital, anal, or oral contact while imiquimod cream is on skin 4