Specific management of genital (anogenital) warts

Treatment options include cryotherapy or topical application in clinic, with the option of home treatment with podophyllotoxin cream or lotion depending on the clinical picture. In some cases, curettage or surgical removal may be indicated.

Imiquimod 5% cream is another treatment option

• imiquimod is an immune response modifier. The topical preparation eliminates warts by enhancing cell-mediated immune pathways that target the cells harbouring HPV
• initial efficacy of imiquimod 5% cream is comparable with physician-administered therapies and podophyllotoxin; however, the recurrence rate after imiquimod treatment is considerably lower
  • data from two open-label studies where female patients with anogenital warts applied imiquimod 5% cream three times a week for up to 16 weeks showed, that, of the female patients who applied imiquimod 5% cream, 75% (449/600) experienced complete clearance of their warts (2)

Other points related to the management of genital warts:

• podophyllotoxin and trichloroacetic acid are effective in soft, non-keratinised warts. Physical ablative methods including cryotherapy, excision, or electrocautery are better suited to keratinised warts. Imiquimod is suitable in both cases (3)
  
  
• most smear tests showing HPV changes are likely to be reported as borderline and managed as per degree of abnormality (4). The National Health Service Cervical Screening Programme recommends that no changes are required to screening intervals in women with ano-genital warts (3)
  
  
• the partner should be seen for a check up, and the couple treated at the same time if necessary
  
  
• some sources suggest that 25% of patients with warts have another STD and they should be thoroughly screened
  
  
• sexual intercourse should be avoided during treatment, though condoms may protect against transmission
  
  
• women should not become pregnant during treatment therefore good contraception is essential
  
  
• warts grow in warm, moist areas, therefore it may be advisable to wear loose clothing and underwear
  
  
• the use of condoms for three months after the disappearance of lesions is empirical (1)

Another treatment option for genital warts is topical photodynamic therapy (5).

Reference:

• (1) The Practitioner 1999; 243: 556-63.
• (2) Buck HW et al. Imiquimod 5% cream in the treatment of anogenital warts in female patients. IntJournal of Gynaecol & Obst 2002 ;77(3): 231-238
• (3) Clinical Effectiveness Group (British Association for Sexual Health and HIV). United Kingdom National Guideline on the Management of Anogenital Warts, 2007
• (4) Personal email communication: Jenny Brick (August 2007). MRCGP Programme Coordinator for Cervical Screening Wales.
• (5) Morton CA et al; British Association of Dermatologists Therapy Guidelines and Audit Subcommittee and the British Photodermatology Group. Guidelines for topical photodynamic therapy: update. Br J Dermatol. 2008 ;159(6):1245-66