There are many modalities for treating GW, depending on the morphology, number and distribution of warts and patient preference. However, none of them provide 100% chance of clearance or 0% chance of recurrence. Also, there is no clear evidence that any one treatment is superior to the others.

Therapy may be applied by the patient or by the provider. A treatment response is usually seen within 3months.

The US latest (2010) guidelines on GW treatment recommend the following options:

External genital warts

Patient-applied therapy:

• Podofilox 0.5% solution or gel or
• Imiquimod 5% cream  or
• Sinecatechins 15% ointment

Provider-administered therapy:

• Cryotherapy with liquid nitrogen or cryoprobe or
• Podophyllin resin 10-25% in a compound tincture of benzoin or
• Trichloroacetic acid (TCA) or bichloracetic acid (BCA) 80-90% or
• Surgical removal by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.

Alternative Regimens

Alternative regimens include treatment options that might be associated with more side effects and/or less data on efficacy. These include:
- intralesional interferon
- photodynamic therapy
- topical cidofovir.

Vaginal warts

• Cryotherapy with liquid nitrogen or
• TCA or BCA 80-90%

Urethral meatus warts

• Cryotherapy with liquid nitrogen or
• Podophyllin 10-25% in compound tincture of benzoin

Anal warts

• Cryotherapy with liquid nitrogen or
• TCA or BCA 80-90% or
• Surgical removal

Because all available treatments have shortcomings, some clinics employ combination therapy (simultaneous use of two or more modalities on the same wart at the same time). Data are limited regarding the efficacy or risk of complications associated with use of such combinations.

Clearance and recurrence rates for individual treatments in the published literature are shown in the following table (according to the UK National Guideline on the Management of Ano-genital Warts, 2007).

*Studies using more than one treatment strength have been grouped together.

It is important to mention that these studies are not comparable in design, methods and endpoints.

References
Genital warts. In: Sexually transmitted diseases treatment guidelines, 2010. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2010 Dec 17;59(RR-12):70-4.

United Kingdom national guideline on the management of anogenital warts. London (UK): British Association for Sexual Health and HIV (BASHH); 2007. 18 p. Clinical Effectiveness Group, British Association for Sexual Health and HIV (BASHH).

PODOPHYLLIN and PODOPHYLLOTOXIN (PODOFILOX, CONDYLOX)

Podophyllin is a resin derived from the rhizome (underground root) of the mayapple (Podophyllum peltatum), a plant that grows wild in eastern North America. Podophyllin  was the first topical treatment ever applied on GW. It is also used nowadays as a 10-25 % suspension in tincture of benzoin (physician applied). Podophyllin is an antimitotic agent that interferes with viral activity by inducing local tissue necrosis.

Applied directly to each genital wart, it is left for six hours and then washed off. This process may be repeated one time per week, for up to 6 weeks or until the warts are gone. Once applied to each wart it should be allowed to air-dry before the treated area comes into contact with clothing; over application or failure to air dry can result in local irritation caused by spread of the compound to adjacent areas. The preparation should be thoroughly washed off 1–4 hours after application to reduce local irritation. In rare cases the use of podophyllin is associated with side effects due to systemic absorbtion and toxicity. To avoid such effects, application should be limited to <0.5 mL of podophyllin or an area of <10 cm2 of warts per session. Also, the area to which treatment is administered should not contain any open lesions or wounds. In very rare cases liver dysfunction, bone marrow suppression, nausea, diarrhea or constipation, abdominal pain, neurological impairment or even psychosis may occur. The safety of podophyllin during pregnancy has not been established.

The resin formula is made a few hours before the appointment. It is unstable so it cannot be stored easily; therefore it must be applied fresh and later disposed in a biohazard bin since it is poisonous.

In terms of relative effectiveness, the study results are conflicting. A randomized study in 60 patients with once weekly podophyllin showed initial complete clearance of 93 percent versus 77 percent for surgical excision. Recurrence rates were 18% for surgical excision and 43% for podophyllin at 3 months, 22% and 56% at 6 months, 26% and 56% at 9 months, 29% and 65% at 12 months (Jensen SL, 1985). In another study (Khawaja HT, 1989) at 6 weeks scissor excision completely cleared the warts in 89% compared with 79 % treated with podophyllin. Recurrence was 19% in the surgery group, compared to 60% in the podophyllin group.

A randomized controlled trial in 97 patients evaluated the efficacy of intralesional interferon 2b and podophyllin versus podophyllin alone for the therapy of anogenital warts. The conclusion was that intralesional administration of interferon seemed to enhance the effect of topical podophyllin (Douglas JM, 1990).

Another study has shown that in a cohort of 409 individuals with new or recurrent warts, randomly allocated to one of 5 treatments on a weekly basis, single therapy with either trichloracetic acid or podophyllin 25% resulted in longer time to wart clearance, and more persistent warts (Sherrard J, 2007).

Thus, the disadvantages to the use of podophyllin include unstandardized preparation, side effects, lower effectiveness, failure to induce lasting remission. It may also contain the mutagenic flavonoid compounds quercetin and kaempherol. Podophyllin preparations vary greatly in their active component and contaminant concentrations.

Podophyllotoxin is the main active ingredient of podophyllin resin that has been purified and prepared to a well standardised concentration. Also known as Podofilox or Condylox (brand name), it is available as cream, gel, or solution preparations that can be self applied by the patient. Because of its purity and ease of use, podophyllotoxin is to be preferred over podophyllin.

Podofilox solution is applied with a cotton swab, or podofilox gel with a finger, to visible genital warts twice a day for 3 days, followed by 4 days of no therapy. This one week cycle of treatment may be repeated until there is no visible wart tissue or for a maximum of 4 cycles. If there is incomplete response after four treatment cycles, it is recommended to discontinue treatment and consider alternative treatment. No evidence suggests that more frequent application will increase efficacy. However, additional applications do increase the rate of local adverse reactions and systemic absorption. The total wart area treated should not exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day. If possible, the health-care provider should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated. Mild to moderate pain or local irritation might develop after treatment. The safety of podofilox during pregnancy has not been established.

Eight randomized controlled trials (RCTs), involving   1035 patients compared the efficacy of podophyllotoxin versus placebo (Syed TA, 1995; Greenberg MD, 1991; Beutner KR, 1989; Kirby P, 1990; Tyring S, 1998; von Krogh G, 1992; 1994; Syed TA, 1994). All found that, within 16 weeks of treatment, podophyllotoxin was more effective for clearance than placebo (RRs of clearance v placebo ranged between 2.0 [95% CI 0.9 to 4.3] and 48.0 [95% CI 3 to 773]). RCTs of 0.5% cream or solution found recurrence rates ranging from 4% to 33%. One RCT (57 patients) of 0.5% podophyllotoxin solution as prophylaxis against recurrence of external genital warts found fewer recurrences among people taking placebo.

When comparing podophyllotoxin versus podophyllin, five RCTs found no significant difference in wart clearance (RR values for podophyllin vs podophyllotoxin ranging between 0.7 [95% CI 0.4 to 1.1] (Hellberg D, 1995) and 1.7 [95% CI 0.9 to 3.2]) (Lassus A, 1984). One of these RCTs used a 2% podophyllin solution in a limited study of self-treatment for penile warts, and found no significant difference in clearance between podophyllotoxin and podophyllin (RR for podophyllin v podophyllotoxin 0.6, 95% CI 0.3 to 1.3) (White DJ, 1997). The sixth RCT (358 immunocompetent men and women with genital warts for 3 months or less, 276 [77%] completed) compared podophyllotoxin (self-treatment with 0.5% solution or 0.15% cream twice daily for 3 days with 4 days off) versus podophyllin (25% applied twice weekly at a clinic) (Lacey CJ, 2003). Both treatments were given until warts were cleared, up to a maximum of 4 weeks. The RCT found that podophyllotoxin solution, but not podophyllotoxin cream, significantly increased complete remission of warts at 4 weeks compared with podophyllin (intention to treat analysis: OR 1.92, 95% CI 1.13 to 3.27 for solution; OR 1.17, 95 % CI 0.69 to 2.00 for cream). It found no significant difference between treatments in recurrence of warts at 12 weeks among those with initial clearance (74 people analysed: 15/33 [45%] with podophyllotoxin solution v 12/22 [54%] with podophyllotoxin cream v 5/19 [26%] with podophyllin; P reported as not significant). High withdrawal, and the potential for selection bias among returning people, limit the reliability of these results.

One study comparing podophyllotoxin with topical interferon has found that topical interferon significantly increased wart clearance at 4 weeks after treatment compared with podophyllotoxin (18/20 [90%] with topical interferon v 12/20 [60%] with podophyllotoxin; P = 0.0285) (Syed TA, 1995).

Possible side effects reported with podophyllotoxin are local inflammation or irritation, erosion, burning, pain, itching, and more rarely dyspareunia, bleeding, scarring, and insomnia.

RCTs examined the efficacy of podophyllotoxin solutions more often than cream preparations, but cream or gel preparations may be easier to apply than solutions. This and other differences may cause variable efficacy.

Podophyllotoxin does not contain the mutagenic flavonoid compounds quercetin and kaempherol, which are contained in podophyllin resin preparations.

References

Reutner KR, Conant MA, Friedman-Kien AE, et al. Patient-applied podofilox for treatment of genital warts. Lancet 1989;i:831–834

Bonnez W, Elswick RK Jr, Bailey-Farchione A, Hallahan D, Bell R, Isenberg R, Stoler MH, Reichman RC. Efficacy and safety of 0.5% podofilox solution in the treatment and suppression of anogenital warts. Am J Med. 1994;96:420-5.

W Buck H Jr. Warts (genital). Clin Evid (Online). 2010 Aug 13;2010. pii: 1602.

Douglas JM Jr, Eron LJ, Judson FN, Rogers M, Alder MB, Taylor E, Tanner D, Peets E. A randomized trial of combination therapy with intralesional interferon alpha 2b and podophyllin versus podophyllin alone for the therapy of anogenital warts. J Infect Dis. 1990;162:52-9.

Greenberg MD, Rutledge LH, Reid R, et al. A double-blind, randomized trial of 0.5% podofilox and placebo for the treatment of genital warts in women. Obstet Gynecol1991;77:735–739

Hellberg D, Svarrer T, Nilsson S, et al. Self-treatment of female external genital warts with 0.5% podophyllotoxin cream (Condyline) vs weekly applications of 20% podophyllin solution. Int J STD AIDS1995;6:257–261

Jensen SL, Comparison of podophyllin application with simple surgical excision in clearance and recurrence of perianal condylomata acuminata. Lancet. 1985;2(8465):1146-8.

Khawaja HT. Podophyllin versus scissor excision in the treatment of perianal condylomata acuminata: a prospective study. Br J Surg. 1989;76:1067-8.

Kirby P, Dunne King D, Corey L. Double-blind randomized clinical trial of self-administered podofilox solution versus vehicle in the treatment of genital warts. Am J Med1990;88:465–469.

Lassus A, Haukka K, Forsstrom S. Podophyllotoxin for treatment of genital warts in males: a comparison with conventional podophyllin therapy. Eur J Sex Transm Dis 1984;2:31–33.

Lacey CJ, Goodall RL, Tennvail GR, et al., for the Perstorp Pharma Genital Warts Clinical Trial Group. Randomised controlled trial and economic evaluation of podophyllotoxin solution, podophyllotoxin cream, and podophyllin in the treatment of genital warts. Sex Transm Infect2003;79:270–275.

Sherrard J, Riddell L. Comparison of the effectiveness of commonly used clinic-based treatments for external genital warts. Int J STD AIDS. 2007 Jun;18(6):365-8.

Syed TA, Khayyami M, Kriz D, Svanberg K, Kahlon RC, Ahmad SA, Ahmad SA. Management of genital warts in women with human leukocyte interferon-alpha vs. podophyllotoxin in cream: a placebo-controlled, double-blind, comparative study. J Mol Med (Berl). 1995 May;73(5):255-8.

Tyring S, Edwards L, Cherry LK, Ramsdell WM, Kotner S, Greenberg MD, Vance JC, Barnum G, Dromgoole SH, Killey FP, Toter T. Safety and efficacy of 0.5% podofilox gel in the treatment of anogenital warts. Arch Dermatol. 1998;134:33-8.

Von Krogh G. Topical self-treatment of penile warts with 0.5% podophyllotoxin in ethanol for four or five days. Sex Transm Dis1987;14:135–140.

Von Krogh G. Penile condylomata acuminata: an experimental model for evaluation of topical self-treatment with 0.5–1.0% ethanolic preparations of podophyllotoxin for three days. Sex Transm Dis1981;8:179–186

White, DJ, Billingham C, Chapman S, et al. Podophyllin 0.5% or 2.0% v podophyllotoxin 0.5% for self treatment of penile warts: a double blind randomised study. Genitourin Med1997;73:184–187.

HPV stands for Human Papillomavirus, which is a virus that establishes infections through the skin and mucous membranes. There are about 200 strains of HPV, many of which cause no symptoms at all in humans. Some, however, are known to cause warts, including genital warts, and infections that can lead to cervical and other cancers.

Around 40 HPV strains can be transmitted via sexual contact and certain ‘high-risk’ HPV viruses are thought to be the main cause of cervical cancer in women. They may also cause other genital cancers such as penile, vulvar, vaginal, anal, and cancers of the head and neck. Most infections with these viruses do not, however, lead to serious disease.

Due to intervention of the immune system, 70% of infections by the HPV virus resolve by themselves within one year and 90% resolve within two years. In about 5-10% of infected women, the infection can lead to precancerous lesions or invasive cancer of the cervix. This process is a very slow one, thought to take at least 5-15 years for detectable changes to develop in the cervix.

In most developed countries, women undergo a regular Pap smear test, which involves collecting cells from the outer opening of the cervix. The cells are examined under a microscope to see whether there are any pre-cancerous changes, known as cervical intraepithelial neoplasia or dysplasia, which is usually caused by the HPV virus. If abnormal cells are found, the test is repeated in 6-12 months. If there continues to be an abnormality a colposcopy is recommended. During the colposcopy the cervix is examined visually and a biopsy may be taken. Abnormal areas of cells can be removed using a cauterizing loop or using cryotherapy (freezing). Regular Pap screening allows detection of abnormalities which, if found, can be treated, enabling early detection of cervical cancer and preventing progression to invasive cervical cancer.

During the last few decades, the incidence of severe illness and death from cervical cancer has been substantially reduced by use of the Pap smear, which is considered to be a preventive measure. In the USA in 2008, there were around 11,000 cases and 3,900 deaths from cervical cancer. About 50% of women who develop cervical cancer have never had a Pap smear. In areas of the world where women have reduced access to health care and regular Pap smears, mortality rates from cervical cancer are much higher. Worldwide, there are around 490,000 cases and 270,000 deaths from cervical cancer. Even so, cervical cancer is still a comparatively rare form of cancer.

In recent years two vaccines designed to protect against infection with the HPV virus have been launched onto the market: Gardasil and Cervarix. The pharmaceutical companies that manufacture these vaccines claim that they prevent cervical cancer, but let’s take a closer look at these claims, starting with the first vaccine on the market, Gardasil.

Gardasil
Manufactured by Merck, Gardasil was licensed for use in girls by the FDA in 2006. Also known as Gardisil and Silgard, this vaccine is intended to prevent infection by the sexually transmitted HPV viruses, especially the high-risk strains, 6, 11, 16 and 18. This vaccine is touted as a preventative measure, to prevent infection by HPV and resulting cervical, vulvar and vaginal cancers. However, the vaccine is not effective if the recipient has already been infected by the above HPV strains. Gardasil is administered in 3 x 0.5 ml injections over 6 months, at 2 month intervals. Compliance rates are low, in that only 27% of girls complete the 3-dose regimen. What current recipients of the vaccine are not told is that during the clinical trial for this vaccine, participants were actually given FOUR doses of the vaccine to boost the number of HPV antibodies in the blood. Strangely, Gardasil was ‘fast tracked’ through the federal regulatory system even though it does not meet any of the criteria for fast tracking.

Cervarix
Another vaccine, manufactured by GlaxoSmithKline, and approved by the FDA for use in girls in 2009 is Cervarix. Cervarix is designed to prevent infection by HPV virus strains 16 and 18, which are thought to be responsible for 70% of cases of cervical cancer. The manufacturer claims that Cervarix is superior to Gardasil as it generates a greater antibody response to the virus than Gardasil. After the initial injection, Cervarix is administered by 1 injection a month afterwards, and another 5 months later.

Both these vaccines must be administered before the recipient becomes sexually active.

The FDA has now approved the use of Gardasil in boys. Merck claims that vaccination will prevent them from carrying the cancer-causing strains and infecting women. Gardasil was approved for use in boys in the US in 2009 and in the UK in 2006.

Limitations of these vaccines
There are a few things wrong with this picture …

For a start, the vaccine manufacturers claim that an HPV vaccine can prevent the development of cervical cancer. The HPV vaccines are NOT cancer vaccines. The vaccines only provide limited protection against infection by certain strains of the HPV virus and may only be effective for 3-5 years following vaccination.

Cervical cancer takes an estimated 5-15 years to develop, and the clinical trials carried out by the manufacturers before bringing the vaccines to market only lasted 5-6 years. Therefore, contrary to claims by Merck and GlaxoSmithKline, there is no proof whatsoever that HPV vaccines actually prevent cervical cancer!

Cervical cancer is one of the rarest cancers – in most cases, HPV infection is attacked and destroyed by the immune system before it can develop into cancer.

Federal authorities have decreed that all female immigrants between the ages of 11 and 16 must be vaccinated with Gardasil before entering the country, despite the fact that HPV has a very low infection rate. What could be behind this sinister move?

Side effects of the vaccines
Despite being termed ‘safe’ by the pharmaceutical industry there are serious questions about their safety records, particularly that of Gardasil. A number of serious side effects have been reported following administration of these vaccines. These include life-threatening illnesses, spontaneous abortion, permanent disablement and death.

Gardasil side effects
Minor side effects of Gardasil include dizziness and fainting. These may be categorized as ‘non-serious’, but, read on …. Serious side effects associated with Gardasil include blood clots in the legs, heart and lungs, stroke, heart attack, short-term memory loss, seizures, blindness, paralysis, ovarian cysts, pain, mood changes, movement disorders, speech problems, pancreatitis, and development of Guillain-Barré syndrome. Guillain Barré syndrome is a rare neurological disorder characterized by muscle weakness.

As of September 15th 2011, the CDC reports that there have been 71 reported deaths directly linked to the vaccine, mostly among girls. The true figures may be much higher.

During the clinical trials a number of young women died in car crashes, but Merck does not report whether they were the driver or the passenger. This is critical information in view of the fact that a neurological event such as fainting or seizures could cause a car driver to crash.

In some states, attempts have been made at making vaccination with Gardasil mandatory. This unusual step is explained by the fact that in the state of California alone, 24 legislators are known to have received payments from Merck. The same is doubtless true of other states such as Texas where, happily, attempts at making Gardasil vaccination mandatory ultimately failed.

Gardasil can be considered as one of the most dangerous vaccines ever pushed on young children. All this begs the question: why are these vaccines being promoted by doctors and health authorities alike? The answer may shock you.

Hidden agenda
Part of the answer is about money, of course. Merck has made billions of dollars from selling Gardasil worldwide, although happily sales in the USA have slumped recently due to the number of adverse reports. Even more sinister forces may be at work, however.

According to Dr Joseph Mercola the World Health Organization has a task force uniquely dedicated to developing anti-fertility vaccines. They are not alone. In Brazil a mandatory rubella vaccination program has been instigated, despite the fact that only about 17 children a year are born with birth defects due to the disease. Moreover, free tetanus injections were handed out in Mexico, Nigeria, Tanzania and Philippines. It was later discovered that these vaccines contained human gonadotrophin (HCG) a hormone which causes spontaneous abortions in pregnant women and may lead to permanent infertility.

Gardasil contains Polysorbate-80, a surfactant that helps deliver pharmacological substances across the blood-brain barrier. Polysorbate-80 has been linked to infertility in mice. It decreases the size of the ovaries and uterus and can result in chronic stimulation of cells that produce estrogen.

Another odd ingredient of Gardasil is L-histadine, which has been found to increase blood clot formation when combined with certain surfactants, of which Polysorbate-80 could be one. Death from blood clots within hours or days of being vaccinated with Gardasil is the most common cause of Gardasil-related death in the young women who received the vaccine.

It is bad enough that these dangerous vaccines are touted for girls, but promoting them for use in boys is simply nonsensical. Again, questions remain as to their safety in boys as well as in girls. It is likely they will have many of the same effects in boys as in girls. Parents need to be aware of the likely adverse effects of these vaccines before making crucial health decisions for their children. Forewarned is forearmed.

Genital warts is a health subject that those who are (or who are about to become) sexually active should be familiar with. Genital warts are caused by certain types of Human Papillomavirus (HPV). HPV is a virus that can be contracted by direct genital contact such as vaginal and/or anal sex. The Centers for Disease Control and Prevention (CDC) reports that at least 50% of sexually active people will get genital HPV

The types of HPV that are associated with the visible skin changes known as genital warts fall into the low risk category. This means that genital warts do not put a person at increased risk for cancer. Genital warts are visible growths or bumps that can be raised or flat, small or large, and singular or multiple in number. External warts can be found on the penis, vulva, scrotum, and surrounding skin tissues. Internal warts can be found on the cervix, vagina, urethra, and anus. Often genital warts go unnoticed, but they can be painful, itchy, and bleed easily.

Genital warts can be prevented by abstinence (not having sex). A vaccine is available for women aged 9-26 that prevents certain types of HPV thus reducing the risk of having genital warts. The risk of contracting genital warts can further be reduced by using condoms, and keeping the number of sexual partners you have in your lifetime to a minimum (the partner you select should also have had minimal partners).

While Genital warts may go away on their own, a number of treatment options are available to remove them. When considering the option of having genital warts removed it is important to remember that removal of the wart or warts does not eliminate the HPV infection. Removal also does not prevent the transmission of HPV.

Two self applied treatments that are available are Podofilox and Imiquimod. These medications are well studied and considered easy to use. Podofilox is applied to the warts twice a day for three days followed by 4 days of no medication. This weekly cycle is repeated for up to a month. Imiquimod is applied to warts once a day, three times a week, for up to 16 weeks. Both of these medications can cause local skin irritation and redness with mild to moderate pain during their use. Prior to using these medications a healthcare provider will need to give instructions on their proper application. Alternative provider administered treatments to remove genital warts include cryotherapy, the application of topical medications, interferon therapy, and surgery.

There is a newer third option for self treatment called Wartrol. Wartrol is an alternative treatment  based on homeopathic philosophy. Some studies have shown a positive response from this treatment. More information can be found here.

Cryotherapy is completed with liquid nitrogen or a cryo-probe. Often repeat visits are needed every 1-2 weeks. With cryotherapy over or under treatment is possible. Temporary side effects of this type of therapy include pain, blistering, and an area of blackened dead skin. Cryo-probe use for vaginal warts is not recommended due to the potential for serious complications.

Topical medications a provider can apply to genital warts include Podophyllin resin, Trichloroacetic acid (TCA) and Bichloroacetic acid (BCA). These three topical medications all require weekly applications by the clinician. TCA and BCA are both widely used, but have not been thoroughly studied.

Interferon therapy to remove genital warts has been attempted. Systemic interferon therapy is not recommended as its effectiveness is poor. However, interferon injections directly into the wart itself have proven to be effective. The use of interferon injections requires numerous office visits and is associated with several systemic side effects.

Surgery to remove genital warts can be completed in numerous ways (including via laser) by a skilled healthcare provider. Surgery can be an ideal option for patients with numerous or large warts. Surgery is also the only treatment option that can generally remove a wart with only one visit.

Whatever treatment option is selected follow-up consultation after three months to evaluate effectiveness and assess for reoccurrence is recommended. Genital warts and HPV may not be a subject you feel comfortable discussing, but it is a subject you should educate yourself on. An open discussion with your healthcare provider can help you decide if you want to attempt treatment and which treatment might be best for you.

Genital warts are similar in many ways to regular warts. They are caused by a virus which most people get and fight off eventually on their own. Treatment is also similar, using caustic chemicals, cold or heat to kill off the warts. If you have had warts on your fingers, the main difference between those and genital warts is the area in which they appear and the particular virus that causes them.

Genital warts are caused by a virus called the human papilloma virus or HPV. Papilloma means warts. HPV is a very common infection. It is estimated that most adults who have had sexual contact contract this virus at some time, usually with no apparent symptoms. Some say 80% of adult women have been infected by HPV at least once by the time they are 50 years old, with men similarly affected. Most people with normal immune systems fight this virus off. Many never even have visible warts, but even with warts, most will be rid of the disease in around one to two years.

It is not known why some people have warts and others do not, when infected with HPV. Some may have warts in an area that is not visible (like inside the vagina) or they may have warts that are so small they are not noticed. Having visible warts is not an indicator of any other problem and does not mean the immune system is not normal.

The warts can be found around and in the vagina, the vulva, on the perineum (the area between the vagina and anus), around and in the anus, the penis, and the scrotum. Warts inside the anus (the rectum) usually but not exclusively occur after exposure due to penile penetration. Warts around the anus, usually in a circle, can occur in men or women without anal penetration. The virus just spreads from other genital areas. Genital warts are most commonly found around the vaginal opening, the foreskin of uncircumcised men, and the skin on the penile shaft of circumcised men.

Although it is unusual, genital warts can be found in other places, where there has been sexual contact and the area is moist and warm. This includes the inside of the mouth, the conjunctiva of the eye, the inside of the nose, and the larynx (voice box).

Like common warts that appear on other areas, these warts may be flat or fleshy elevated areas or may look more like skin tags, slightly pink or gray in color. There may be only a few, but there are often many together, such as around the anus, penis or vaginal opening. Most people have less than ten warts.

Warts inside the vagina cannot be seen without a doctors assistance. Warts inside the cervix and warts inside the anus have to be visualized with special instruments. Warts inside the urethra, which is the tube carrying urine and semen out the tip of a man’s penis, cannot be seen. If you have a wart in your urethra, you may notice that your urinary stream is not normal.

Genital warts do not necessarily cause symptoms. Some people experience itching, pain, or bleeding from the warts depending where they are. Many people are very uncomfortable with the appearance of the warts.

It is not known exactly how long a person with warts is contagious, or how long it takes for someone who is exposed to have symptoms. It is believed that the virus can be passed to another person even when there are no visible warts. Since most people are exposed to HPV, it is not recommended to examine or test sexual partners of people with warts, because they have already been exposed. Treatment is only needed if warts appear and the person wants to have them removed.

It is also not known if treatment, by removing tissue with HPV, actually reduces the chance of transmitting the virus.

Genital warts are diagnosed by their appearance. Testing for HPV is not necessary or helpful. Biopsy is only necessary if there is some reason to suspect that the bumps are not venereal warts.

Some doctors use an application of 3% to 5% acetic acid onto the skin to look for genital warts, which turn white. This is not very reliable or necessary, but some doctors believe that they have more success finding all the involved tissue this way.

Human Papilloma Virus and Cancer

There are more than 100 types of HPV. That is one reason why people can get reinfected with HPV. Certain types are most likely to cause genital warts. 90% of genital warts are caused by HPV types 6 and 11. Other types of HPV are associated with certain types of cancer, mainly HPV types 16 and 18.

The most common type of cancer associated with HPV is cervical cancer. Vaccines have been developed to help protect against HPV 16 and 18, and therefore prevent the 70% of cervical cancer that is caused by these two types. One vaccine protects only against these two types, and is called Cervarix. Another vaccine, called Gardasil, includes 6 and 11, which also protects against 90% of genital warts. The other 30% of cervical cancer not caused by HPV types 16 and 18 are caused by so many different types of HPV that a vaccine is not practical.

These vaccines are recommended for adolescent girls before they become sexually active. The first vaccine is recommended at age 11 to 12, but can be given as early as 9 years of age, or later, anywhere between 13 and 26 years of age. The vaccines are not recommended for older women who most likely have already been exposed to the virus. Gardasil is also recommended to protect against genital warts in boys and young men ages 9 to 26 years of age, again, before they become sexually active. There are three doses necessary with each vaccine. The second should be one to two months after the first, and the third should be given six months after the first dose.

Since there is cervical cancer associated with other HPV types, screening by Pap test is still necessary.

Type 16 and 18 HPV, as well as some less common types, are also associated with rectal/anal cancer, as well as cancer inside the mouth. For this reason, Gardasil may also be a good vaccine for adolescent boys and young men, especially men who have sex with men.

Condoms cannot completely protect men or women against HPV because the virus can live on skin not covered by the condom. The only way to prevent HPV absolutely is abstinence.

Treatment of Genital Warts

This section on treatment assumes that you are in general good health. If you have an abnormal immune system because of HIV, cancer chemotherapy or other medication, you need to see the doctor and may need different treatment.
Genital warts themselves are not precancerous and are not dangerous. Treatment is to stop symptoms, and for cosmetic reasons. Since they are not dangerous, the treatment should not be in any way risky. While it is very reasonable to want to get rid of them, no one should undergo treatment in which the cure is worse than the disease.

Most treatments of genital warts are applied directly to the warts. The exception to this is homeopathic remedies which are ingested. All other treatment, in a doctor’s office, at home, by prescription, surgical methods or via alternative medicine involves a way to remove or kill off the affected tissue. The key is to get rid of the areas with HPV and not cause any damage to normal skin. This is not necessarily easy.

Many of the treatments, whether in the doctor’s office or used at home, whether conventional or alternative, have not been subjected to rigorous scientific testing. For the most part they have not been tested against each other in large-scale, placebo-controlled, randomly-assigned trial. No methods are guaranteed to remove all warts. Even if they appear to be gone, they can reoccur. Most methods remove warts about 50% of the time.

If your warts do not go away after an adequate trial of any of these methods, you can switch to a different method. No one method has been proven to be better than any other method.

Your own immune system should eventually get rid of the warts in time. If your warts are not causing symptoms, are not very large or bothersome, and the diagnosis of genital warts is certain, you can opt to wait. When your body eliminates warts there are no side effects.

The most common side effects of all the treatments include:

• Local pain
• Local burning
• Local swelling
• Reoccurrence of warts

The worst complications of all prescription treatments, including those used in a doctor’s office as well as those used at home include

• A change in pigmentation can occur after the warts heal. This depends on the site of the warts, and can be increased or decreased pigmentation.
• Scars, which are rare, but are more likely if there is not enough time for healing in between treatments.
• Severe pain can occur and become chronic either in any treated area
• Pain can occur in the vaginal area which increases with sexual intercourse.
• Pain can occur around the anus which increases when passing stool.

There are almost never any side effects in other parts of the body when treating genital warts with any of these local treatments. Rare reports of problems that may have been caused by podophyllin resin and/or imiquod have been reported. In these cases, large amounts of the chemicals were used.

Treatments in the doctor’s office

There are a number of factors determining the type of treatment given by a doctor. These include the doctor’s preference and what he or she has the most experience with, the patient’s preference, and the availability of the medicines needed to treat the warts.

Treatment with compounds applied to the warts

There are a few chemicals that doctors can apply to genital warts to remove them. These chemicals all damage the tissue, which then dies and falls off. The key is to apply the chemical only to the warts. If there are a lot of warts or if they are very flat and close to normal skin, this is harder than if there are large, visible, discrete warts. Warts in moist, warm areas are best treated by creams or chemicals.

Multiple treatments are usually necessary; 3 months is the length of time it takes for most warts to disappear.

Sometimes petroleum jelly will be applied to the normal skin around the warts to prevent damage if the chemical gets on the skin. The doctor will apply the treatment, and then let you know how long you should leave the chemical on. The length of time will vary depending on the size and amount of warts, the delicacy of the surrounding tissue, and whether or not they have been treated in the past.

The two most commonly used treatments in the office have been podophyllin resin, 10% to 25% strength, applied weekly for up to four weeks, and trichloroacetic acid or bichloroacetic acid, 80% to 90% applied weekly.

Podophyllin is put into a resin to keep it on the skin and prevent it from being absorbed. It should not be used over a very large area. This will usually stay on a number of hours, 6 to 8, and then should be washed off. The warts should shrink. They may form a crust or a scab, and should eventually fall off. Small warts might just disappear.

Unfortunately, there are very few manufacturers of podophyllin resin at this time. Many doctors cannot acquire it. This was a very good treatment which is currently unavailable to many people, leaving the two types of acetic acid as in-office doctor-applied treatments.

Trichloroacetic (TCA) and bichloroacetic acid (BCA) 80% to 90% applied weekly kill wart-containing tissue. Either has to be applied very carefully because it spread onto healthy skin.

The risks and side effects of these treatments are damage to local tissue, and not causing the disappearance of all the warts. Multiple treatments are usually necessary. If chemicals are left on the warts for too long, you can feel burning. You have to wash off the chemicals as instructed. Remaining warts can be treated at another visit. Any damage to adjacent tissue will usually heal well. It is not known if any of these medicines is safe during pregnancy.

Treatment by surgery or energy application

Genital warts can be removed surgically, or destroyed in many ways, by application of heat, cold, and other kinds of energy. Large warts should be physically removed by one of these methods.

Warts can be shaved off with a blade or other types of surgical instruments (called curettage). Warts with thin bases can be cut off with sterile scissors. This type of removal is best for warts that are hanging off of thin bases or otherwise easy to separate from normal tissue. If bleeding results, it can be stopped with chemical cautery, similar to what is in a styptic pencil. A related way to remove warts is with electrocautery. This is delivered by a machine that has a pointed end which heats up. This can destroy the warts at the same time that the heat closes blood vessels so there is no bleeding. Most of these procedures require local anesthetic.

Some doctors have other instruments to destroy warts. Laser therapy (with a carbon dioxide laser) may have a higher success rate and better cosmetic appearance than some of the other methods. In at least one small trial, women treated twice by laser therapy had 100% cure rate with no reoccurrence. The men’s cure rate was slightly lower, at 88%. Most primary care doctors do not have lasers. Dermatologists and plastic surgeons do. If you have large, unsightly warts and you would prefer surgery or laser therapy, you will need to see a specialist.

A method available in almost every primary care doctors’ office is cryotherapy, or freezing. This is usually done with liquid nitrogen. A cold probe or cotton swab is held to each wart until it is sufficiently frozen. This will cause the wart to fall off in 7 to 10 days. Cryotherapy may be the method of choice for many doctors and patients. No anesthesia is needed. There is no bleeding. Although multiple applications are usually necessary, there is no need to put on medication repeatedly or worry about washing it off in time. You need to go back to the doctor after the first treatment to see if there are any small warts that were missed, or any large warts which got smaller but are still there.

All of these methods depend on the skill level and comfort level of the doctor using them. Choice also depends on patient preference. This is something to discuss with the doctor.

The risks and side effects of all these methods are similar. There can be pain, usually very temporary. Normal tissue can be damaged. All of the wart may not be removed, so that warts remain and grow back. Too much cautery, or too deep of a cut that gets into normal tissue will cause more bleeding and potentially cause a scar. Scarring is unlikely in many of the areas where these warts occur. However, very large warts requiring surgery may leave a scar.

Cryotherapy probably has the least risk, and is the most widely available. Multiple treatments are often necessary. If warts are missed, they can be treated at the next visit. Freezing is not the fastest method to get rid of visible warts. Surgical procedures can remove them immediately, but are more painful, cause more bleeding, and have the highest risk of scarring. If done by a doctor skilled in these procedures, surgical removal or laser therapy may be the best choice. Surgery in which anesthesia is used and laser therapy will usually cost considerably more than the other treatments.

Prescription medication to be used at home

Prescription medications to treat genital warts are creams to be applied to the warts that will cause a similar reaction to the medications above. They include podofilox 0.5% solution or gel, imiquimod 5% cream, and sinecatechins 15% ointment. The safety of all of these in pregnancy is unknown. As noted above, the side effects of all creams and gels applied to warts are similar.

Podofilox is generally considered safe. It is made of the active ingredient in podophyllin. It is easy to use and inexpensive to obtain. The solution is applied to the warts twice a day for three days. There are then 4 days when no treatment is done. This cycle can be repeated a total of four times. The prescribing doctor can apply to first treatment to demonstrate, but this is not absolutely necessary. Pain and irritation are side effects. If warts are still there after four cycles of treatment, it is best to switch to another method of treatment.

Imiquimod is an ìimmune enhancerî which causes the body to make chemicals that kill the warts. The cream is applied at bedtime, once a day, three times a week. The cream must be washed off 6 to 10 hours after it is applied, so the following morning. This cream can be used for a maximum of 16 weeks. If warts are still there, a different method should be used. Side effects from imiquimod are somewhat more severe than those with podofilox, and can include irritation, redness, swelling, ulceration of the tissue, and blisters. After healing, there can be a loss of pigmentation. There have been very rare reports of systemic reactions to this chemical which is an immune system activator. It can also weaken the materials that make condoms and diaphragms.

VeregenÆ Ointment 15% is a formulation of sinecatechins from green tea. While it is a prescription medication, it can also be considered alternative treatment because it comes from a natural source. Veregen should be applied three times a day to warts visible on the outside only. It is not to be used for warts inside the vagina or rectum, for example, because you cannot see them yourself to make sure you do not get the cream on normal tissue. You apply it with your
fingers, leaving a thin layer on all warts. It is only approved for 16 weeks of use, which should be enough time to treat warts.

Common side effects are reactions on the skin, including redness, itching, burning, pain, ulceration, swelling, thickening and blister formation.

In trials reported by the manufacturer, Veregen completely clears up warts in approximately 50% of patients. This takes an average 10 to 16 weeks. There is at least one other brand-name, sinecatechin-containing prescription medication.

Previously used medications including 5-fluorouracil and interferon are no longer recommended due to cost and possibly increased side effects with no greater treatment success.

Alternative Remedies

One completely safe alternative remedy is to wait for your body’s immune system to get rid of the warts. You would want to make sure you are eating a good diet with enough nutrients and that you are in generally good health. If you believe you need supplements to maintain good health, continue to take them. For some people, this is the best treatment. It is free of cost as well as free of side effects.

Homeopathy

Homeopathic remedies for genital warts are available. One commonly-used remedy is Thuja alternating with Nitric acid. Ascending potencies of Thuja are given over three to four weeks, after which ascending potencies of Nitric acid are given. This is the treatment suggested by Samuel Hahnemann, the founder of homeopathy, some 200 years ago.
Modern homeopaths suggest that treatment for genital warts actually needs to address more underlying problems, and they have a more complex remedy. Each person’s needs are different, depending on their underlying state of health. The following remedies can be used:

Antimonium crudum  - recommended for swelling and eruptions on mucous membranes
Argentum nitricum  - recommended for pain and sores on genitals
Aurum muriaticum  - recommended for cancerous warts
Aureum muriaticum natronatum – recommended for warts associated with erosions, ulcers, and cancers
Causticum – recommended for some warts along with vaginal discharge
Cinnabaris – recommended for warts including genital and eye. Better than Thuja for some penile warts
Medorrhinum – recommended for general warts with other conditions
Mercurius dulcis – recommended for genital warts, also Mercurius nitrosus or Mercurius precipitatus ruber
Natrum sulphuricum – recommended for warts on hands as well as vaginal pain and discharge
Nitric acid – for all warts plus discharge and pain
Sabina – similar to Thuja and good for large warts
Sarsaparilla – recommended for warts especially with other sexually transmitted diseases
Staphysagria – recommended for genital wars
Thuja – recommended for most kinds of warts (Thuja occidentalis = Arbor Vitae)
In order to get the best homeopathic mix to take for genital warts, seeing a homeopath would be recommended. These kinds of ingredients will be put together so that they can be ingested in very small amounts. Because homeopathy uses such tiny doses of ingredients, it tends to be very safe. Homeopathic treatments are to be taken into the body, not rubbed into the skin.
Tea tree oil has many antibiotic properties. It has been suggested as useful for warts. Baptisia tinctoria has antiviral properties and could also be helpful.
The actual methods of homeopathic diagnoses and treatments are beyond the scope of this article.
The product called Wartrol has most of these homeopathic ingredients.

Home Remedies

Green tea was considered a home remedy until active compounds were found that can destroy warts. There are a variety of slightly irritating or caustic ingredients people have used on genital warts, from lemon juice to garlic. As long as whatever is being placed on the warts does not cause pain or damage normal skin, there is really not much harm in trying. As long as the cure is not worse than the problem, it is probably safe to try.

New and Upcoming Developments

Lasers are being used to treat more and more diseases. Dermatologists, plastic surgeons, and some other kinds of doctors are learning how best to use the lasers. There is more than one type of laser. In addition to the carbon dioxide laser, other lasers may prove useful.

When to See Your Doctor

You should see a doctor when you first discover that you have genital warts, or believe that you do. This is to make sure that your self-diagnosis is correct, and that there is nothing else more serious going on. It is also a time at which the doctor can make sure you don’t have warts in hard to treat places.

You can ask the doctor what he or she recommends, and you can think about what you would like to try based on what your doctor offers, how much the treatments cost, and whether or not you want to try home treatment with a prescription medication, homeopathy, a home remedy, or tincture of time.

If your warts are getting worse or the treatment is causing you pain, you should check back with your doctor. Eventually your warts should go away.

References

Sexually Transmitted Diseases Treatment Guidelines, 2010. Recommendations and Reports. Morbidity and Mortality Weekly Report (MMWR). December 17, 2010 / 59(RR12); 1-110
 HYPERLINK “http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm?s_cid=rr5912a1_w” http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm?s_cid=rr5912a1_w
Accessed December 23, 2010.

Human Papillomavirus (HPV). CDC information page.  HYPERLINK “http://www.cdc.gov/hpv/” http://www.cdc.gov/hpv/
Accessed 13.23/2010

Fatemeh Ghaemmaghami, Zeinab Nazari, Nili Mehrdad. Female Genital Warts. Asian Pacific J Cancer Prev, 8, 339-347. 2007.

Reichman Richard C, “Chapter 178. Human Papillomavirus Infections” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17e: http://www.accessmedicine.com/content.aspx?aID=2895508.

CRAIG SCHNEIDER, TIFFANY SEGRE. Green Tea: Potential Health Benefits. Am Fam Physician. 2009; 79(7):591-594.

Kate Birch. Genital Warts. Vaccine Free Prevention and Treatment of Infectious Contagious Disease with Homeopathy. Pages 251-260. 2007. Victoria, BC Canada. Trafford Publishing.

Garg, SC. Essential oils as Therapeutics. Natural Product Radiance. 2005; 4(1): 18-26.

Bergner, P. Antiviral Botanicals in Herbal Medicine. Medical Herbalism (Spring 2005)14(3):1-12.

With that is mind, there are a number of natural treatment options for warts and genital warts that you may want to explore. They encompass nutritional supplementation, herbal remedies, homeopathy, and other alternative medical interventions.

Almost every lesion in the skin, including genital warts, involves the immune system. Even before the genital wart forms, the immune system is what protects the body against human papillomavirus (HPV) infection. The immune system also has the ability to detect and remove the abnormal skin cells that are rapidly reproducing and growing into a wart. In fact, some of the medical treatments for genital warts include drugs to stimulate or mimic the actions of the immune system. Therefore, natural treatments for genital warts primarily include things that help your body resist or fight HPV infection and to change the way the skin reacts to it.

Diet, nutrients and supplements

Numerous clinical studies have shown a positive link between exercise and the immune system. A person that exercises for 30 minutes per day, three to five times a week has a much stronger immune system than someone that leads a sedentary life. The type of exercise is not critically important, but you should get your heart pumping and try to break a sweat each time you exercise. While it is not clearly known how exercise boosts the immune system, it clearly does. Regular exercise can equip your body in the fight against genital warts (and many other diseases).

Another helpful intervention is to remove the things that may be taxing your immune system unnecessarily. Allergies drive the immune system—in fact, they put the immune system into overdrive and serve no known useful purpose. Identifying and eliminating allergens from the environment and from the diet can reduce the burden on the immune system.

Dust, molds, mites, and other microscopic substance can lead to allergic reactions and breathing problems. Using filtration devices (one brand name is a Hepa filter) can remove particles from circulating air. Make sure heating vents are clean, mattresses and bedding do not harbor allergens and that carpets are routinely cleaned (or avoided when possible). Animal dander is difficult since we love our pets, but it is just as easy to love a pet that has less dander or no dander; this should be considered before you get your next furry family member.

People often seem to underestimate the role of food allergens in health and disease. Since food allergens rarely lead to stuffy nose, sneezing, and breathing problems, most people do not seem to think of food as stoking up an allergy. In truth, doctors are recently beginning to appreciate the near-epidemic of food allergies. Food allergies cause upset stomach, headache, and, less frequently, they cause some more serious consequences. One common food allergen is milk, which can be an allergy to a protein in milk or lactose intolerance. Lactose intolerance is not an “allergy” but is caused by the inability to digest a sugar in milk. Another common food allergen is wheat or gluten. There are wheat allergies and the more serious celiac disease, which is a serious reaction to gluten in the gut. Aside from these examples, there are a large number of possible food allergens. It may be reasonable to be tested for the presence of food allergies if you are particularly sensitive.

Despite their robust reaction to foreign invaders, the cells of the immune system are fragile entities. In order to keep these important cells as healthy as possible, it is critical to give them a good home. Where is the immune system’s home? Their home is in blood, lymph nodes and other lymph tissues, mainly. The way to give them a good home is to protect them from destructive molecules, like free radicals and reactive oxygen species. Vitamins C and E are excellent antioxidants. Coenzyme Q10, resveratrol, and N-acetylcysteine are also very powerful at neutralizing reactive oxygen species.

Veregen is a green tea extract that has been developed into a medical treatment for genital warts. Veregen is prescription cream that is placed on genital warts, but green tea extract is available as a supplement without a prescription. The supplement is called Camellia sinensis and can be taken up to 250 to 500 mg per day to fight genital warts.

If you want to take the fight directly to the HPV, grapefruit seed extract (Citrus paradisi) has antiviral properties. Grapefruit seed extract comes in 100 mg capsules or can be added to beverages. Cat’s claw (Uncaria tomentosa) has both antiviral properties and can boost the immune system. Cat’s claw can be taken as a 20 mg supplement, three times per day. Olive leaf (Olea europaea) is another antiviral and immune system enhancer. Like the green tea extract, it comes in 250 or 500 mg doses but can be taken up to three times per day. Finally, 150 to 300 mg of Reishi mushroom (Ganoderma lucidum) can be taken up to three times daily for virus-fighting, immune-improving power.

For those that want a topical ointment for genital warts, you should avoid some of the natural remedies that are used for plain warts since these are ineffective and may not be safe for use near the genitals. These ineffective agents include banana peel patch and garlic patch. A topical treatment that is safe and may be helpful is to coat the genital warts in vitamin A (retinoic acid) or beta-carotene up to two times a day. For an added boost, you can add tea tree oil (Melaleuca alternifolia) and/or Echinacea to the treatment.

Homeopathic Remedies

Homeopathic remedies should only be used under the direct supervision of a trained homeopath. In addition to using the ingredients listed, the dilutions and the process of dilution of homeopathic treatments are very important according to homeopathy theory. Note that homeopathy should not be used instead of treatment by a trained medical doctor (allopath) but may be used to supplement traditional treatment.

A homeopath may recommend the use of Causticum for the treatment of genital warts. This agent may be best suited for fleshy warts. Another option is Nitricum acidum. In fact, Nitricum acidum might be the homeopathic treatment of choice for genital warts. It can be used on warts located on the genitals or anus (external use only). The third homeopathic treatment option is Thuja. Thuja is used for painful or bleeding warts of all kinds, including genital warts that cause pain or bleeding.

Acupuncture

Acupuncture is a therapeutic intervention that is derived from Traditional Chinese Medicine. It employs the use of thin metal needles placed in specific points across the body along meridians. Along these 14 to 20 meridians flow the life force known as qi. According to Traditional Chinese Medicine, health and disease are determined by the flow of qi along these meridians in the body. If qi is blocked or stagnant, disease follows. Acupuncture seeks to locate and relieve these blockages and improve flow.

Doctors of Traditional Chinese Medicine may use acupuncture, along with other remedies to treat genital warts and to improve the immune system in general. Acupuncture may take up to ten sessions, each lasting about an hour, to treat genital warts. In addition to needling, moxibustion and cupping may be added to the treatment plan. Moxibustion is the burning of dried herbs (moxa) near the skin. Cupping is the application of heated half-spheres to the skin to create a vacuum.

It is important to mention every skin lesion, including genital warts, to your acupuncture practitioner. Needles should not be applied to or near any skin lesion as this may push HPV deeper into the skin and into the bloodstream.

Massage therapy

While massage therapy is not a direct treatment for viral infection, it can create deep relaxation and stress relief. Since stress can interfere with the proper functioning of the immune system, massage therapy can be used to boost the immune system.

There are various forms of massage therapy. Many forms have the potential to be helpful, but for stress relief it is best to choose one that is less stimulating. For example, Thai traditional massage is more invigorating than relaxing. This form of massage is actually a series of forced yoga poses and may not be the best choice for genital wart treatment.

Of the Eastern traditions of massage therapy, Tui Na and Reiki may be the most appropriate. Considering the approach of Western massage techniques, any that primarily employ effleurage would be applicable. Effleurage is the form of Western massage in which the practitioner uses gliding hands. Effleurage may be more appropriate than deep friction approaches or percussion techniques (tapotement).

Please note that for any massage therapy style that requires nudity or near-nudity and the use of oils, it is critical that you mention your genital warts to the practitioner. This is especially true if you have symptomatic or broken skin lesions. You do not want to risk infection or inoculation of the massage therapist with human papillomavirus (HPV). While infection in this way is very unlikely, it should still be mentioned.

Yoga

Performing yoga serves two important functions in the fight against genital warts. First, it is an extremely good form of exercise. Yoga poses require strength, stamina, balance, and flexibility. Second, yoga can be both relaxing and energizing. Recent research suggests that yoga can improve or undo the damage that stress and harmful emotions can wreak on the immune system. Actively participating in yoga can influence the axis which is the system in the body that responds to stressors by releasing adrenalin and other factors into the blood.1 Yoga also may change neural pathways involved in acute and chronic stress.

There are several ways to incorporate yoga into your life. Videos and television programs now teach yoga poses and exercises. However, many yoga poses are tricky and should be performed properly to avoid injury. It may be best to seek out a class or a professional yoga instructor to demonstrate the proper technique before you go about it on your own.

Mediation

Many of the stresses that affect us in our daily lives—work, school, finances, family—can slowly eat away at our immune system. This gives genital warts a foothold and then a stronghold. Removing this stress from our lives is often as simple as setting aside some quiet time each day for personal reflection. In more formal terms, this “rebooting” is called meditation.

People tend to shy away from many meditation traditions because of the associated mysticism and religious affiliations. In truth, many forms of mediation are devoid of mystical or religious practices and these can be avoided altogether and still receive many of the benefits of meditation. If you are looking for spiritual mediation techniques, these certainly exist as well, but are beyond the scope of this article.

Meditation can be as simple as being quiet and alone for a period of time. The length of time that people can devote to meditation varies, but you should try to set aside 20 minutes at the very least in order to realize the healing benefits of meditation. This time can be increased, but, as you become better at meditation, you may not need more than 20 minutes per day.

In the simplest form, meditation involves clearing the mind of all distractions and thought. It should be done in a quiet, softly lit or dark room. The goal is not to sleep but to remain conscious and awake during meditation. One easy meditation technique is to pick a neutral, two-syllable word and repeat it in your mind. As thoughts of the day and life try to invade your attention, elevate the “volume” of your mind’s voice to overcome the intrusion. “Say” the word faster in your mind. As the impetuous thoughts start to quiet, you can lower the mental volume and slow down the speed of the syllables. Towards the end of the 20 minutes you should have cleared your mind and, perhaps surprisingly, you will feel refreshed and rejuvenated.

Reference List
(1) Kulkarni DD, Bera TK. Yogic exercises and health–a psycho-neuro immunological approach. Indian J Physiol Pharmacol 2009;53:3-15.

Despite the various locations that can serve as a reservoir for human papillomavirus (HPV) and its DNA, the lion’s share of the virus and, by extension, the greatest chance for infection, is in the genital wart itself. Therefore most of the therapeutic interventions are designed to remove the wart and destroy the virus contained inside of them.

Not all treatments are equally effective at clearing the wart and not one is 100% effective. However, in some clinical studies, certain treatments were as high as 90% effective at eradicating the genital warts. Among the most successful treatments are cryotherapy, interferon placed on the wart, electrosurgery.

The various clearance rates of selected therapies are shown in the table. Note that there is significant discrepancy in the clearance rates listed for topical interferon (placed on the wart). The range of clearance rates across studies is 6 to 90%. In other words, while this may be a potentially successful treatment approach, it may not be terribly reliable and is not often used.

• Cryotherapy 63–88%
• Electrosurgery 61–94%
• Imiquimod 37–56%
• Interferon (topical) 6–90%
• Interferon (intralesional) 17–63%
• Laser surgery 23–52%
• Podofilox 45–77%
• Podophyllin 32–79%
• Surgical excision 35–72%
• Trichloroacetic acid 50–81%
• Placebo or no treatment 0–56%

Finally, since the primary concern with human papillomavirus is cervical cancer and men are born without that anatomical structure, they feel an unwarranted sense of protection.

In truth, there are many reasons why men should be concerned with human papillomavirus (HPV). If for no other reason, human papillomavirus causes genital warts in women and men. While the rates of infection may be higher in women, HPV infection and genital warts are still the most common sexually transmitted disease.
Another reason for concern is that men may be infecting their sexual partners even though they have no apparent symptoms.

The lesions that occur on men may be nearly impossible to see with the naked eye. While many men may not recognize genital warts, once men have this HPV infection they become a “reservoir” for the virus. Human papillomavirus can live in the vas deferens (the tube that brings semen from the testes), the prostate gland, pubic hair follicles, and within the urethra (the tube through which urine exits the body).

While they are fairly rare, human papillomavirus infection has been associated with cancers of the penis and cancers of the urethra and anus in men. In fact, several of the over 80 identified types of HPV can cause cancer in men. For all of these reasons, it is important that men be aware of the problems that human papillomavirus (HPV) can cause, how to recognize the associated illnesses, and how to access the help that they need.

Genital warts can be skin-colored, whitish or gray. They are often raised above the level of the skin, but in men, maybe only slightly. In fact, it has been suggested that most men with genital warts only get a slightly raised, flat lesion that is barely noticeable. Also, symptoms may not ever occur with the eruption of genital warts in men.

Therefore men may not seek treatment. Another factor that makes genital warts in men difficult to detect is the fact that they may occur in areas obscured by pubic hair or behind the scrotum and are therefore rarely seen.

Genital warts may occur in any location on the body, even the mouth, throat, lungs, arms, or legs; however, genital warts in these locations are rare. In most cases, men will have genital warts:

• On the head or shaft of the penis
• Inside the urethra (the tube within the penis that passes urine)
• Within the foreskin of uncircumcised men (perhaps on the inside fold)
• Between the scrotum and the anus
• On the scrotum
• In the fold of the leg at the inner thigh
• On and around the anal sphincter
• Within the anus itself

Because genital warts on men can be so difficult to detect, a physician may need to perform a test for warts that are not immediately visible to the naked eye. By placing a small amount of acetic acid (vinegar) on a suspected wart, the area that made up of warty cells will turn white. Unfortunately the acetic acid test is not very sensitive or specific. In other words, it may miss a lot of genital warts that are really there and in other cases normal skin may show up like a wart. While there are more sophisticated tests available to detect the presence of HPV (by testing for human papillomavirus DNA) these are only used in a laboratory and clinical research settings and are not routinely commercially available.

It is reasonable to be as cautious as possible when it comes to human papillomavirus infection. Condoms do not fully prevent transmission of HPV, but using them properly and consistently can greatly reduce the risk. Since many genital warts on men are believed to be barely visible flat lesions on the shaft of the penis, covering that area with a latex condom separates the wart from the sexual partner. Since the highest concentration of HPV is in the genital wart itself, physical separation is an excellent way to reduce spread.
It is also important to know your sexual partner. Do not have sexual intercourse (vaginal, oral, or anal) with someone that has visible genital warts. It is difficult to know if the lesions are genital warts and if they are infectious at the time, but the transmission rate of HPV after a single sexual encounter with an infected person is 60%–that is extremely high. It is always best to encourage anyone with genital lesions or sores to seek medical advice and to avoid sexual intercourse until the condition is properly identified and treated.
The risk of genital warts and HPV-related cancers is higher in homosexual men, especially in men who participate in receptive intercourse with other men. While men and woman can get genital warts around the outside of the anus, it is exceeding rare to get genital warts inside of the anus without receptive anal intercourse with an infected person. Anal cancer occurs about 10 to 15 times as often in homosexual men than in heterosexual men (when both groups are actively having sex).

Also, men with HIV/AIDS are at greater risk for all HPV-related illnesses, including cancers. It is particularly important for men who have sex with men to routinely and consistently wear barrier protection (condoms) and to be completely open and forthcoming with the physicians that provide them with medical care.

Currently, the vaccine that is used to immunize against certain types of HPV is not available or approved by the FDA for use in men. Studies are currently being done to determine if the vaccine is effective in men at stopping the spread of HPV and if that translates into reduced rates of genital warts and certain cancers. If the research results are as expected, it could represent a huge breakthrough in the fight against human papillomavirus and genital warts in men.

What is worse is that several of the over 80 identified types of human papillomavirus can cause serious diseases in women including genital warts, cervical cancers, and cancers of vulva, vagina, urethra, and anus. Because sexually active, heterosexual women primarily engage in receptive intercourse (oral, anal, and vaginal) their risk for contracting these diseases is higher than it is in men.

Genital warts in women can appear in many different forms and in many different locations. In general, genital warts are flesh-colored and elevated slightly above the surface of the skin. They can also be white, gray, pink, or slightly purple and flat or shaped like the head of a cauliflower. They can occur anywhere on the surface of the body, even the hands and feet, though these locations are uncommon sites for genital warts. Genital warts in women appear most often:

• Around the vagina
• On the vulva
• Inside the vagina
• On or around the cervix
• In the mouth and/or throat
• Between the vagina and the anus
• In the folds between the legs and the genitals
• On and around the anal sphincter
• Within the anus itself

While women can get genital warts on and around the anal sphincter, it is extremely uncommon for them to occur inside the anus without the person having engaged in receptive anal intercourse with an infected person. The same holds true for genital warts within the vagina; they are rare unless the woman engages in receptive vaginal intercourse with an infected partner.

It is quite possible to have genital warts that cause no symptoms whatsoever. If they do cause symptoms, the symptoms are usually pain, tenderness and itchiness around the genital wart. genital warts may bleed or discharge a liquid. When they occur inside the vagina, genital warts may cause bleeding or discharge that is not associated with menstruation or ovulation. If they become quite large it is possible that the genital warts obstruct urine flow, obstruct the flow of stool, or make intercourse too painful or physically impossible (these occur very rarely).

Protection against HPV infection is a reasonable first goal when it comes to genital warts in women. Women and girls between the ages of 9 and 26 are eligible to receive a vaccine that provides immunity and protection against the four main types of HPV that most commonly cause serious diseases: HPV types 6, 11, 16, and 18. These four types cause the majority of genital warts and cervical cancers. The vaccination takes place over six months and three separate injections are required; however, once the immune system has been fully immunized, the transmission rate of these four types of human papillomavirus decreases dramatically.

If you do not fall within this age range or you have decided with your doctor that the HPV vaccine is not right for you, you can still take steps to improve your chances of staying free of infection. While they are not 100 percent effective at blocking HPV transmission, barrier protection (either male or female condoms) can reduce the risk somewhat. Moreover, you should avoid having sexual intercourse of any kind with a partner that has suspicious genital lesions until they have been examined by a doctor and treated. Since genital warts contain high amounts of human papillomavirus and that this virus gains access to others through breaks in the skin and mucous membranes, limiting exposure reduces HPV infection.

There is no complete cure once genital warts do occur but there are several treatment options that can eliminate the appearance of the warts and reduce the chance of infecting others with HPV. Often the procedures that destroy the genital warts are the most effective. These include cryotherapy (freezing the genital warts), electrosurgery (cutting and cauterizing the warts with an instrument that provides electrical cutting ability), and acid ablation (burning the genital wart with trichloroacetic acid, for example). Medical therapy includes podophyllum resin, interferon alfa-2b (Intron A), 5-fluorouracil, podofilox , imiquimod (Aldara) and Veregen.

Some creams and local injections can be helpful as well though special care must be taken with these treatments when there is a chance of pregnancy. In fact, trichloroacetic acid or TCA is usually the treatment of choice for genital warts in women of childbearing age. The genital warts may be burnt and destroyed using a laser as this poses little threat to the fetus.
Genital warts that occur inside the anus or vagina are particularly challenging for women. Not only may they cause symptoms during bowel movements or sexual intercourse, but they also increase the risk of infection to sexual partners because of their location. Moreover, they are difficult to treat because many of the existing genital wart treatments are intended to treat external warts.

For genital warts inside the vagina or anus, it may be perfectly reasonable to wait to see if they heal on their own—a course of action known as “watchful waiting.” This may be the best course of action during periods of sexual abstinence or when the warts are not causing distressing symptoms. When active treatment is desired, cryotherapy is the treatment of choice for internal lesions. Trichloroacetic acid (TCA) and laser ablation are also possible treatment options for internal genital warts.

An alternative treatment for vaginal warts that is not currently used very often is 5-FU or 5-fluorouracil. This is a chemotherapeutic agent that can be infused deep within the vagina and will destroy HPV-infected cells. If this approach is used, the areas without warts should be protected with petroleum jelly and a tampon may be kept in place to prevent leakage. Even though the drug stays mostly within the region close to the vagina, this risk of potentially serious side effects makes 5-FU use a less attractive option than others.

Avoiding HPV infection

Genital warts are a sexually transmitted disease. In fact, HPV infection is the most common sexually transmitted disease in the United States. Fighting the disease begins with prevention. Heterosexual women are at increased risk for contracting genital warts over heterosexual men because of the mechanics of heterosexual intercourse. Participants that receive bodily fluids during intercourse are more likely to become infected with human papillomavirus and, as a result, develop genital warts and other diseases. Therefore the first step of protecting yourself and your unborn fetus is through prevention.

Unfortunately, barrier protection is only partially protective against HPV transmission. That is because the genital warts themselves have a significant amount of virus in them. Whether you use male or female condoms, various forms of sexual intercourse can still transmit HPV. While you should still use a condom during every sexual encounter, it is important to realize that condom use does not provide complete protection.

Abstinence is the only complete protection from HPV infection or inoculation. If total abstinence is not feasible, sexual contact should be avoided if one participant has visible, internal or external genital warts. This is especially true if the warts are bleeding, oozing, or the skin in or around the lesion is broken. However, genital warts can still shed virus when they appear dormant or stable. Thus the best solution is to postpone sexual relations until the infected party is treated. Even after treatment, the risk of sexual transmission of HPV is not zero.

Changes that occur during pregnancy and genital warts

If you ask any woman that has been pregnant, she will tell you how radically the body changes during pregnancy. From a physiological perspective, essentially every organ and cellular system in the body changes in some way during pregnancy. The skin and immune system are no different.

Several dermatologists and OB/GYN physicians have documented the changes that can occur with genital warts during pregnancy. Women that apparently have their HPV and genital warts under good control before pregnancy often notice a flare-up once they become pregnant. The immune system and skin go through major changes. Previously quiet or dormant genital warts can become active during pregnancy. In fact, it is not unusual for the most abundant and aggressive lesions to occur exclusively during pregnancy.

The prevalence of genital warts increases from the first to the third trimester. After birth, the lesions seem to “quiet” very quickly. Thus something about the HPV infection is fundamentally different during pregnancy. The risk of genital warts doubles during this time. If genital warts do occur during pregnancy, they can become very large, very rapidly. The growth of the genital warts is so rapid that the skin can break down. If this occurs, prompt medical or surgical treatment is usually required.

It is not clear whether women are more susceptible to contracting an HPV infection when they are pregnant. However, the rate of HPV infection certainly increases during pregnancy. Whether this increase represents new infection or simply the eruption of genital warts that were dormant or latent is not known. The prudent approach would be for women to be additionally careful about not contracting HPV during pregnancy.

HPV diagnosis during pregnancy

Pregnant women that receive appropriate prenatal care will be subjected to a battery of prenatal screening tests. These include blood type testing, sexually transmitted disease (STD) testing, along with testing for other infections. Despite this extensive testing process, human papillomavirus is not one of the STDs or infections that is tested.

This lack of testing is not an oversight, per se, but rather it is a matter of pragmatism and economics. The rate of HPV infection in the population is so high—approximately 24 million people in the United States have HPV—that diagnosis is not always needed. In most cases, unless there is an active genital wart lesion, the overall risk to the baby is low. However, under some circumstances, special considerations must be made.

First, it is possible to pass genital warts from mother to newborn, but the manner in which the virus is transmitted is not known. It does not seem that HPV crosses the placenta to any great degree. What is much more likely is that genital warts are passed to the newborn during vaginal delivery.

If genital warts are passed from mom to baby, the most worrisome outcome is childhood laryngeal papillomatosis or recurrent respiratory papillomatosis. This condition is rare but can be dangerous if it occurs. Large genital wart lesions in the airway can interfere with baby’s breathing.

In most cases, genital warts will not need to be removed prior to delivery, however if genital warts are on or near the cervix, inside the vagina, or on the vulva, it is reasonable to remove them prior to delivery. If it is not possible to remove all genital warts before delivery, the baby may be delivered through Cesarean section to avoid vaginal inoculation.

HPV treatment during pregnancy

Unfortunately many of the main drugs that are used to treat genital warts are not safe for use in pregnant women. They can cause irreparable damage to the developing infant or their effects on the unborn baby are not known. Therefore, genital warts treatment options are fairly limited during pregnancy.

In most cases, the treatment of choice for genital warts in pregnant woman is trichloroacetic acid or TCA. Trichloroacetic acid is a powerful caustic agent that burns the genital warts. It usually must be administered repeatedly over one to two months in order to achieve the desired result. Surrounding tissue (without warts) should be protected with petroleum jelly prior to treatment. The benefit of trichloroacetic acid is that very little of the substance is absorbed across the skin, if any.

If trichloroacetic acid does not destroy the genital warts as anticipated, the next best option for treatment is cryotherapy. Cryotherapy involves the use of liquid nitrogen or other highly cooled liquid/gas to freeze and destroy genital warts. After three months of therapy, about 75% of patients receiving cryotherapy will be free of genital warts.

Carbon dioxide laser therapy may also be an option for treatment of genital warts in pregnant women. The laser is selective enough that complications and side effects are rare and usually mild.

Key points for people with Genital Warts:

• Genital warts are bumpy lumps that grow near your genitals
• Almost all genital warts are benign (non-cancerous).
• Genital warts are caused by a virus called the human papilloma virus (HPV).
• Increased risks for infection with HPV include multiple sexual partners, another sexually transmitted disease, or a condition that affects your immune system.
• Genital warts aren’t usually serious, and treatments work well.
• After your genital warts are removed, the HPV virus that causes the warts remains in your body.

Treatments for genital warts have traditionally been intended to destroy the lesion by some means. Recently though, medications have been developed that affect the immune system rather than attacking the lesion directly.

Genital warts treatment options can be divided into medical and surgical treatments. Since most of the lesions are on the outside of the body, there is considerable overlap between the two treatment types. In other words, dermatologists (a medical specialty) may use techniques to excise or cut out the genital warts and plastic surgeons may administer medications as part of their treatment plan.

It is often more useful to separate genital warts treatments into self applied treatments, physician applied treatments, and surgical treatments. Self applied treatments include over-the-counter treatments and prescription medications that can be applied at home. Physician applied treatments are applied by the doctor and are not available in a pharmacy. Surgical treatments are performed by a physician using one of a number of surgical approaches.

The decision between these three genital warts treatment options is based on the size and extent of the lesions and their location. In general, genital warts located inside the body usually require treatment by a physician. In every case, it is important to meet with a physician to diagnose genital warts and to direct care. While over-the-counter medications may be available, they should only be used in addition to some other, more definitive treatment. Currently all definitive treatments are only available through a physician and by prescription.

Patient-applied genital wart treatments

The three patient-applied treatments for genital warts are Podofilox (Condylox), Imiquimod (Aldara) and Veregen. Each of the three agents treats genital warts by a different mechanism; one but direct disruption of the genital wart, one by affecting the immune system, and one uses a botanical extract that works by an unknown mechanism.

Podofilox (Condylox)

Podofilox (Condylox) is the most commonly prescribed patient-applied genital wart treatment. It is an antimitotic agent but the exact mechanism of action of Podofilox (Condylox) is not known. It comes in a 0.5% solution that is applied to external genital warts twice a day for three days. No treatment is performed on the fourth day. This three day on-one day off cycle is repeated up to three times. After three cycles, a subjective determination is made as to whether Podofilox (Condylox) is having any effect on the visible genital warts.

The side effects of Podofilox (Condylox) are not exactly rare. As many as 15% of patients report pain, burning, irritation, and skin breakdown at the site where the drug was applied. Part of the reason that these side effects occur is because patients tend to put too much Podofilox (Condylox) on the site or spread the solution to skin without warts. With repeated treatment, these side effects are less severe or no longer occur.

Imiquimod (Aldara)

Imiquimod (Aldara) is dispensed as a 5% cream that is applied to the genital wart three times per week. A small amount of the cream is applied to the visible, external genital warts and rubbed in until the white cream is no longer visible. Imiquimod (Aldara) needs to remain in place for between six and ten hours. Therefore it is recommended that the cream be used just before going to bed and left on the genital warts overnight. After six to ten hours, the area should be cleaned thoroughly and any cream that was not absorbed should be removed. Your doctor should demonstrate the proper application of Imiquimod (Aldara).

The exact mechanism of action of Imiquimod (Aldara) is not known. It is known that the cream modulates the immune system by causing the release of interferon and other cytokines. In general, these immune system modulators enhance and focus the body’s own healing processes; however, the role that this substances play in genital warts and HPV infection is not known.
There is a slightly increased risk of certain side effects in patients using Imiquimod (Aldara) compared to placebo (a cream containing no drug). Imiquimod (Aldara) may cause itching, burning, redness, and swelling. In a few cases, patients using Imiquimod (Aldara) reported soreness in the area beyond symptoms caused by the genital warts themselves.

Veregen

The only botanical extract that has been approved by the Food and Drug Administration (FDA) for the treatment of genital warts is Veregen. The primary active ingredient in Veregen is a green tea extract that contains sinecatechins. Sinecatechins are antioxidants although it is not clear whether the antioxidant action of Veregen explains its beneficial effect on genital warts. In addition to sinecatechins, Veregen also contains caffeine and theobromine, which are commonly found in coffee and tea. Like other patient-applied genital wart treatments, the precise mechanism of action of Veregen is not known.

A small amount of Veregen is applied to the genital wart three times a day. The drug is administered in this way until improvement can be seen or for up to four months. Most times, if an improvement is not seen within a few weeks, Veregen is stopped and another genital wart treatment option is tried.
Despite being a botanical extract, side effects occur in one-fifth of all patients who tried Veregen in one study. The most common side effects were quite mild, however, and included redness, burning, and some discomfort. In more severe skin reactions to Veregen, the skin became inflamed, raw, and swollen. More severe side effects were much less common than mild side effects.
Physician-applied genital wart treatments
There are four physician-applied, medical genital wart treatments currently available: Podophyllum resin (Podocon or Pododerm), Trichloroacetic acid (TCA, Tri-Chlor), Interferon alfa-2b (Intron A), and 5-Fluorouracil or 5-FU (Adrucil, Efudex, or Fluoroplex).

Podophyllum resin (Podocon or Pododerm)

The most commonly used medical genital wart treatment is Podophyllum resin. Podophyllum resin works by halting cell division, which means that it stops cells from reproducing. Since genital warts are an abnormal growth of cells, podophyllum resin works to inhibit this growth. It can also destroy the cells that are already present. In fact, this solution is used to treat a variety of warts, not just the genital variety.
Podophyllum resin is a natural extract from the mandrake plant. The primary active ingredient in podophyllum resin is podophyllotoxin thus, while it is “natural,” it is an extremely potent substance. Originally, patients were allowed to apply podophyllum resin to their own genital warts, however it was soon determined that “overapplication” was common. Today, physicians typically apply this agent in the treatment of genital warts.
Podophyllum resin is available as a 20% solution in benzoin and other carrier substances. The doctor will carefully apply the medication to any genital warts and allow the solution to dry completely. After administration, the patient must allow the substance to stay on for one hour, after which time the area is thoroughly cleaned. Treatment is usually repeated in one week.

Another reason that podophyllum resin is administered by a physician is that the solution can readily enter the bloodstream even though it is applied on the skin. When this substance enters the blood, it can cause a number of potentially severe side effects. These side effects include polyneuritis (numbness and weakness is various nerves), paralytic ileus (intestines that will not propel swallowed food in the proper direction), leucopenia (low white blood cell count), thrombocytopenia (low platelet count), coma, and even death. Fortunately these side effects are very rare, but they reinforce the notion that physician supervision is required during treatment.

In addition, it is important to tell any physician or healthcare provider if you have ever been treated with podophyllum resin. One strange and not entirely rare side effect is the formation of strange looking skin cells in treated areas. These cells can look like cancer—but they are not—and so doctors must be aware of the possibility of a misdiagnosis.

Trichloroacetic acid (TCA, Tri-Chlor)

Trichloroacetic acid simply burns or cauterizes the genital wart causing it to flake off about a week after treatment. The physician applies trichloroacetic acid to the lesion while avoiding the surrounding healthy skin. Trichloroacetic acid will burn most biological tissues to which it is applied, so care must be taken to avoid misapplication.

There are several advantages to using trichloroacetic acid to treat genital warts. It is inexpensive, especially compared to the newer immune-modulating agents. Trichloroacetic acid is also reasonably effective. It can destroy the tissue on which it was applied, virus and all. If the genital wart was not destroyed after a single application, trichloroacetic acid can be applied again in a week or two. Also, the acid is not absorbed into the bloodstream like other genital wart treatments. This means that it may be useful to treat genital warts in pregnant women. Finally, trichloroacetic acid is less destructive to the skin than freezing or laser therapy.
There are few side effects associated with trichloroacetic acid. In truth, the major expected effect of the acid is that it causes pain when it is applied. Since it is burning skin, nerve endings detect this as being painful. However, this pain can be minimized in most cases. Aside from a burning sensation, the major risk of trichloroacetic acid is the destruction of surrounding, healthy skin.

Interferon alfa-2b (Intron A)

Interferon alfa-2b is primarily used as a treatment for malignant melanoma, which is a form of skin cancer. However, it is also used in a number of other conditions including condylomata acuminata (genital warts). Interferon alfa-2b in a dose of 1 to 1.5 million units is injected directly into each genital wart. Depending on the treatment approach, interferon alfa-2b may be injected three times a week for three weeks. Despite the large number of units administered, the amount of fluid injected into each genital wart is relatively small, about a fifth of a teaspoon.
Interferon alfa-2b is a naturally occurring protein that functions as part of the immune system. While its exact mechanism of action is not clear, it is known to have antitumor effects. While genital warts are not technically considered cancer, they are an abnormal growth of cells. In this respect, genital warts are “tumors” and can be treated with interferon alfa-2b. While every person has interferon alfa-2b in their bodies, the interferon alfa-2b that is commercially available is made by genetically engineered bacteria.
In clinical trials, interferon alfa-2b was very effective in the treatment of genital warts. Two fifths of patients experienced a complete disappearance of their lesions. In another 20% of patients, the lesion size was clearly less or the number of genital warts was fewer. When interferon alfa-2b was combined with other topical treatments, like podophyllin resin, the success rate was even higher.
Interferon alfa-2b has very few side effects, especially when the drug is injected directly into the genital wart rather than being taken orally or as an injection into the bloodstream. Patients sometimes report that they have flu symptoms for about a day after treatment that then passes. Rarely interferon alfa-2b can raise liver enzymes or reduce white blood cell counts but these are generally temporary and not serious if identified.
The main drawback of interferon alfa-2b is that it is very expensive. In fact, it is the most expensive genital wart treatment, either medical or surgical. A round of treatment with interferon alfa-2b for genital warts can cost three to six thousand dollars.

5-Fluorouracil or 5-FU (Adrucil, Efudex, or Fluoroplex)

5-Fluorouracil is best known as a treatment of cancer. It has been used for decades in the treatment of certain skin and other cancers. 5-Fluorouracil works by inhibiting the growth and reproduction of skin cells, which can be very helpful in the treatment of genital warts. 5-Fluorouracil is not considered a “first line” treatment for genital warts and is usually considered when other treatment options have failed. The chemotherapeutic may be used for genital warts that occur inside the vagina.
5-Fluorouracil is administered into the vagina as a 5% cream through a special applicator. Given the depth and precision with which it must be administered, a physician must insert the drug. 5-Fluorouracil is given once a week for up to 10 weeks. In patients that fail to achieve success with other treatments, 5-fluorouracil is effective in as many as 80%. Despite this success, the use of 5-fluorouracil in the treatment of genital warts is limited.
The main concern of using 5-fluorouracil to treat genital warts is to protect the non-warty areas from coming into contact with the chemotherapy. This usually means that non-warty areas are covered with petroleum jelly and the entrance of the vagina is blocked with a tampon. The risk of the drug entering the bloodstream when applied in this way is reasonably small.
Surgical treatment options for genital warts
There are four main surgical treatments for genital warts: surgical excision, cryotherapy, electrosurgery, and laser treatment. The clinical decision between surgical alternatives is made based on the size and extent of the genital warts. Patient preference and the physician’s expertise are also taken into consideration.
Surgical excision
Historically surgical excision was the primary surgical option for genital warts. Surgical excision is simply cutting the diseased tissue away from the healthy tissue and suturing the healthy skin together. This treatment option is still considered for very large genital warts that are not likely to be removed by other means. Also, if the lesion appears to be cancerous for any reason, surgical excision is done to remove all traces of the genital wart along with some healthy tissue on all sides. Lymph node biopsy may also be done at this genital wart surgery.
A more sophisticated surgical excision procedure is Mohs surgery. Mohs surgery is a specialized technique in which the skin is taken off in thin layers. After the layer is removed, it is immediately viewed under a microscope to determine what kinds of cells are present. If genital wart cells remain, more layers of skin are removed. Cutting stops once only healthy tissue remains.
The obvious advantage of Mohs surgery for genital warts is that the maximum amount of healthy skin can be preserved. However, Mohs surgery can be expensive and quite involved. It is done when cosmetic appearance of the wart is a major consideration.

Cryotherapy

Cryotherapy is a process in which the abnormal tissue is frozen through the use of a cooling agent (cryogen) like liquid nitrogen. The liquid nitrogen instantly freezes the tissue which makes the cell walls brittle and freezes the water inside the cells. As the cells thaw, the tissue is damaged, like freezer burn on stored meats. This freezing process causes a local inflammation and calls other cells to come to the site of the destroyed cells and clear them away.
Cryotherapy is most effective in treating many small genital warts. The liquid nitrogen can be sprayed or dabbed on the warts. Cryotherapy is usually more effective for warts on the shaft of the penis and on the vulva. For genital warts on the anus, cryotherapy is less effective and more painful, so it should be used with caution. Because of its completely local effect (does not spread) cryotherapy is an excellent choice for the treatment of genital warts during pregnancy.
There are few different types of complications that can arise from cryotherapy. Some occur right after treatment (acute complications) while others do not appear for some time (delayed complications). Acute complications of cryotherapy include pain and blisters. Delayed complications may include bleeding, infection, and unusual skin formation. The treated area may lose color (pigmentation), lose hair (alopecia) and develop scars—these three complications can be permanent.
Electrosurgery
Electrosurgery is a surgery which uses surgical tools that supply an electrical current for cutting and cauterization. There are a number of instruments that can be used for electrosurgey—indeed, electrosurgical tools are found in many surgical disciplines. One of the more commonly performed genital wart treatments is the loop electrocautery excisional procedure (LEEP). A LEEP is the procedure of choice when there is the possibility of cervical cancer.
Electrosurgery is extremely effective for warts on the shaft of the penis. This form of genital wart removal surgery can also be effective for lesions on the rectum and vulva. Lesions in other locations may not be suited for removal using an electrosurgery device.
There are few complications associated with electrosurgery. It should be used with caution or avoided in patients that have cardiac pacemakers or other implanted heart devices. This is because most devices use the patient to ground the alternating electrical current. This current could interfere with the function of some cardiac devices. Also, electrosurgery can be painful. In general, the pain is proportional to the area that is cut. Therefore for large genital warts, general or epidural anesthesia may be required for comfort.
Laser treatment
Lasers are one of the newest genital warts treatment options. The concentrated light energy in the laser heats the genital wart and ablates (destroys) it. It also cauterizes the blood vessels as they are cut, making laser treatment a virtually bloodless surgery. While several lasers have been used in the treatment of genital warts, the carbon dioxide laser has the most impressive track record. Studies using carbon dioxide lasers have shown a greater than 90% cure rate on condyloma acuminata.
Laser therapy is among the treatments of choice in pregnant women with large or treatment-resistant genital warts. When performed by a capable surgeon, laser genital wart treatment is very safe. The most common complication is burns to tissue surrounding the lesion. Carbon dioxide laser treatment can be used to remove warts within the vagina, anus, or inside the urethra. It may also be the treatment of choice for genital warts in HIV-infected patients.
It is important to note that when genital warts are destroyed with a laser, the damaged cells can release human papillomavirus in the vapors. Therefore, anyone in the room during laser genital wart treatment should wear a mask capable of blocking the virus.