Physicians’ philosophy on HPV management has changed in recent years, from the immediate genital warts treatment of a patient with a mildly abnormal Pap smear ﬁnding to a more conservative, wait-andsee approach. This is beneﬁcial because administration of multiple cervical treatments has potential for affecting future fertility, so postponing treatment can beneﬁt long-term health. The downside are the patient’s anxiety over facing abnormal Pap smear ﬁndings over time and fear of the disease’s progression to cancer.
The patient should request as much information from the doctor as he or she needs to alleviate anxiety. If no additional information is wanted, the patient can simply follow the guidelines for treatment advanced by her physician. The new self-treatment options for patients with EGWs, combined with some older therapies, present a huge array of treatment options. It is interesting to note that today’s therapies do not permit the perfect outcome of treatment—that is, eradication of infection, prevention of all sequelae, and elimination of the possibility of transmission to others or of local spread.
The treatment can, however, remove visible warts and eliminate symptoms such as irritation, bleeding, and pruritus. Having the warts debulked and the viral load lessened serves to reduce the likelihood of transgenital warts 61mission to sex partners and to other parts of the body.
External genital warts were treated with surgery and heat for many years. Then, in 1942, a New Orleans physician reported his use of podophyllum for condyloma acuminata, a treatment he supposedly learned from local Native Americans. Treatment was effective but had the downsides of toxicity on absorption and high recurrence rate. Later cryosurgery, laser surgery, and electrosurgery provided surgical choices; trichloroacetic and bichloroacetic acid were used for physical dissolving of warts. Also used were interferon and 5-ﬂuorouracil, now in disfavor because of their side effects and cost.
The 1990s saw a rapid expansion of understanding of HPV, with two new medicines that allowed private patient treatment of the malady. These are podoﬁlox (Condylox) 0.5 percent gel, a simpler-to-use version of podoﬁlox solution, and imiquimod (Aldara) 5 percent cream; both of these topical medications are for external genital and perianal warts only. They are not for use in treating intravaginal, cervical, urethral, rectal, or intraanal warts. Unless the doctor states otherwise, a patient should not continue using topical podofilox and imiquimod beyond the FDA recommendation of four and 16 weeks, respectively.
Most treatments result in wart-free periods, and some eliminate the warts with no recurrence. Other possible treatments are 5-fluorouracil cream, which is contraindicated in pregnant women, and trichloroacetic acid (TCA).
Over the years, the approach to treating HPV has changed radically. Since physicians have seen that most low-grade cervical intraepithelial lesions regress spontaneously, doctors no longer treat cervical abnormalities as they did in the early 1990s. Then, women in their teens and early twenties were treated more aggressively after detection of the problem. A conservative approach has been adopted by U.S. physicians, most of whom agree that no invasive procedure is needed unless the patient has a high-grade squamous intraepithelial lesion (HGSIL). However, if the infection persists through several positive Pap smear results, treatment will probably be required.
Intraepithelial lesions that are moderate- to high-grade can be obliterated via any one of several safe treatments: cryotherapy, laser vaporization, loop electrosurgical excision procedure (LEEP), or cold-knife cone biopsy (CKCB). Cryotherapy has the disadvantage of a greater probability of recurrent disease than that of the others. CKCB has some downsides: it can increase future risk of secondtrimester abortion, preterm labor, and low birth weight. It is important for those with HPV to understand that eradication of their lesions does not eliminate the need for follow-up Pap smears.
Many doctors prefer to remove genital warts with cryosurgery (freezing), electrocautery (burning), or laser treatment. Large warts that do not respond to treatment may require surgery. Some doctors inject the antiviral drug alpha-interferon into the warts, especially when the warts have recurred after traditional treatment. The drug is expensive and has not been proved to affect rate of recurrence; plus, it has the disadvantage of considerable discomfort for the patient, who must endure shots in the genital area.
Most patients go through a regimen that includes several doctor-administered treatments along with patient-applied options. In many cases, what is required are multiple courses of different treatments to solve the problem. Often, a patient is prescribed one therapy for home use and one that the doctor administers.
A wide variety of approaches to treatment exist because of deficient outcome data and lack of access to modalities such as cryotherapy and surgery. There is increasing agreement that some longtime treatments require too many office visits, and one treatment that was commonly used in the past—podophyllin resin—appears to be ineffective.
The following are some of the factors that affect the treatment selection for EGWs:
• There is a lack of studies in pediatric populations of the safety and efﬁcacy of EGW treatments.
• Pain is associated with treatments.
• Wart size and number, anatomic location, circumcision status in men, and epithelial presentation can determine treatment choice; generally, for genital warts example, topical treatments are not ideal for large areas of warts.
• Warts on moist surfaces and between skinfolds respond better than do warts on dry and open
areas to topical treatment.
• Aggressive ablative or surgical therapy should not be performed over the clitoris, glans penis, urinary meatus, prepuce, and preputial cavity in the uncircumcised.
• Patient preference insofar as applying selftreatment versus having the health care provider perform treatment is a factor.
• Patient attitude toward the prospect of pain, cost of treatment, and number of visits affects
One report concludes that the most cost-effective therapy option is to start patients on imiquimod and then switch them to a provideradministered therapy if it is needed. This achieves the highest overall sustained clearance and does so at the lowest average cost per sustained clearance. The goal of treatment is to remove symptomatic warts. There is no evidence it eradicates infection and no evidence that it affects the natural history or cancer risk, according to USTD 2001.
Treatment choice should be patient-guided; the health care provider should not overtreat; and no treatment modality is superior. Treatment selection should be determined by considering wart size, number, sites, and morphological features; patient preference; cost; convenience; adverse effects; and doctor’s experience.
For keratinized warts, local destructive methods are used. Possible complications of ablation are cosmetic alterations, such as scarring and hypo- or hyperpigmentation. For HPV combined therapies there is potential for increased complications and no increased efﬁcacy.
For external condyloma treatment
• Patients can apply podoﬁlox 0.5 percent solution or gel or imiquimod 5 percent cream.
Doctors can administer
• Trichloracetic acid (TCA) or bichloracetic acid (BCA)
• Sharp excision
• Cavitron ultrasonic surgical aspirator (CUSA)
Alternative therapies for genital warts include intralesional interferon use and laser surgery. According to the CDC (1998), in the absence of dysplasia, treatment is not indicated for subclinical HPV diagnosed by any technique. There is a high spontaneous regression rate. Also according to 1998 CDC guidelines, evaluation and treatment of the male partner are not needed to conﬁrm the presence of HPV. There are unproven beneﬁts to the female partner of successful treatment and no proven beneﬁts to the male partner or future partners as far as infectivity.
Speciﬁc considerations determine treatment of EGWs during pregnancy. Some treatments cannot be used because they carry risk for the fetus. However, treatment is often needed because EGWs can grow during pregnancy, and obstetrical complications of delivery may occur when the mother has large EGWs. Doctors usually use TCA or BCA, cryotherapy, or surgical removal. Since the FDA has labeled imiquimod a Pregnancy Category B drug, it may be an option for use during pregnancy if the patient is properly briefed.
Check out this video on different types of treatment for genital warts.