I. Pathophysiology and clinical fetaures

  1. Caused by HPV
  1. Usually type 6 or 11; these strains aren't strongly implicated in genital cancers
  2. Genital warts aren't strongly associated with cervical cancer or with cervical infection with HPV types 16 or 18, which are most strongly ass'd with cervicl cancer
  1. No evidence as to whether visible warts are more infectious than subclinical HPV infection
  2. In men, condylomata are usually on penile glans or shaft and condom use may reduce risk of spread, though again no data
  3. Will spontaneously regress in < 3mos in 10-30% of cases in observational studies.
  4. Anal warts may be associated with high-grade intraepithelial neoplasia or cancer (more likely in presence of HIV infection but even without); cytology had sensitivity for high-grade findings on histopathology of 93% in HIV-positive men and 89% in  HIV-negative men in one case series (Clin. Inf. Dis. 51:107, 2010-JW)

II. Treatment

  1. In general, it's painful, expensive, and ineffective (doesn't eradicate infection; recurrences very common)
  2. No evidence as to whether treating visible warts affects transmission to sexual partners; areas surrounding warts are quite frequently subclinically infected
  3. No evidence as to whether treating skin infected with HPV but without visible warts affects subsequent risk of visible warts or transmission
  4. No evidence as to whether treating visible warts affects subsequent risk of malignancy which is in itself low (see above).
  5. Some very sketchy evidence that earlier treatment may increase chance of initial clearance and reduce chance of recurrence, but this could be confounded by lower spont. regression rates in warts of long duration
  6. Treatment with podophyllin 25% resin
  1. 32-79% initial clearance rates; recurrence in 27-65% in 9mos
  2. More efficacious than systemic interferon-alpha-2a in randomized trials
  3. Should not be used on mucosa
  1. Treatment with podofilox (aka podophyllotoxin) 0.5% solution or gel
  1. The most biologically active component of podophyllin
  2. Lower potential for systemic toxicity than podophyllin; more effective in randomized trials as well
  3. Apply with cotton swab for up to 4 tx cyclis; each cycle consists of BID application x 3d then no tx x 4d
  4. Apply the 1st tx in office then have pt do rest at home
  5. Can cause local irritation; Not approved for mucosal or perianal warts
  6. 45-88% initial clearance rates; 33-60% recurrence in 3 mos
  1. Treatment with cryotherapy
  1. 68% initial clearance rates; 28% recurrence in 1mo
  1. Topical 5-fluorouracil
  1. BIW X 10WKS
  2. 41-68% initial clearance rates with vulvovaginal warts; 0-10% recurrence in 6-12mos
  3. Adjunctive 5-fu didn't sig. increase effectiveness of laser tx of women with vulvar condylomata
  1. Intralesional interferon-alpha-2b
  1. 44-60% initial clearance rates; no recurrences in 5mos (7 pts)
  2. Adjunctive interferon increased effectiveness but didn't change recurrence rates with podophyllin tx
  1. Systemic interferon
  1. Less efficacious at initial clearance than either podophyllin or cautery
  2. Adjunctive tx with systemic interferon didn't increase efficacy of cryotherapy but did increase initial clearance rates of laser therapy
  1. Laser
  1. Initial clearance rates 22-40%; little good evidence on recurrence
  1. Trichloroacetic acid
    1. Can be used on vaginal mucosa and during pregnancy
    2. Must be professionally applied
  2. Imiquimod 5% cream (Med. Lett. 39:118, 1997)
    1. 209 pts with genital or perianal warts randomized to imiquimod 3x/wk vs. placebo for up to 16wks led to clearing in 72% of women and 33% of men c/w 20% in women and 5% in men w/placebo. Median time to clearing was 12wks for males and 8wks for females (unpublished study summarized in package insert)
    2. 50% healing rate in 311 pts with 13% 12-wk recurrence rate among responders (Arch. Derm. 134:25, 1998--JW)
    3. Dosing: apply 3x/wk at bedtime and leave 6-10h before removing w/soap & water, for max 16wks.
    4. Can cause erythema, erosion, excoriation and flaking; rarely severe
    5. Should not be used on mucosa

(Source: Clin. Inf. Dis 20 (suppl. 1) S91-7, 1995)