management of genital wart

The appropriate management of genital warts involves a comprehensive approach, beginning with assessment and, ideally, referral to a sexual health specialist ¹.

• Initial Assessment and Referral: All individuals with anogenital warts should ideally be referred to a sexual health specialist ¹. If referral is not possible or acceptable, management can occur in primary care, provided the necessary expertise and resources for comprehensive assessment, treatment, screening for other sexually transmitted infections (STIs), and contact tracing are available ¹. Screening for co-existing STIs is essential, particularly for individuals under 25 years of age or those with other genital symptoms ¹. A vaginal speculum examination should be performed in women, and proctoscopy considered if there is a history of anal receptive sex ¹. Referral is specifically recommended if the diagnosis is uncertain, there are recurrent perianal warts, accompanying urinary symptoms, suspected malignancy or intraepithelial neoplasia, immunosuppression (including HIV), or present/suspected cervical, intrameatal, or intra-anal warts ¹. Pregnant women, children, and elderly individuals should also be referred ¹. For children, especially those younger than 13 years, sexual abuse should be considered, and appropriate child protection procedures followed ¹,³. Partner tracing for anogenital warts alone is not recommended unless other STIs are present ¹.
• Treatment Goals and Options: The primary aim of treatment is to remove the warts ¹. Treatment is not always indicated, as approximately 30% of warts may disappear spontaneously within six months, making deferral of treatment an acceptable option if preferred by the patient ¹. Available treatment options include self-applied topical treatments and clinician-applied therapies ¹.
• Self-Applied Treatments: These treatments are not licensed for use in children and are generally avoided in pregnancy due to safety concerns or lack of data ¹. They carry a high likelihood of adverse effects such as pruritus, irritation, and pain at the application site ¹. If a self-applied treatment is chosen, patients should be shown the exact location for application to prevent undertreatment ¹.
  • Podophyllotoxin: Available as 0.5% solution (Condyline® or Warticon®) or 0.15% cream (Warticon®), it is effective for soft, non-keratinized external lesions but is not licensed for anal warts ¹. The solution may offer slightly superior efficacy for initial clearance, though the cream may be easier to apply ¹. Supervision by a healthcare professional is recommended for lesions larger than 4 cm² ¹.
  • Imiquimod 5% Cream (Aldara®): Suitable for both keratinized and non-keratinized external genital and perianal warts, but not recommended for internal use ¹. It should be applied as a thin layer three times a week (e.g., Monday, Wednesday, Friday) at bedtime, remaining on the skin for 6 to 10 hours before being washed off with mild soap and water ¹. Treatment continues until visible warts clear or for a maximum of 16 weeks per episode ¹. Patients should be advised to avoid applying it to normal or broken skin, wash hands thoroughly, and be aware that latex condoms and diaphragms may be weakened by contact with imiquimod ¹. Response and adverse effects may be delayed, and inflammation may occur due to immune stimulation ¹.
  • Sinecatechins 10% Ointment (Catephen®): Contains green tea extract and is licensed for external genital warts in individuals aged 18 years or over who are not immunocompromised ¹.
• Clinician-Applied Treatments: These include cryotherapy, trichloroacetic acid (TCA), and surgical options [1, (Kodner and Nasraty, 2004), (Mayeaux EJ Jr and Dunton, 2008)].
• Management in Pregnancy: Anogenital warts may enlarge and multiply during pregnancy and become more easily irritated ¹. While wart removal can be considered, the presence of warts rarely impacts pregnancy outcome, and resolution may be incomplete until after delivery ¹. Spontaneous resolution is often seen within six weeks postpartum, making delaying treatment until after delivery common practice ¹. Topical treatments are generally avoided in pregnancy due to safety concerns or lack of data; cryotherapy, TCA, or surgical treatment options are preferred ¹. Pregnant women can be counselled about the low risk of vertical human papillomavirus (HPV) transmission and recurrent respiratory papillomatosis in the child ¹.
• Patient Education and Follow-up: Patients should receive both written and verbal explanations about anogenital warts, including their causes, complications, treatments, and prognosis ¹. It is important to explain that several treatment attempts are often needed, active treatments may take 1–6 months to work, have significant failure and relapse rates (as they do not eliminate HPV), and can cause discomfort and skin reactions ¹. Condom use and smoking cessation are recommended to improve treatment response ¹. Psychological counselling should be considered if psychological distress is an issue ¹. Patients can be reassured that warts do not always imply recent partner infidelity due to HPV's long latency period (3 weeks to 8 months) ¹. Current sexual partners may benefit from assessment for undetected STIs or advice, with consent ¹.
• Recurrence and Resistant Cases: Recurrences are common after treatment [1, (Plotzker et al., 2023)]. While specific guidelines for treatment-resistant cases are not available, a longer duration or combination of treatment options may be necessary ¹. Clinical assessment over time should guide treatment ¹. In resistant cases, surgical excision followed by non-invasive therapies or other combination therapies may be required ¹.