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

Treatment of Human Papillomavirus (HPV) Infection

There is no treatment for HPV infection itself—only the clinical manifestations (genital warts, precancerous lesions, and cancers) caused by the virus can be treated. 1, 2

Understanding HPV Infection Natural History

The vast majority (approximately 90%) of HPV infections are transient and resolve spontaneously within 2 years through immune clearance. 1 Only about 10% of infections persist, and merely 1% of those will progress to neoplastic lesions. 1 This natural history is critical because it explains why treatment targets disease manifestations rather than the virus itself.

Treatment Approaches for HPV-Related Conditions

Genital Warts (Condylomata Acuminata)

For external genital warts, choose between patient-applied therapies or provider-administered destructive methods:

Patient-Applied Options:

• Imiquimod 3.75% or 5% cream applied to warts according to package instructions 1, 2, 3
• Podofilox 0.5% solution or gel applied to visible warts 1

Provider-Administered Options:

• Cryotherapy with liquid nitrogen (can be repeated weekly if necessary) 1
• Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90% applied directly to warts until white frosting develops 1
• Surgical removal via excision, electrocautery, or laser therapy 1, 2

Cervical, Vaginal, and Vulvar Precancerous Lesions

Treatment requires local ablative or excisional procedures:

• Cryotherapy for appropriate lesions 1, 2
• Electrocautery for tissue destruction 1, 2
• Laser therapy (CO2 laser ablation) 1, 2
• Surgical excision including loop electrosurgical excision procedure (LEEP) or cold knife conization 1, 2

These treatments remove abnormal tissue but do not eliminate HPV from surrounding normal-appearing tissue. 1

Anal Warts and Intra-anal Disease

For anal warts, use the same approaches as external genital warts:

• Cryotherapy with liquid nitrogen 1
• TCA or BCA 80-90% application 1
• Surgical removal 1

Critical caveat: Patients with anal warts should undergo digital rectal examination or anoscopy, as many also have rectal mucosal involvement requiring specialist consultation. 1 For HIV-infected men who have sex with men (MSM) with abnormal anal cytology, high-resolution anoscopy with biopsy is recommended. 2

Prevention as Primary "Treatment" Strategy

Since HPV infection itself cannot be treated, prevention becomes paramount:

Vaccination (Most Effective Prevention)

The nonavalent HPV vaccine (9vHPV) should be administered routinely at age 11-12 years for all genders (can start as early as age 9). 2, 4 This vaccine prevents approximately 90% of cervical and other HPV-related cancers by targeting types 6,11,16,18,31,33,45,52, and 58. 2

Catch-up vaccination is recommended:

• Females through age 26 years 2
• Males through age 21 years (through age 26 for MSM and immunocompromised individuals) 2

Dosing schedule:

• Two doses if initiated before age 15 years 4
• Three doses if initiated at age 15 years or older, or if immunocompromised 4

Important limitation: Vaccination does not protect against HPV types already present at time of vaccination, nor does it treat existing infections or lesions. 2

Risk Reduction Measures

Consistent condom use reduces HPV transmission risk by approximately 70% when used correctly and consistently. 1, 2 However, skin not covered by condoms remains vulnerable to infection. 1

Complete sexual abstinence is the only method that completely prevents genital HPV infection. 1, 2 For sexually active individuals, monogamous relationships with uninfected partners provide the next best protection. 1, 2

Screening for Early Detection

Cervical cancer screening with Pap testing should begin within 3 years of sexual activity initiation or by age 21 years, whichever comes first. 2 Women aged >30 years with three consecutive normal Pap tests can extend screening intervals to every 2-3 years. 2

Co-testing with HPV DNA testing may be appropriate in women >30 years, allowing for 3-year screening intervals if both tests are negative. 2

Common Pitfalls and Critical Considerations

Partner notification and routine surveillance are not useful for HPV prevention because the infection is so prevalent that most partners of infected individuals are already infected, often asymptomatically. 1, 2 No clinically validated test exists for HPV infection in men. 1

Available treatments may reduce but probably do not eliminate infectiousness since HPV can persist in normal-appearing tissue adjacent to treated lesions. 1

Counseling is essential to address the psychosocial impact of HPV diagnosis, emphasizing that: most sexually active adults acquire HPV at some point; infection does not indicate infidelity in monogamous relationships; most infections clear spontaneously; and detection of HPV can occur years after acquisition. 1, 2

Smoking is associated with increased oral HPV infection prevalence and worse prognosis in HPV-related cancers. 2