External Genital Warts: An Update

Mayeaux
Provider-administered Therapies
Surgical Excision.—Surgical excision directly
removes wart tissue. Studies demonstrate clearance
in 35% to 72% of patients, with recurrence
in 19% to 29% at 1 year. 9
The loop electrosurgical excisional procedure
(LEEP) is indicated for perineal condylomata;
in skilled hands, it may be used for
anal verge lesions. Late bleeding has been
reported in 4% of patients, and can usually
be controlled with Monsel’s solution or fulguration.
In rare cases of infection, topical
antibiotics can be applied. Hypopigmentation
and hypertrophic scars are also rarely
reported. Success rates range from 90%
to 96%. 11
Cryotherapy.—Cryotherapy with liquid
nitrogen, nitrous oxide, or carbon dioxide
cryoprobe is especially useful for discrete
lesions. It is probably the safest therapy
for use during pregnancy. The treated tissues
slough after several days, followed by
inflammation and then healing. Therapy is
repeated every 1 to 2 weeks if necessary.
Common complications include pain and
local infection. The success rate is 71% to
79%, and recurrence rates are 38% to 73%
by 6 months. 9
Trichloroacetic/bichloroacetic (dichloroacetic)
Acid.—Topical acid is also safe for use
during pregnancy, but should not be applied
to the cervix or urinary meatus. Trichloroacetic
acid (TCA) must be compounded at
a pharmacy, but bichloroacetic acid (BCA)
can be obtained in a standard preparation. A
50% TCA solution is applied in a thin layer
with a cotton-tipped applicator three times
a week for a maximum of 4 weeks, or an
80% solution can be applied twice a day for
3 consecutive days per week for a maximum
of 4 weeks. BCA may be applied to the wart
weekly. Bicarbonate, talc, or soap and water
may be used to neutralize any excess acid. 11
Complications include ulceration, pain, and
damage to adjacent skin. Response rates are
50% to 81%, and recurrence rates are high
but undefined. 9,11
Podophyllin.—A solution of 10% to 25%
podophyllin in tincture of benzoin is best
suited for small external lesions. Its use in
pregnancy is contraindicated, and it is not
recommended for use in occluded mucous
membranes. Systemic reactions and death
can occur when application is extensive/prolonged
or involves the mucous membranes.
Adverse reactions include nausea, vomiting,
fever, confusion, coma, renal failure, ileus,
and leucopenia. Podophyllin is applied by
trained personnel once or twice weekly for a
maximum of 4 weeks. The solution should be
washed off 1 to 4 hours after the first application,
and 4 to 6 hours after subsequent applications.
Complications include local erosion,
ulceration, and scarring, as well as irritation
of adjacent skin. Success rates range from
20% to 77%, with recurrence rates of 23%
19, 20
to 65%.
CONCLUSION
External genital HPV infections
are common in sexually
active individuals.
Although such infections
are low-risk with regard to
subsequent cancer, considerable
psychological distress
and social disruption can
occur. Selection of treatment
depends on the number,
size, and location of
lesions, as well as patient preference and the
physician’s training. There is little evidence
that one treatment option is more effective
than any other.
REFERENCES
There is
little evidence
that one
treatment option
is more effective
than any other.
1. Revzina NV, DiClemente RJ. Prevalence and
incidence of human papillomavirus infection in
women in the USA: a systematic review. Int J STD
AIDS. 2005;16(8):528-537.
2. Weinstock H, Berman S, Cates W Jr. Sexually
transmitted diseases among American youth: incidence
and prevalence estimates, 2000. Perspect
Sex Reprod Health. 2004;36(1):6-10.
3. Chuang TY, Perry HO, Kurland LT, Ilstrup DM.
Condyloma acuminatum in Rochester, Minn.,
1950-1978. I. Epidemiology and clinical features.
Arch Dermatol. 1984;120(4):469-475.
4. Winer RL, Lee SK, Hughes JP, Adams DE, Kiviat
NB, Koutsky LA. Genital human papillomavirus
infection: incidence and risk factors in a cohort of
female university students. Am J Epidemiol. 2003;
157(3):218-226.
5. Winer RL, Hughes JP, Feng Q, et al. Condom
use and the risk of genital human papillomavirus
The Female Patient VOL. 32 DECEMBER 2007 43