Drug update: genital warts. (Gynecology).

Medical treatment of external genital warts falls into two basic categories: patient applied and provider applied. Patient-applied treatments include imiquimod and podofilox. Agents administered by providers include podophylilin resin, trichloroacetic acid, and bichloroacetic acid. Another treatment option is to physically remove warts using methods such as cryotherapy, surgical excision, and laser ablation, but these treatments are beyond the scope of a drug update.

Cryotherapy in particular, with either liquid nitrogen or a cryoprobe, is the option many physicians use when physical removal is the goal.

Deciding between home or office treatment and between medical or physical treatment depends on the extent of the warts, patient and physician preferences, available resources, and cost considerations. No option is considered substantially better than the rest. In general, a few small warts are easily treated topically, whereas extensive, severe warts may require physical removal. Although subcutaneous injection of interferon-[alpha] is available, it is almost never used, and guidelines from the Centers for Disease Control and Prevention recommend that interferon not be used. Patient self-treatment obviously also requires that the patient be able to identify and reach the warts.

There are no clear guidelines for selecting among the provider-administered therapies; selection is guided by physician preference. Experts suggest that clinicians be familiar with at least one patient-applied treatment and one office-based therapy.

Compliance and motivation are essential for patient self-treatment because these regimens require several weeks of application. Office-based therapies often require only one or two treatments, but sometimes as many as six treatments are needed. Treatment methods should be changed if the patient has not substantially improved after three provider-administered treatments or if complete clearance is not obtained after six treatments.

So few patients older than 70 years present with genital warts that there are no recommendations for tapering dosages in the elderly. A recent report on the efficacy of duct tape occlusion for treating common warts may not apply to genital warts because of mucosal involvement.

Warts may not appear for weeks or months after infection with the human papillomavirus (HPV), and most HPV infections never lead to wart formation; therefore, patients without symptoms can transmit them. Most warts are caused by HPV type 6 or 11. Eradicating warts is not a guarantee against recurrence. Patients with genital warts should be tested for other sexually transmitted diseases.