What are the recommended first-line treatments for genital warts in primary care?

In primary care, the management of anogenital warts is possible if referral to a sexual health specialist is not feasible or acceptable, and if the appropriate expertise and resources are available ¹. While there is no single clear first-line treatment option for all clinical presentations, and the choice of treatment is individualised, several self-applied topical treatments are commonly used ¹.

• Podophyllotoxin: The 0.5% solution (e.g., Condyline® or Warticon®) is considered a likely cost-effective first-line treatment option and is preferred over the 0.15% cream due to slightly superior efficacy for initial wart clearance ¹. It is useful for soft, non-keratinized external lesions ¹. Podophyllotoxin and imiquimod are broadly equivalent in safety and efficacy, but podophyllotoxin may be preferred due to lower cost, shorter treatment duration, and faster action ¹.
• Imiquimod 5% cream (Aldara®): This may be suitable for both keratinized (horny) and non-keratinized, external genital and perianal warts ¹.
• Sinecatechins 10% ointment (Catephen®): This is licensed for external genital warts in people aged 18 years or over who are not immunocompromised ¹. While it has similar clearance rates in trials, the three-times-daily dosing frequency may affect adherence ¹.

These self-applied treatments (podophyllotoxin, imiquimod, and sinecatechins) are suitable for home treatment, and patients should be shown the location of warts and how to apply the treatment ¹. It is important to note that self-applied treatments cannot be used in pregnancy and are not licensed for use in children 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. The choice of treatment depends on factors such as the type, number, and volume of warts, response to previous treatments, site of lesions, availability, cost, clinician experience, and the person's preference ¹. Screening for co-existing sexually transmitted infections (STIs) is essential, particularly in people younger than 25 years of age or those with other genital symptoms ¹.