Patient-applied therapy. Podofilox 0.5% solution is applied with a cotton swab (podofilox 0.5% gel, with a finger) to visible genital warts bid for 3 days, followed by 4 days of no therapy. This regimen may be repeated as necessary for a total of 4 treatment cycles. The total area treated should not exceed 10 cm2, and the total dose should be no more than 0.5 mL/d. Most patients experience mild to moderate pain or local irritation after treatment.
Imiquimod 5% cream is applied at bedtime 3 times a week for up to 16 weeks. Six to 10 hours after application, the treatment area should be washed with soap and water. Mild to moderate local inflammatory reactions are common with the use of imiquimod.
Follow-up visits are not mandatory for patients who use self-administered therapy. However, consider asking the patient to return several weeks after treatment has started to determine whether the medication is used correctly and to assess the response to therapy.
Provider-administered therapy. Cryotherapy with either liquid nitrogen or a cryoprobe destroys warts by thermal-induced cytolysis. Repeat applications every 1 to 2 weeks. After liquid nitrogen is applied, pain followed by necrosis and sometimes blistering is common. A topical or injected local anesthetic may facilitate therapy if the patient has warts at many sites or has a large single area of warts.
Podophyllin resin, 10% to 25% in a compound tincture of benzoin, is antimitotic. Apply a small amount to each wart and allow to air dry. Some experts recommend limiting application to no more than 0.5 mL of podophyllin (or no more than 10 cm2 of warts per session) to avoid systemic absorption and toxicity. Others suggest washing off the preparation after 1 to 4 hours to reduce local irritation. Repeat the application weekly if necessary.
Both TCA and BCA (80% to 90%) destroy warts by chemical coagulation of proteins. Apply a small amount only to warts and allow to dry, at which time a white “frosting” develops. If an excess amount is applied, powder with talc or sodium bicarbonate or use a liquid soap preparation to remove unreacted acid. Repeat weekly if necessary.
Surgical removal by tangential scissor excision, tangential shave excision, curettage, or electrosurgery can destroy all visible genital warts in a single visit; however, substantial training and equipment are required. Surgery is most beneficial for patients who have a large number or area of warts. Carbon dioxide laser treatment may be useful in patients with extensive or intraurethral warts, particularly those whose warts have not responded to other therapy.
Intralesional interferon (either natural or recombinant) is not recommended for routine use because of inconvenient administration and a high risk of systemic adverse effects. Its efficacy and recurrence rates are similar to those of other treatments.
Counseling. This is a key aspect of management. When talking to patients about genital warts, be sure to include the following points:
• Genital HPV infection is common among sexually active adults.
• The incubation period varies, and the source of infection is often difficult to determine. If the patient is in an ongoing relationship, the sex partner is usually infected as well.
• The natural history of genital warts is generally benign. Their presence in women is not an indication for an increase in the frequency of Papanicolaou tests or for cervical colposcopy.
• Recurrence of genital warts within the first several months after treatment is common. No data indicate that reinfection plays a role in recurrence.
• The likelihood of transmission to future partners and the duration of infectivity after treatment are unknown.
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