NHS Borders clinical guidelines
Treatment:
1. Fleshy External Genital Warts
1st Line: Topical treatment with Podophyllotoxin, Cataphen or Imiquimod
Podophyllotoxin (Warticon)
Use twice per day for 3 consecutive days of the week followed by 4 days off. This is then repeated for 4-5 cycles. If the warts have responded to this treatment then continue for further cycles.
Podophlyllotoxin can cause local skin reactions.
And is contraindicated in pregnancy.
Note: Podophyllotoxin 0.5% solution is sold as Warticon Solution or Condyline. Podophyllotoxin 0.15% cream is sold as Warticon cream.
If partial response -
Further cycle of the same therapy
If non-response -
Change to alternative treatment (i.e.imiquimod or cataphen)
Catephen 10% ointment: - extract of leaf of green tea plant.
Apply a small amount 3 times a day for up to 16 weeks.
Do not apply to mucous membranes.
Mild local reactions are very common and should not lead to discontinuation as they decrease after the first few weeks of treatment.
An interruption of treatment may be required however if there is a severe local
reaction-occurs in up to 26% of patients so please warn patients but encourage them to restart treatment once the skin has settled.
Skin reactions are most common in the first few weeks of use.
Cetaphen should be avoided in pregnancy.
or
Imiquimod cream - an immune response modifier.
Imiquimod cream stimulates local tissue macrophages to release interferon alpha and other cytokines as part of a local cell mediated response.
Apply 3 times a week at night on non-consecutive days and wash off 6-10 hours later for up to 16 weeks. The course can be prolonged beyond this if there has been a response.
Imiquimod frequently causes local skin reactions particularly after the second or third treatment. Temporarily halting the treatment and restarting once the skin has settled means treatment can be continued. A further reaction is then unlikely. Continuing treatment at reduced frequency (e.g. twice a week only) is a further option for managing local side effects.
Not licensed for use in pregnancy.
2. Keratinised External Genital Warts
Imiquimod is licensed for use on keratinised warts
3. External genital warts: extensive
As 1, but consider use of Imiquimod particularly if the warts are scattered or recurrent. Imiquimod is an appropriate first line therapy for perianal and intrameatal warts.
4. Urethral warts:
If clearly visible and do not extend deeply within urethra, use Imiquimod. If they persist, refer to consultant for consideration of cryotherapy.
5. Intra-anal warts:
No treatment is an option. If external warts are being treated with Imiquimod, there is usually a regional effect and the intra-anal warts will regress.
Imiquimod can be used cautiously in the anal canal. This is an off licence indication – discuss with consultant.
6. Vaginal warts:
No treatment. If warts are very large, or distressing, refer to gynaecology for consideration of surgery.
7. Cervical warts:
Treat any co-existing external warts as above. BASHH do not recommend referral for colposcopy unless there is diagnostic uncertainty.
8. Anogenital warts in pregnancy:
Clearing genital warts in pregnancy is often unsuccessful due to the suppressed immune system. Warts nearly always resolve completely in the immediate post-partum period however. Warts often start to reduce in number spontaneously in the third trimester. The only treatment that can be used safely is liquid nitrogen.
See: SEXUALLY TRANSMISSIBLE INFECTIONS IN PREGNANCY.
Background: Genital Warts: Condylomata Acuminata
Genital warts are caused by the human papillomavirus (HPV), most commonly HPV 6/11. The majority of sexually active people will be infected transiently and asymptomatically. Certain types of HPV (especially HPV-16 and HPV-18) are associated with anogenital malignancy.
The diagnosis is clinical: In men, fleshy, hyperplastic warts occur most often on the glans penis and on the inner lining of the prepuce. Warts within the urethral meatus are not uncommon and they may also be found in the perianal region (in both heterosexual men and amongst men who have had receptive anal intercourse). Moisture and accompanying inflammation may enhance their size and tendency to coalesce. Hyperplastic warts also occur in women, most often appearing first at the posterior part of the vaginal introitus and on the adjacent labia majora and minora. They tend to cluster at the orifices of the greater vestibular glands (Bartholin’s glands). In both sexes, condylomata may be found in the anal canal, and can cause bleeding during defaecation.
Sessile warts, resembling plane warts on the non-genital skin, tend to be seen on the shaft of the penis, and although often multiple, they do not coalesce. Sessile warts do not seem to occur on the vulva.
Multiple common skin warts (verrucae vulgaris) present as raised lesions; they tend to occur on the shaft of the penis and occasionally on the vulva and perianal skin.
The differential diagnosis of condylomata acuminata includes:
- Penile papillae.
- Vestibular papillae.
- Pilosebaceous and Tyson’s glands.
- Molluscum contagiosum (see below).
- Skin tags
- Condylomata lata (a feature of secondary syphilis).
Treatment of anogenital warts
Most anogenital warts in immunocompetent patients undergo spontaneous regression (cell-mediated immune responses) within months. Not treating is the best management if warts are very small and should be offered as an option in all cases. Smoking may mean warts take longer to clear and are more likely to recur.
If the warts do not resolve spontaneously or if patients seek treatment due to social unacceptability or psychological distress they can contact their GP for topical treatment.
Many patients believe that cryotherapy works instantly to get rid of warts. This is not the case. Warts resolve when enough HPV antibody is produced.
The exclusion of other STIs is important. Genital wart infection is not a sole indication for STI testing. A sexual history should be taken to identify risk factors.
Sometimes warts regress after local inflammation has been controlled. Be aware of the possible Koebner phenomenon. Underlying skin conditions, vulvovaginal candidiasis, local trauma and allergies may trigger recurrences or make warts refractory to topical treatments. Treating the underlying cause is often the answer.
The Table below shows the most commonly used treatments for external anogenital warts.
Patient Information:
- Caused by human papillomavirus.
- Very common.
- Latent period is months or years.
- Asymptomatic carriage is common.
- No implication of infidelity in regular relationship.
- Spread almost always sexual.
- New warts may appear even during treatment.
- About 70% of people are clear of warts after 5 weeks of therapy.
- Recurrence is very common.
- Damaged skin may make them worse; make sure you look after your skin. It may be worth recommending that patients discontinue shaving the genital skin until warts have resolved, especially in cases of recurrence or resistance to treatment.
- The vast majority of genital warts (>85%) are caused by viruses having no connection with cervical carcinoma.
- Women with genital warts require routine cervical smears only and no additional intervention or screening.
- Women born in the UK from 1996-1999 were given Cervarix vaccine - which provides protection against HPV 16 and 18 only. Women born in
2000 onwards were given Gardasil Vaccination which also protects against HPV 6 and 11 which are the commonest causes of genital warts. Gardasil significantly reduces the risk of developing genital warts. - From 2018, boys aged 11-13 in the UK (as well as girls) are also now receiving Gardasil vaccination as part of their school vaccination programme. From 2018, boys aged 11-13 in the UK (as well as girls) are also now receiving Gardasil vaccination as part of their school vaccination programme.
Condom Use:
- With any new partner, or a partner with whom sex has previously been protected, use condoms while warts are being treated and for six months after clearance although this does not guarantee prevention of transmission.
- With a partner with whom sex regularly took place without a condom before warts appeared, there is little evidence of benefit in starting to use condoms. There is some evidence that the rate of clearance of warts is improved in those using condoms.
- Condom use cannot be guaranteed to prevent transmission. Condoms do protect against the acquisition of HPV – young people without warts can be advised that condoms will provide some protection.