How are genital warts treated in adults, including first‑line topical agents and procedural options, and what considerations apply for pregnancy and immunocompromised patients?

Treatment of Genital Warts

For most patients with genital warts, begin with patient-applied podofilox 0.5% solution or gel as first-line therapy, or offer provider-administered cryotherapy with liquid nitrogen for those preferring immediate office-based treatment. 1, 2

Treatment Goals and Expectations

• The primary objective is removal of visible, symptomatic warts—not eradication of HPV infection. 3, 1
• Current treatments do not clearly reduce future transmission risk to partners. 3, 2
• 20–30% of untreated warts resolve spontaneously within 3 months, making observation an acceptable option for asymptomatic patients. 2
• Recurrence occurs in approximately 30% of cases regardless of treatment modality, typically from reactivation of subclinical infection rather than reinfection. 2, 4

First-Line Patient-Applied Therapies

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 as needed. 3, 1
• Use cotton swab for solution or finger for gel application to visible warts only. 3, 1
• Limit total treatment area to ≤10 cm² and total volume to ≤0.5 mL per day. 3, 1
• Most effective patient-administered option for wart clearance. 4
• Contraindicated in pregnancy. 3, 1, 4

Imiquimod 5% cream:

• Apply at bedtime three times weekly for up to 16 weeks. 3, 1
• Wash treatment area with soap and water 6–10 hours after application. 3, 1
• May weaken condoms and vaginal diaphragms. 1
• Contraindicated in pregnancy. 3, 1, 4

Sinecatechins 15% ointment:

• Apply three times daily until complete clearance, but not longer than 16 weeks. 1
• Not recommended for HIV-infected or immunocompromised patients, or during pregnancy. 1

First-Line Provider-Administered Therapies

Cryotherapy with liquid nitrogen:

• Preferred office-based option with 63–88% cure rates and 21–39% recurrence. 2
• Repeat every 1–2 weeks until clearance. 3, 1, 2
• Does not require anesthesia and produces no scarring when performed properly. 1, 2
• Most effective destructive treatment alongside carbon dioxide laser and electrosurgery. 4, 5

Trichloroacetic acid (TCA) 80–90%:

• Apply small amount only to warts until white "frosting" develops. 3, 1
• Neutralize with soap, sodium bicarbonate, or talc if excess applied. 3, 1
• Repeat weekly as necessary; achieves approximately 81% efficacy with 36% recurrence. 2

Podophyllin resin 10–25%:

• Apply only to warts, limit to ≤0.5 mL or ≤10 cm² per session. 3
• Wash off after 1–4 hours. 2
• Contraindicated in pregnancy. 3

Treatment Selection Algorithm

Location-based considerations:

• Warts on moist surfaces or intertriginous areas respond better to topical treatments (podofilox, imiquimod, TCA) than ablative methods. 1, 2
• Warts on drier surfaces respond better to cryotherapy or surgical excision. 3, 1

Patient factors:

• Patient must be able to identify and reach warts for self-treatment options. 1
• Consider patient preference for office visits versus home treatment. 3, 1
• Most patients have <10 warts with total area 0.5–1.0 cm² that respond to most modalities. 3

When to Change or Escalate Therapy

Switch treatment modality if: 3, 1, 2

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

Advanced/surgical options for refractory disease:

• Electrosurgery/electrodesiccation under local anesthesia for extensive warts. 2
• Surgical excision (tangential scissor, shave excision, curettage). 1
• Carbon dioxide laser ablation reserved for extensive or treatment-resistant disease. 2, 4
• Most warts respond within 3 months; lack of response warrants escalation. 2

Special Population Considerations

Pregnancy:

• Avoid podofilox, imiquimod, sinecatechins, and podophyllin. 3, 1, 4
• Use cryotherapy, TCA, or surgical excision only. 3, 1

Immunocompromised patients (including HIV):

• May have larger, more numerous warts with poorer treatment response and higher recurrence rates. 2
• Higher risk for squamous cell carcinomas arising in warts. 2
• Avoid sinecatechins. 1
• Consider biopsy for atypical, pigmented, indurated, or ulcerated lesions. 2, 4

Common Pitfalls and Complications

Avoid overtreatment: 3, 1

• Persistent hypopigmentation or hyperpigmentation are common with ablative modalities and may be permanent. 3, 2
• Depressed or hypertrophic scars can occur, especially with insufficient healing time between treatments. 3, 2
• Rarely, disabling chronic pain syndromes (vulvodynia, hyperesthesia) may develop. 3, 2

Critical safety warning:

• Never use wart treatments (podofilox, imiquimod, cryotherapy) on genital herpes lesions—this causes significant harm. 6

Biopsy indications:

• Reserve for uncertain diagnoses, treatment failure, immunocompromised patients, or atypical lesions (pigmented, indurated, ulcerated). 2, 4
• Routine biopsy of typical genital warts is not recommended. 2

Prevention and Counseling

HPV vaccination:

• Quadrivalent HPV vaccine (Gardasil) recommended for males and females aged 9–26 years, even with existing warts or prior HPV infection. 2
• Prevents infection with HPV types 6 and 11, which cause approximately 90% of genital warts. 2, 4
• Does not treat existing warts but reduces risk of acquiring new vaccine-covered HPV types. 2

Patient counseling points:

• HPV diagnosis does not indicate sexual infidelity; the virus is highly prevalent and many partners are already infected. 2
• Consistent condom use may reduce but not eliminate transmission risk, as HPV infects uncovered genital skin. 2
• Treatment does not eliminate HPV infection or demonstrably lower transmission risk to partners. 2
• No evidence links wart treatment to reduced cervical cancer risk in female partners. 2