What are the treatment options for genital warts?

Treatment Options for Genital Warts

Primary Recommendation

Start with patient-applied podofilox 0.5% solution or gel as first-line therapy for most patients with genital warts, as it is the most effective patient-administered option with the best evidence for wart clearance. 1, 2

Patient-Applied Therapies (First-Line Options)

Podofilox 0.5% Solution or Gel

• Apply twice daily for 3 consecutive days, followed by 4 days off therapy, repeating this cycle up to 4 times until warts clear 1, 3
• Total treatment area must not exceed 10 cm² of wart tissue 1, 3
• Total volume must not exceed 0.5 mL per day 1, 3
• Use cotton swab for solution or finger for gel application 4
• Works through direct cytotoxic effects as an antimitotic drug 4
• Contraindicated in pregnancy 1, 3
• Most effective patient-administered therapy for wart removal 2

Imiquimod 5% Cream

• Apply once daily at bedtime, 3 times per week for up to 16 weeks until complete clearance 1, 5
• Wash treatment area with mild soap and water 6-10 hours after application 5
• Works as immune enhancer, stimulating interferon and cytokine production 1, 4
• Many patients achieve clearance by 8-10 weeks 1
• May weaken condoms and vaginal diaphragms 1, 5
• Contraindicated in pregnancy 1, 5
• Avoid sexual contact while cream is on skin 5

Sinecatechins 15% Ointment

• Apply three times daily until complete clearance, but not longer than 16 weeks 1, 4
• Green tea extract with catechins as active ingredient 1, 4
• May weaken condoms and diaphragms 1
• Not recommended for HIV-infected or immunocompromised persons 4
• Contraindicated in pregnancy 1, 2

Provider-Administered Therapies (Alternative Options)

Cryotherapy with Liquid Nitrogen

• Most common provider-administered treatment with 63-88% efficacy 1, 4
• Destroys warts through thermal-induced cytolysis 1, 6
• Repeat every 1-2 weeks as necessary 1, 4
• Relatively inexpensive, requires no anesthesia, does not cause scarring if performed properly 1, 4
• Recurrence rates of 21-39% 7, 6
• Safe option during pregnancy 6

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

• Apply only to warts, neutralize with talc or sodium bicarbonate to remove unreacted acid 7, 1
• Can be neutralized with soap or sodium bicarbonate if pain is intense 1, 4
• Repeat weekly if necessary 7, 1
• Efficacy of 81% with 36% recurrence rate 6
• Safe option during pregnancy 6

Podophyllin 10-25% in Compound Tincture of Benzoin

• Limit application to ≤0.5 mL or ≤10 cm² per session 7, 4
• Wash off thoroughly in 1-4 hours 7
• Repeat weekly if necessary 7
• Contraindicated in pregnancy 7, 6

Surgical Options (Reserved for Extensive or Refractory Disease)

• Surgical excision: 93% efficacy with 29% recurrence rate 7
• Carbon dioxide laser: 43% efficacy with 95% recurrence rate 7
• Electrodesiccation or electrocautery available but contraindicated for patients with cardiac pacemakers 7
• Reserve for extensive warts or patients who have not responded to other treatments 7

Treatment Selection Algorithm

Choose treatment based on:

• Wart location (moist surfaces respond better to topical treatments than dry surfaces) 7, 4
• Number and size of warts 7, 1
• Patient preference and ability to self-apply medication 7, 1
• Pregnancy status (use only cryotherapy or TCA if pregnant) 6
• Cost and convenience 7, 1
• Provider experience and available resources 7

When to Change Treatment

Change treatment if:

• No substantial improvement after 3 provider-administered treatments 7, 1
• No substantial improvement after 8 weeks of patient-applied therapy 1
• Warts have not completely cleared after 6 provider-administered treatments 7, 1

Critical Warnings and Limitations

Treatment removes visible warts but does NOT eradicate HPV infection or affect its natural history 7, 4

Recurrence rates are high (approximately 25-30%) with ALL treatment modalities 7, 1

20-30% of genital warts clear spontaneously within 3 months without any treatment 7, 6

Treatment does NOT eliminate the risk of future transmission 1, 4

Common complications include:

• Persistent hypopigmentation or hyperpigmentation 7, 1, 4
• Depressed or hypertrophic scars (rare but possible) 7, 1
• Disabling chronic pain syndromes such as vulvodynia (rare) 7, 1

Common Pitfalls to Avoid

• Do not exceed recommended treatment areas or volumes for podofilox (10 cm², 0.5 mL/day) 1, 6, 3
• Do not use podophyllin, podofilox, imiquimod, or sinecatechins in pregnancy 1, 6, 2
• Do not treat intra-anal warts in primary care—refer to specialist 6
• Do not use interferon therapy—not recommended due to cost, high adverse effects, and no greater efficacy than other options 7
• Do not use 5-fluorouracil cream—not evaluated in controlled studies and frequently causes local irritation 7
• Avoid expensive therapies, toxic therapies, and procedures that result in scarring for routine cases 7

Special Population Considerations

Pregnant patients:

• Use ONLY cryotherapy or TCA 6
• Avoid all patient-applied therapies 6, 2

HIV-positive/immunocompromised patients:

• May have reduced treatment response and higher recurrence rates 6
• Avoid sinecatechins 6

Extensive or refractory disease:

• Refer to specialist for consideration of surgical options 7