EXTERNAL GENITAL WARTS – CLINICAL PRESENTATION, DIAGNOSIS AND TREATMENT

Treatment recommendations

• The goal of treatment for genital warts is the removal of visible warts. Grade C
• Standard therapies for genital warts can eventually remove most warts, although no one treatment is ideal for all warts or all individuals.
  Grade A & C
• Clinicians should be knowledgeable about, and have available to them, at least one self-applied treatment and one healthcare provider-administered therapy. Grade C

Treatment selection

The most appropriate treatment option(s) for external genital warts by indication/site are summarised in Table 3. Most treatment modalities are eventually effective in eliminating small numbers of warts. Patients with limited disease (i.e. one to five warts) may benefit most from cryotherapy or simple office surgery. Ablative therapy (cryotherapy) should be considered in those with large or extensive areas of warts to at least debulk their warts (although ablative treatment, especially to the introitus, can result in disabling chronic pain syndrome or hyperaesthesia at the treatment site). 

For self-applied therapeutic modalities, treatment beyond the manufacturer’s recommendations is not advisable and concurrent use of multiple therapeutic modalities on a single wart is not recommended as routine treatment because of a lack of data showing that this improves clearance or recurrence rates. However, possible combinations include the use of podophyllotoxin after cryotherapy, and the combination of laser therapy and imiquimod (which has been shown to be safe and well tolerated(13)). A change of treatment modality or onward referral should be considered if there has not been any significant response to treatment within 4–6 weeks (continuing lack of response might indicate other pathology and the need for further assessment).

Surgical removal of warts, by diathermy, laser ablation or excision under local or general anaesthesia, may render an individual wart-free, usually in a single visit. However, the disadvantages are that significant training, specific equipment, and a longer clinic visit are required. Although surgery is of most benefit when warts are present in large numbers or over large surface areas, it also has a role in other cases. While the cost of a single surgical visit may be higher, surgery can accomplish in one visit what often requires multiple visits for other ablative modalities, which may result in greater cost effectiveness for some individuals. However, recurrence rates might be the same as other therapeutic modalities and the morbidity of treatment may be greater, with increased risk of pain, infection and scarring.

Treatment of immunocompromised individuals

Management of immunocompromised individuals with genital warts should be performed in consultation with a sexual health specialist and any other specialists involved in the care of that individual.

Persons who are immunocompromised due to concurrent HIV infection or other causes may respond less well to therapy for genital warts than immunocompetent individuals, and may have more frequent recurrences after treatment.(1) Squamous cell carcinomas arising in squamous intraepithelial lesions resembling genital warts are more common in immunosuppressed individuals. Immunosuppressed women should undergo annual cervical screening, with early referral for colposcopy if abnormalities are detected.

Although not contraindicated, imiquimod should be used with caution in individuals with autoimmune conditions or those taking systemic immunosuppressants, although systemic absorption from topical treatment is likely to be negligible.

Therapy management

The response to treatment should be continually evaluated to avoid over-treatment and a therapeutic course that is worse than the disease itself. There are several things that can make a course of treatment less painful and stressful for individuals. Saltwater baths can help soothe and heal the genital area during treatment (put two handfuls of plain salt per bath or two tablespoons in a large bowl, preferably twice daily, and then dry the area with a hairdryer). Local anaesthesia using lignocaine gel 2% (Xylocaine) can be applied to raw areas two minutes prior to micturition and defaecation to reduce discomfort. For large areas made raw by wart ablations, 1% silver sulphadiazine cream is useful. Furthermore, a concomitant yeast infection is common, which can be managed using local imidazole preparations and/or oral fluconazole.

Emerging or alternative therapies

A number of ablative therapies have been trialled in the destruction of anogenital warts. Sinecatechins (an active product of green tea extract) inhibits telomerase production via its role in cell signalling pathways, and is approved for the treatment of genital warts in the US.(1) Other treatment options being investigated include photodynamic therapy and intralesional immunotherapy.(14)

HPV vaccine as therapy 

It is not yet clear whether administration of the HPV vaccine to individuals who already have HPV infection alters the natural history of infection. For example, does vaccination result in faster clearance (or undetectability), reduce viral persistence, or prevent disease recurrence? Several trials are assessing the benefit of adjuvant HPV vaccination in people being treated for high grade CIN.(15-17)

Unvaccinated individuals attending colposcopy clinics who are eligible for funded HPV vaccine should be offered it because this will protect against the acquisition of new HPV types, and may protect against recurrent CIN. Older people may benefit from adjuvant vaccine after treatment for CIN, but this would need to be self-funded.

Post-treatment follow-up

The benefit, frequency, interval and type of follow-up care necessary after treatment of genital warts has not been studied. Follow-up evaluation can provide the opportunity for education and counselling. The need to monitor for complications of therapy will vary based on the experience and cognitive ability of the affected individual, the number and location of warts, and the treatment modality used. Individuals concerned about recurrences could be offered an evaluation 3 months after successful treatment because most recurrences occur during this period. Recurrence of warts is much more common in immunosuppressed individuals and periodic follow-up evaluation may be necessary. Management of genital warts must include careful assessment and testing for other sexually transmitted infections (STIs), depending on the patient’s sexual history, because individuals with genital warts are at risk of other STIs.