What are the treatment options for penile warts?

Treatment of Penile Warts

For penile warts, start with patient-applied podofilox 0.5% solution/gel or imiquimod 5% cream as first-line therapy, reserving provider-administered cryotherapy for patients who prefer office-based treatment or cannot self-apply medication. 1, 2

Patient-Applied First-Line Options

Podofilox 0.5% Solution or Gel

• Apply twice daily (every 12 hours) for 3 consecutive days, followed by 4 days off therapy 3
• Repeat this weekly cycle up to 4 times until warts clear completely 3
• Use a cotton swab (solution) or finger (gel) to apply the minimum amount necessary to cover lesions 1
• Limit treatment to <10 cm² of wart tissue and ≤0.5 mL per day 4, 3
• Allow solution to dry before skin surfaces return to normal position 3
• Relatively inexpensive, easy to use, and safe with mild to moderate local irritation expected 4, 1
• Contraindicated in pregnancy 4, 3

Imiquimod 5% Cream

• Apply 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 an immune enhancer stimulating interferon and cytokine production 4, 1
• Many patients achieve clearance by 8-10 weeks 2
• For uncircumcised men with penile warts on the foreskin, the 3 times/week regimen achieves 62% total clearance and is better tolerated than daily dosing 6
• May weaken condoms and vaginal diaphragms 5
• Contraindicated in pregnancy 5

Sinecatechins 15% Ointment (Alternative)

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

Provider-Administered Options

Cryotherapy with Liquid Nitrogen (Most Common Provider Treatment)

• Destroys warts by thermal-induced cytolysis with 63-88% efficacy 4, 1
• Repeat every 1-2 weeks as necessary 4, 1
• Relatively inexpensive, does not require anesthesia, and does not result in scarring if performed properly 4, 1
• Patients commonly experience moderate pain during and after the procedure 4
• Requires proper training to avoid over- or under-treatment 4

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

• Apply sparingly only to warts and allow to dry before patient sits or stands 4
• Destroys warts by chemical coagulation of proteins 4, 2
• Can be neutralized with soap or sodium bicarbonate if pain is intense 4
• Repeat weekly if necessary 4, 2
• TCA has low viscosity and can spread rapidly if applied excessively, damaging adjacent tissue 4

Podophyllin 10-25% in Compound Tincture of Benzoin

• Apply thin layer only to warts and allow to air dry before contact with clothing 4
• Limit application to ≤0.5 mL or ≤10 cm² per session 4
• Thoroughly wash off in 1-4 hours 4
• Repeat weekly if necessary 4
• Contraindicated in pregnancy 4

Surgical Options for Extensive or Refractory Disease

Surgical Excision

• Offers advantage of eliminating warts in a single visit with 93% efficacy and 29% recurrence rate 4, 7
• Most beneficial for patients with large number or area of warts 4
• Tangential excision with scissors or scalpel creates wound extending only into upper dermis 4
• Hemostasis achieved with electrosurgical unit or chemical styptic; suturing neither required nor indicated in most cases 4

Electrodesiccation or Electrocautery

• Physically destroys visible warts once local anesthesia is applied 4
• No additional hemostasis required 4
• Contraindicated for patients with cardiac pacemakers 4

Carbon Dioxide Laser

• Reserved for extensive warts or those not responding to other treatments 4
• Efficacy of 43% with recurrence among 95% of patients in randomized trials 4

Treatment Selection Algorithm

Choose treatment based on:

• Wart location, number, and size 2
• Patient ability to self-apply medication and comply with treatment 2
• Patient preference for home vs. office-based therapy 1, 2
• Pregnancy status (avoid podofilox, podophyllin, imiquimod, sinecatechins) 4, 1, 5
• Cost and convenience 2

When to Change Treatment

Switch therapy if: 2

• No substantial improvement after 3 provider-administered treatments 2
• No improvement after 8 weeks of patient-applied therapy 2
• Warts have not completely cleared after 6 provider-administered treatments 2
• Podofilox shows no response after 4 treatment weeks 3

Critical Warnings and Limitations

Treatment Does Not Cure HPV Infection

• Treatment removes visible warts but does not eradicate HPV infection or affect its natural history 4, 1, 2
• Recurrence rates are approximately 25-30% with all treatment modalities 2, 8
• Effect on future transmission is unclear 2

Natural History Without Treatment

• 20-30% of untreated genital warts clear spontaneously within 3 months 4
• Approximately one-third regress without treatment with average duration of 9 months prior to resolution 7
• Untreated warts may remain unchanged or grow 4, 1

Potential Complications

• Persistent hypopigmentation or hyperpigmentation 1, 2
• Depressed or hypertrophic scars 1, 2
• Rare but serious disabling chronic pain syndromes 2

Common Pitfalls to Avoid

• Avoid expensive therapies, toxic therapies, and procedures that result in scarring for limited lesions 4
• Interferon therapy is not recommended due to cost, high frequency of adverse effects, and efficacy no greater than other available therapies 4
• 5-fluorouracil cream is not recommended as it has not been evaluated in controlled studies and frequently causes local irritation 4
• Combination therapy (simultaneous use of two or more modalities on same wart) does not increase efficacy but may increase complications 4
• For uncircumcised males treating warts under the foreskin, retract foreskin and clean area daily 5
• Sexual contact should be avoided while imiquimod cream is on the skin 5