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Managing HPV: A New Era in Patient Care

(Published June 2009)

HPV and External Genital Warts

External genital warts (EGW), also called condyloma acuminata, are fleshy lesions located in the genital area that are caused by HPV. EGW are usually associated with low-risk HPV types—that is, those that have not been linked to anogenital cancers.1,2 Thus, the main consequence of EGW is aesthetic. Ninety percent of EGW lesions are associated with low-risk HPV types 6 and 11.3

EGW are common, at any point in time affecting approximately 1percent of sexually active adults in the United States.4 Genital warts are usually asymptomatic, but depending on the size and location, they can be pruritic, painful, or friable.5 Left untreated, genital warts may remain unchanged or entirely disappear. However, they often grow in size or number.3 During pregnancy, warts may proliferate and become friable.5

Diagnosis

Genital warts are diagnosed by visual inspection. The lesions, which have a pedunculated, flat, or papular appearance, are located on the external genitalia of both women and men, on the cervix, or in the vagina, urethra, or anus. Application of vinegar or acetic acid may turn lesions white, but this technique is not recommended for diagnosis because of a lack of specificity for HPV-associated lesions.5 Diagnosis can be confirmed by biopsy if lesions are black, brown, or red in color, unresponsive to treatment, or worsen during treatment.5 HPV DNA testing is not indicated for evaluation of EGW.3 Similarly, examination of partners is not necessary, because data do not suggest that reinfection plays a role in recurrences.5

Treatment

The exact impact of treatment on reducing infectivity is unknown.3 Therefore, the primary goal of EGW treatment is removal of lesions for cosmetic reasons. Recurrences are common, and most patients require a series of treatments rather than a single treatment.

Both provider-delivered and patient-applied treatments are available (see Table 2).

Table 2: Treatments for External Genital Warts3,5
  Treatment Directions
Provider-delivered Trichloroacetic acid
(TCA) and bichloroacetic
acid (BCA) 80% to 90%
  • Apply directly to the wart and allow to dry.
  • Reapply weekly if necessary.
  • Apply talc, baking soda, or liquid soap after treatment to remove excess acid.
 

Cryotherapy with liquid
nitrogen or cryoprobe

  • Repeat every one to two weeks, as needed.
  Podophyllin resin 10%
  • Apply directly to the wart and allow to dry.
  • Repeat weekly if necessary.
  • To avoid systemic absorption, do not use more than 0.5 mL of podophyllin and treat no more than 10 cm2 in a single session.
  • Do not apply on mucosal surfaces (e.g., intravaginal or intra-anal locations) or near open lesions or wounds.
  Other options: excision,
laser ablation, and
electrosurgery
  • Use if initial treatment is unsuccessful or if lesions are very large.
Patient-applied Imiquimod (Aldara®),
available as a cream
  • For use once daily at bedtime, three times a week for up to 16 weeks.
  • Six to 10 hours after application, patients should wash area with soap and water.
  Podofilox (Condylox®),
available as a gel or
solution
  • For use in a seven-day treatment cycle: application twice a day for three days, then no treatment for four days, then repeat cycle.
  • No more than 0.5 mL of podofilox should be used per day and no more than 10 cm2 of
    affected area should be treated.

Evidence does not suggest that any one EGW treatment is superior to the others.5 Therefore, treatment choice should be based on size, number, and location of lesions and tailored to the needs and preference of the particular patient. In addition, clinicians should use the least invasive and least costly approach possible to address a particular patient’s needs.

Counseling Points

When counseling a patient about external genital warts, make sure she understands these points before she leaves your office or clinic:

  • The types of HPV that usually cause EGW do not cause cervical cancer.
  • The purpose of removing EGW is aesthetic. Treatment of EGW does not appear to alter the risk of transmission.
  • Successful removal of warts usually requires a series of treatments rather than a single treatment.

Planned Parenthood® Federation of America (PPFA) has published a treatment algorithm for cost-effective treatment of EGW.6 Based on a retrospective chart review, PPFA investigators evaluated the cost of treatment modalities and time for clearance of lesions. They found that 47 percent of clinic resources were spent on the 26 percent of patients who required four or more clinic visits before clearance of EGW. These results informed the creation of the algorithm (see Figure 3).

Providers should consider these factors when selecting treatment:3,5

  • Lesions located on dry surfaces respond less readily to topical treatments than warts on moist surfaces or intertriginous areas.
  • Small isolated lesions often respond to provider-applied therapy such as TCA.
  • Large lesions or multiple-site involvement may be more amenable to other options.
  • Podophyllin resin, imiquimod, and podofilox should NOT be used for treatment of EGW in pregnant women, because their safety during pregnancy has not been established.
  • Imiquimod is not approved for the treatment of intravaginal warts.
  • Intra-anal and intravaginal warts should not be treated with podophyllin resin; instead, warts in these locations can be treated with TCA, or surgical therapy if needed.
  • Although employed in the past, 5-FU is rarely used now for treatment of EGW.

Based on the algorithm, a first-time EGW patient with lesions in a single location would be treated with TCA or cryotherapy. If lesions clear in three visits or fewer, treatment would be considered complete. If lesions do not clear within three visits, patients would be provided with imiquimod for treatment at home, along with educational materials for proper use. Patients who have recurrent EGW lesions and first-time EGW patients with lesions in multiple locations would be provided with imiquimod for treatment at home, along with educational materials for proper use. Although it is not included in the algorithm, ablative therapy with a laser could be considered if lesions persist despite treatment.

References:

  1. Lacey CJN, Lowndes CM, Shah KV. Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease. Vaccine. 2006;24(suppl 3):S3/35-41.
  2. Munoz N, Castellsagué X, de Gonzalez AB, Gissmann L. HPV in the etiology of human cancer. Vaccine. 2006;24(suppl 3):S3/1-10.
  3. Centers for Disease Control and Prevention. Human Papillomavirus: HPV Information for Clinicians. November 2006. Available at: www.cdc.gov/std/HPV/hpv-clinicians-brochure.htm. Accessed March 20, 2007.
  4. Koutsky LA, Galloway DA, Holmes KK. Epidemiology of genital human papillomavirus infection. Epidemiol Rev. 1988;10:122-63.
  5. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2006. MMWR. 2006;55(RR-11):62-7.
  6. Fine P, Ball C, Pelta M, McIntyre C, Momtaz M, Morfesis J, et al. Treatment of external genital warts at Planned Parenthood Federation of America Centers. J Reprod Med. 2007;52:1090-6.