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Practice Algorithm

Treatment Protocol for External Genital Warts

Paul M. Fine, MD; Savita Y. Ginde, MD, MPH

There are about 1 million new cases of external genital warts (EGW) in the United States annually.1 Standard treatments include surgical (eg, cryotherapy, excision, laser therapy, electrosurgery), and nonsurgical (eg, bichloroacetic acid [BCA]/trichloroacetic acid [TCA], podophyllotoxin, imiquimod). Ablative or surgical therapies are effective in the short term, but recurrence rates can be high.2 Clearance rates of 63% to 70% can be obtained with BCA/TCA, while imiquimod—a topical immune response modifier—produces complete clearance in 37% to 70% of cases. 3-7

To determine the most efficacious and cost-effective treatments for EGW, Planned Parenthood conducted a retrospective study involving 5 of its major US affiliates that reviewed the charts of 422 women and 78 men undergoing treatment for EGW.8 Treatment must have been successful, and statistical analysis incorporated anatomic site, frequency of office visits, treatment modality, and cost of treatment and office visits. The treatment algorithm presented here was derived from these data, and represents the most efficacious and cost-effective treatment strategy in the Planned Parenthood clinic setting. The algorithm strikes a careful balance between cost-effective management of health care resources and patient need to achieve treatment success with a minimum number of clinic visits. Residual lesions following imiquimod therapy are easily treated by surgical excision, with high success rates.9 Appropriate partner counseling must be considered, as well as screening for other sexually transmitted infections, including HIV.

The authors report no actual or potential conflicts of interest in relation to this article.

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Paul M. Fine, MD, is Medical Director, Planned Parenthood of Houston & Southeast Texas. Savita Y. Ginde, MD, MPH, is Medical Director, Planned Parenthood of the Rocky Mountains, Denver, CO.

References

1. Gunter J. Genital and perianal warts: new treatment opportunities for human papillomavirus infection. Am J Obstet Gynecol. 2003;189(3 Suppl.):S3-S11.
2. Stanley M. Chapter 17: Genital human papillomavirus infections?current and prospective therapies. J Natl Cancer Inst Monogr. 2003;(31):117-124.
3. Wiley DJ, Douglas J, Beutner K, et al. External genital warts: diagnosis, treatment, and prevention. Clin Infect Dis. 2002;35(Suppl. 2):S210-S224.
4. Edwards L, Ferenczy A, Eron L, et al. Self-administered topical 5% imiquimod cream for external anogenital warts. HPV Study Group. Human PapillomaVirus. Arch Dermatol. 1998;134(1):25-30.
5. Beutner KR, Spruance SL, Hougham AJ, Fox TL, Owens ML, Douglas JM Jr. Treatment of genital warts with an immune-response modifier (imiquimod). J Am Acad Dermatol. 1998;38(2 Pt 1):230-239.
6. Arican O, Guneri F, Bilgic K, Karaoglu A. Topical imiquimod 5% cream in external anogenital warts: a randomized, double-blind, placebo-controlled study. J Dermatol. 2004;31(8):627-631.
7. Sauder DN, Skinner RB, Fox TL, Owens ML. Topical imiquimod 5% cream as an effective treatment for external genital and perianal warts in different patient populations. Sex Transm Dis. 2003;30(2):124-128.
8. Fine P, Ball C, Pelta M, et al. Treatment of external genital warts at Planned Parenthood Federation of America centers. J Reprod Med, 2007:52(12):1090-1096.
9. Carrasco D, vander Straten M, Tyring SK. Treatment of anogenital warts with imiquimod 5% cream followed by surgical excision of residual lesions. J Am Acad Dermatol. 2002;47(4 Suppl.):S212-S216.

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