Warts%20-%20anogenital Treatment

• Primary goal of treatment is to eliminate warts that cause physiological or psychological symptoms
• All treatments have significant failure and recurrence rates as treatment does not eradicate the virus itself
• No definitive evidence suggests that any of the treatment options are better than the others
• Warts found in intertriginous areas or moist surfaces respond best to topical therapy
• Sex partner evaluation is of no proven benefit in preventing transmission/reinfection or complication since the majority of partners are already subclinically infected
  
  • Assessment of presence of warts and other sexually transmitted infections (STIs) may be beneficial both to the patient and the sexual partner
• Treatment choice depends on:
  • Morphology, number and distribution of warts
  • Cost and convenience of treatment
  • Adverse effects
  • Available resources
  • Experience of the physician
  • Age of the patient
  • Condition of the patient, eg pregnant or immunocompromised
  • Patient preference
• Absence of significant response within 4-6 weeks warrants consideration for an alternative diagnosis, change in treatment, or referral to a specialist

Symptomatic Therapy

Saltwater Bath

• Helps soothe and heal the genital area during treatment
• 2 handfuls of plain salt per bath or 2 tbsp in large bowl done at least twice daily

Anesthetic

• Xylocaine gel (2% preparation)
  
  • Local anesthetic that may be applied on raw areas prior to micturition and defecation

Local Imidazole Preparation

• May be used if there is concomitant thrush infection

Silver Sulfadiazine Cream (1% Preparation)

• May be used for large raw areas after ablation

Patient-Applied

Imiquimod (Topical)

• May be used for all external anogenital warts, keratinized or nonkeratinized
• Suitable for women and some men with foreskin-associated warts
• Particularly useful for carpet warts (eg female introitus and perianal area)
• Topical immune response modifier that stimulates the production of interferons and cytokines which produces localized immune response at the site of application
• Wart clearance is comparable with other chemical agents, though response is slow in onset
  
  • Recurrence rate is said to be low
• Not recommended in pregnancy or for internal lesions
• Response to treatment may be delayed for several weeks
• If warts do not clear up in 4 weeks, continue treatment
• Therapy may be continued up to 16 weeks with clinical assessment every 4 weeks

Podophyllotoxin (Topical)

• Podophyllotoxin is the purified extract of Podophyllin
• May be used for visible, external, nonkeratinized genital warts and in certain urethral meatus warts
• Binds to cellular microtubules and inhibits mitotic division causing necrosis of condylomas
• Clearance of warts seems to be better than Podophyllin
  
  • Soft nonkeratinized warts respond well to treatment
  • Erosions that occur as the warts necrotize are shallow and heal within a few days
• Not recommended for use in extragenital lesions eg anal warts, wart areas >10 cm2, internal warts, or warts not visualized
• Exercise caution whenever applying to lesions, total volume used should be <0.5 mL/day
• Contraindicated in pregnancy, lactation and children

Sinecatechins (Topical) 

• Applied on external wart for up to 16 weeks 
• Have antioxidant and immune-enhancing actions though exact mechanism of action is unknown 
• Should not be used in the anus or vagina or by immunocompromised, pregnant or active-herpes infected women 
• Can weaken diaphragms and condoms and should be washed off prior to inserting a vaginal tampon or sexual contact

Physician-Applied

TCA (Topical)

• May be used at most anatomical sites but is most suitable for small acuminate or papular warts
  
  • Tends to be less effective for keratinized or large lesions but effective for dry and moist warts
  • Not recommended for large-volume warts because ulceration into the dermis may occur
• Caustic agent that results in cellular necrosis
• Initial response may be 70-81% but relapse may be up to 36%
• Multiple applications may be necessary but are not well tolerated
• Extremely corrosive to the skin
  
  • Careful application and protection of the surrounding skin with petroleum jelly is recommended
  • Neutralizing agents (eg Na bicarbonate or soap) should always be available
• An intense burning sensation may be experienced after application
• Can be used in pregnant women

No Treatment

• An option at any site because of the possibility of spontaneous resolution and the uncertainty with regards to the effect of treatment and future transmission

Physician-Applied

• Keratinized warts tend to respond better to physical ablative methods

Cryotherapy

• Suitable for external and internal warts, and both dry and moist warts
• Damages the cell membranes and organelles by freezing affected cells
  
  • Human papillomavirus (HPV) is not destroyed but is released into the extracellular area which may produce an immunologic response

• Studies show efficacy rates between 65-85%
  
  • Repeated applications are usually needed

• Liquid nitrogen is applied to each wart until 2 mm of surrounding skin has turned white
  
  • A freeze-thaw-freeze technique is used, freezing the lesion for 10-30 seconds depending on its size
  • Perform at weekly intervals
  • Due to the risk of vaginal perforation and fistula formation, use of vaginal cryoprobe is not recommended

• Use of local anesthetic may ease pain if multiple warts or a large area of warts are to be treated
• 1st-line therapy for pregnant patients
• If 50% resolution is not achieved after 4 weeks, treat with Imiquimod
• Contraindicated in patients with cryoglobulinemia
• Pain followed by necrosis and sometimes blistering is common

Laser Treatment

• Carbon Dioxide (CO₂) Lasers
  
  • Useful for large-volume/extensive anogenital warts and warts at difficult anatomical sites (eg intra-anal, urethral meatus)
  • Vaporization of warts
  • Treatment can be painful and may leave scars
  • Not considered 1st-line treatment because of cost
  • Adequate protection of healthcare workers should be observed as smoke plume may contain HPV DNA

Photodynamic Therapy

• Used in sensitive mucosal tissue including venereal warts and intraepithelial neoplasia
• Uses 5-aminolevulinic acid (ALA) to stimulate porphyrin accumulation in the tissue which then acts as a photosensitizing agent
• Studies show that results are equal or better than other treatment modalities with less or no scarring