What is the recommended treatment for genital warts?

Treatment of 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 those who prefer office-based treatment or cannot self-apply medication. 1

Patient-Applied First-Line Options

Podofilox 0.5% solution or gel:

• Apply twice daily for 3 consecutive days, followed by 4 days off therapy 1
• Repeat this cycle up to 4 times until warts clear 1
• Total treatment area must not exceed 10 cm² of wart tissue and total volume should not exceed 0.5 mL per day 1, 2
• Apply using a cotton swab (solution) or finger (gel) to visible genital warts 2
• Works through direct cytotoxic effects as an antimitotic drug 2
• Relatively inexpensive, easy to use, and safe for self-application 2
• Contraindicated in pregnancy 2

Imiquimod 5% cream:

• Apply 3 times per week for up to 16 weeks until complete clearance 1, 3
• Many patients achieve clearance by 8-10 weeks 1
• Works as a topically active immune enhancer that stimulates interferon and cytokine production 1, 3
• Complete clearance rates of 50% in immunocompetent patients, with partial clearance (≥50% reduction) in 76% 4
• Female patients experience higher clearance rates than males 4
• Recurrence occurs in 13-19% of patients who achieve complete clearance 4
• May weaken condoms and vaginal diaphragms; concurrent use not recommended 3
• Contraindicated in pregnancy 3
• Wash treatment area with mild soap and water 6-10 hours after application 3

Sinecatechins 15% ointment (alternative patient-applied option):

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

Provider-Administered Options

Cryotherapy with liquid nitrogen:

• Most common provider treatment, destroying warts by thermal-induced cytolysis 1, 2
• Efficacy ranges from 63-88% 1, 2
• Repeat every 1-2 weeks as necessary 1, 2
• Relatively low cost, no anesthesia required, and does not result in scarring if performed properly 2
• First-line destructive treatment based on cost-effectiveness 5

Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90%:

• Destroys warts by chemical coagulation of proteins 6, 1
• Apply sparingly only to warts and allow to dry until white frosting develops 6, 1
• If excess acid applied, neutralize with talc, sodium bicarbonate, or liquid soap 6, 1
• Can be repeated weekly if necessary 6, 1
• If pain is intense, neutralize with soap or sodium bicarbonate 2

Podophyllin 10-25% in compound tincture of benzoin:

• Apply only to warts, limited to ≤0.5 mL or ≤10 cm² per session 2
• Treatment area and adjacent normal skin must be dry before contact 6
• Can be repeated weekly if necessary 6
• Contraindicated in pregnancy 2
• Less consistent efficacy; not recommended as primary treatment 5

Surgical Options for Extensive or Refractory Disease

Surgical removal, electrocautery, or laser therapy:

• Most beneficial for patients with large number or area of genital warts 6, 1
• Eliminates warts at a single visit with 93% efficacy and 29% recurrence rate 7
• After local anesthesia, warts can be destroyed by electrocautery (no additional hemostasis required) 6
• Alternative: tangential excision with scissors or scalpel, laser, or curettage 6
• Carbon dioxide laser and surgery useful for extensive warts or intraurethral warts, particularly for non-responders 6
• Care must be taken to control depth of electrocautery to prevent scarring 6

Treatment Selection Algorithm

Choose treatment based on: 1, 2

• Wart location, number, and size
• Patient ability to self-apply medication and comply with treatment
• Patient preference for home versus office-based therapy
• Pregnancy status (eliminates most patient-applied options)
• Cost and convenience
• Warts on moist surfaces or intertriginous areas respond better to topical treatments than warts on drier surfaces 2

When to Change Treatment

Change treatment if: 1, 2

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

Site-Specific Considerations

Cervical warts:

• Biopsy evaluation required to exclude high-grade squamous intraepithelial lesions before treatment 6
• Management should include consultation with a specialist 6

Vaginal warts:

• Cryotherapy with liquid nitrogen (cryoprobe not recommended due to perforation/fistula risk) 6
• OR TCA/BCA 80-90% applied weekly 6

Urethral meatus warts:

• Cryotherapy with liquid nitrogen 6
• OR Podophyllin 10-25% in compound tincture of benzoin (contraindicated in pregnancy) 6

Anal warts:

• Cryotherapy with liquid nitrogen, TCA/BCA 80-90%, or surgical removal 6
• Intra-anal warts should be managed in consultation with a specialist 6
• Patients with anal/intra-anal warts may benefit from rectal mucosa inspection by digital examination or anoscopy 6

Critical Warnings and Limitations

Treatment does not cure HPV infection:

• All treatments remove visible warts but do not eradicate HPV infection or affect its natural history 1, 2
• Effect on future transmission is unclear 1, 7
• Recurrence rates are approximately 25-30% with all treatment modalities 1, 7

Natural history without treatment:

• 20-30% of untreated genital warts clear spontaneously within 3 months 7
• Approximately one-third regress without treatment with average duration of 9 months prior to resolution 7
• Untreated warts may remain unchanged or increase in size or number 1, 2

Potential complications:

• Persistent hypopigmentation or hyperpigmentation 1, 2, 3
• Depressed or hypertrophic scars 1, 2
• Rare but serious disabling chronic pain syndromes 1
• During treatment, the treatment area is likely to appear noticeably different from normal skin 3

Special precautions:

• Sexual (genital, anal, oral) contact should be avoided while imiquimod cream is on the skin 3
• Female patients should take special care if applying cream at vaginal opening due to risk of pain, swelling, and urinary retention 3
• Uncircumcised males treating warts under foreskin should retract foreskin and clean area daily 3
• New warts may develop during therapy 3