The goal of genital wart treatment is to eliminate or prevent the lesions themselves. By eliminating the genital warts, the chance of passing the sexually transmitted disease to others is reduced. Most of the human papillomavirus (HPV) is contained within the genital warts themselves, so by eradicating them the amount of virus is reduced.
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) 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) 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.
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.
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 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 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.
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.
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