Treatment Protocol for External Genital Warts

PRACTICE
ALGORITHM
Treatment Protocol for
External Genital Warts
Paul M. Fine, MD; Savita Y. Ginde, MD, MPH
There are about 1 million new cases
of external genital warts (EGW) in the
United States annually. 1 Standard treatments
include surgical (eg, cryotherapy,
excision, laser therapy, electrosurgery),
and nonsurgical (eg, bichloroacetic acid [BCA]/
Paul M. Fine, MD, is Medical Director, Planned Parenthood
of Houston & Southeast Texas. Savita Y. Ginde,
MD, MPH, is Medical Director, Planned Parenthood of
the Rocky Mountains, Denver, CO.
trichloroacetic acid [TCA], podophyllotoxin,
imiquimod). Ablative or surgical therapies are
effective in the short term, but recurrence rates
can be high. 2 Clearance rates of 63% to 70%
can be obtained with BCA/TCA, while imiquimod—a
topical immune response modifier—
produces complete clearance in 37% to 70%
of cases. 3-7
To determine the most efficacious and
cost-effective treatments for EGW, Planned
External Genital Warts Treatment Algorithm
Patient presents
with EGW
Patient with initial
episode
Patient with
recurrence
Single location
of lesions
YES
Treat with TCA/cryo
NO
Warts in multiple
locations
Not cleared in
>3 visits
Imiquimod with
patient education
materials
Patient cleared in
≤3 visits
Treatment
completed
EGW = external genital warts; TCA = trichloroacetic acid; cryo = cryotherapy
The Female Patient | VOL 33 SEPTEMBER 2008 15

PRACTICEALGORITHM
Treatment Protocol for External Genital Warts
Parenthood conducted a retrospective study
involving 5 of its major US affiliates that
reviewed the charts of 422 women and 78 men
undergoing treatment for EGW. 8 Treatment
must have been successful, and statistical analysis
incorporated anatomic site, frequency of
office visits, treatment modality, and cost of
treatment and office visits. The treatment algorithm
presented here was derived from these
data, and represents the most efficacious and
cost-effective treatment strategy in the Planned
Parenthood clinic setting. The algorithm strikes
a careful balance between cost-effective management
of health care resources and patient
need to achieve treatment success with a minimum
number of clinic visits. Residual lesions
following imiquimod therapy are easily treated
by surgical excision, with high success rates. 9
Appropriate partner counseling must be considered,
as well as screening for other sexually
transmitted infections, including HIV.
The authors report no actual or potential
conflicts of interest in relation to this article.
REFERENCES
1. Gunter J. Genital and perianal warts: new treatment
opportunities for human papillomavirus infection. Am J
Obstet Gynecol. 2003;189(3 Suppl.):S3-S11.
2. Stanley M. Chapter 17: Genital human papillomavirus
infections current and prospective therapies. J Natl Cancer
Inst Monogr. 2003;(31):117-124.
3. Wiley DJ, Douglas J, Beutner K, et al. External genital
warts: diagnosis, treatment, and prevention. Clin Infect
Dis. 2002;35(Suppl. 2):S210-S224.
4. Edwards L, Ferenczy A, Eron L, et al. Self-administered
topical 5% imiquimod cream for external anogenital
warts. HPV Study Group. Human PapillomaVirus. Arch
Dermatol. 1998;134(1):25-30.
5. Beutner KR, Spruance SL, Hougham AJ, Fox TL, Owens ML,
Douglas JM Jr. Treatment of genital warts with an
immune-response modifier (imiquimod). J Am Acad
Dermatol. 1998;38(2 Pt 1):230-239.
6. Arican O, Guneri F, Bilgic K, Karaoglu A. Topical imiquimod
5% cream in external anogenital warts: a randomized,
double-blind, placebo-controlled study. J Dermatol.
2004;31(8):627-631.
7. Sauder DN, Skinner RB, Fox TL, Owens ML. Topical
imiquimod 5% cream as an effective treatment for external
genital and perianal warts in different patient populations.
Sex Transm Dis. 2003;30(2):124-128.
8. Fine P, Ball C, Pelta M, et al. Treatment of external genital
warts at Planned Parenthood Federation of America
centers. J Reprod Med, 2007:52(12):1090-1096.
9. Carrasco D, vander Straten M, Tyring SK. Treatment of
anogenital warts with imiquimod 5% cream followed by
surgical excision of residual lesions. J Am Acad Dermatol.
2002;47(4 Suppl.):S212-S216.
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