Patient information: Condyloma (genital warts) in women

GENITAL WARTS OVERVIEW

Condyloma acuminata (genital warts) are a sexually transmitted condition that causes small, skin-colored or pink growths on the labia, at the opening of the vagina, or around or inside the anus. Genital warts are the most common sexually transmitted condition in the United States. Although warts affect both genders, more women have warts than men.

CAUSES OF GENITAL WARTS

Condyloma are caused by the human papillomavirus (HPV). Over 70 different types of HPV have been identified, each of which infects a specific area of the body. Researchers have labeled the HPV types as being at high or low risk for causing cervical cancer. The HPV viruses that cause most genital warts are low-risk types. HPV types 6 and 11 are a major cause of warts, and types 16 and 18 are major causes of cervical cancer. (See "Patient information: Cervical cancer screening".)

HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to become infected with HPV by touching a toilet seat.

GENITAL WARTS SYMPTOMS

Warts appear skin-colored or pink, and may be smooth and flat or raised with a rough texture. They are usually located on the labia or at the opening of the vagina, but can also be around or inside the anus (picture 1).

Rarely, women with genital warts have itching, burning, or tenderness in the genital area, depending upon the number of warts and their location. However, most women with warts do not have any symptoms at all.

Warts may appear weeks to a year or more after coming in contact with human papillomavirus; it is not usually possible to know when, how, or from whom the infection was transmitted.

GENITAL WARTS DIAGNOSIS

Most women with genital warts can be diagnosed by examining the area. In some women, further examination with colposcopy (examination of the vulva, vagina, and cervix) or anoscopy (examination of the anus and rectum) is recommended. For these tests, the healthcare provider uses a magnifying device to closely inspect the skin or tissue for evidence of HPV infection. A weak acid solution (called acetic acid) is applied to the skin or tissue, which can further aid in the diagnosis; this does not cause pain.

A biopsy (removal of a small piece of tissue) may be recommended if the provider is uncertain whether the area in question is a genital wart or in certain other situations. However, most women with genital warts will not need a biopsy. (See "Condylomata acuminata (anogenital warts)".)

GENITAL WARTS TREATMENT

Treatment of warts usually involves using a medication that you or a healthcare provider apply to the skin. Other treatments, such as oral medications and surgery, are generally reserved for people with very large areas of warts or warts that do not improve with topical treatments. A summary of these treatments is provided here (table 1). (See "Treatment of vulvar and vaginal warts".)

It is usually necessary to treat warts for several weeks. Even with treatment, it may not be possible to eradicate the HPV virus from the genital area; therefore, it is possible that the warts will recur. There is currently no treatment that will eliminate the HPV virus.

Medical treatments — Medical treatments include medications that are applied directly to the wart. There are two broad categories of medical therapy: those that directly destroy the wart tissue and those that work through your immune system to clear the wart. Some treatments must be applied in the healthcare provider's office while some can be applied at home.

Podophyllin — Podophyllin is a plant-based resin that destroys the wart tissue. It is only used for vulvar lesions; using it on the cervix or vaginal tissues can cause chemical burns. The healthcare provider applies the solution directly to the warts with a cotton swab, and you should wash the area one to four hours later to avoid excessive skin irritation. The treatment is repeated weekly for four to six weeks, or until the lesions have cleared.

Studies have reported 40 to 75 percent of patients are cleared of warts after using podophyllin, but 25 to 100 percent have a recurrence over time [1]. Side effects range from mild skin irritation to pain and development of skin ulcers.

Podophyllotoxin — Podophyllotoxin (Condylox®) can be self-administered. Using a cotton swab, you apply a gel or liquid solution to the wart(s) twice daily for three consecutive days. Only a small amount of the solution should be used, and no more than a 3 cm by 3 cm area should be treated. No treatment is used for the following four days; the treatment cycle can be repeated up to four times until the warts have resolved.

Clinical studies have described wart clearance rates of 29 to 90 percent [2]. Podophyllotoxin may be recommended as a first-line treatment if you are willing and able to apply it. Podophyllotoxin may be more effective than podophyllin.

Bichloroacetic acid and trichloroacetic acid — Both bichloroacetic acid (BCA) and trichloroacetic acid (TCA) are acids that destroy the wart tissue. TCA is used most commonly, and must be applied by a health care provider. The provider applies a solution to the wart tissue, which will turn white as the solution dries. The treatment is performed once per week for four to six weeks, or until the lesions have cleared. Side effects of TCA may include pain and burning.

One trial that evaluated TCA in women showed a 70 percent clearance rate [3]. In contrast to podophyllin, TCA can be used on the cervix and vagina, and is safe for use during pregnancy.

Imiquimod — Imiquimod (Aldara®) is a cream that causes an immune response; this causes the body to eliminate the wart. You can apply the cream directly to the wart tissue (generally at bedtime), and then wash the area with water six to 10 hours later. You use the cream every other day for a total of three days per week, for up to 16 weeks. Mild irritation and redness are normal while using imiquimod, and indicate that the treatment is working. Imiquimod should not be used internally on vaginal warts, and it is not recommended for use during pregnancy.

Trials show a 50 percent clearance rate with 10 to 20 percent recurrence rates [4].

Interferon — Interferon is a medication that causes an immune response. It is available in several treatment forms (injection, topical gel), but studies have determined that it most effective when given as an injection at the base of the wart two to three times per week for up to nine weeks. Several clinical trials have shown clearance rates of about 20 to 60 percent [5], although other trials have failed to show any benefit [6], perhaps due to too brief a period of follow-up.

Side effects of interferon include flu-like symptoms, fatigue, lack of appetite, and local pain. Given these side effects, the variable rates of effectiveness, and the need for multiple treatments per week, interferon is not generally recommended as a first-line treatment. It may be used in combination with surgical and/or other medical treatments, especially with warts that do not improve with other treatments.

Interferon is not safe for use during pregnancy.

Surgical treatment — Surgery is generally reserved for patients with:

• Warts that do not respond to medical therapy
• Large areas of warts, where medical therapy alone is often inadequate
• Lesions involving the vagina, urethra, or anus
• Areas that have associated pre-cancerous changes

Surgical management options include excisional (removal) and ablative (destructive) procedures. These treatments are often used in a combined fashion.

Cryotherapy — Cryotherapy uses a chemical to freeze the wart tissue. The treatment can be done in a healthcare provider's office, and does not usually require any anesthesia. Studies have reported 50 to 80 percent clearance of warts after cryotherapy. Cryotherapy can be used during pregnancy.

Cryotherapy often causes pain during the procedure; other side effects can include skin irritation, swelling, blistering, and ulceration. Cryotherapy is not usually a first-line treatment.

Electrocautery — Electrocautery uses electrical energy to burn away wart tissues. Patients are treated in an operating room after receiving local anesthesia to prevent pain. It can be used for vaginal lesions.

Excision — Excision involves the removal of an area of warts by surgically cutting it out. Most patients are treated in an operating room after receiving anesthesia to prevent pain. Rarely, excision causes pain, scar formation, and infection.

Excisional therapy is effective. Most studies show success rates of 36 to 100 percent and recurrence rates of 8 to 65 percent within one year [7].

Laser — Lasers produce light energy, which is absorbed by water within wart tissues, leading to its destruction. Physicians who perform laser treatment require specific training and specialized equipment. Patients are treated in an operating room after receiving local anesthesia to prevent pain.

Laser therapy is preferred when multiple warts are spread over a large area. Laser is also useful for treating cervical and vaginal warts, when surgical excision is not possible or would be difficult. Risks of laser surgery include scarring, pain, and changes in the skin's appearance (usually lightened color). Rarely, patients may develop chronic pain in the area of treatment.

Laser therapy clears lesions in 40 to 100 percent of warts, and long-term recurrences occur in 4 to 77 percent of patients.

Ultrasonic aspiration — The CUSA technique (Cavitron ultrasonic aspirator-CUSA) uses ultrasound (sound waves) to break up and remove warts. With this technique, the outer layer of skin is removed without damage to underlying tissue. Patients are treated in an operating room after receiving general anesthesia to induce sleep and prevent pain. One study showed this technique to be effective in the treatment of warts [8]. CUSA requires that a healthcare provider undergo specialized training and purchase specialized equipment, so it is not widely available.

GENITAL WARTS FOLLOW UP

Following successful treatment of warts, you may be instructed to examine yourself periodically to monitor for new warts. Most people who develop recurrent or persistent warts do so within three to six months of treatment. Recurrence is more common in people with a weakened immune system (due to HIV or certain medications).

It is important to understand that completely eliminating visible warts does not necessarily mean that HPV has been eliminated. Therefore, warts may recur even after successful initial treatment. In this situation, the same treatment may be used again and is likely to be successful.

GENITAL WARTS PREVENTION

HPV vaccine — A vaccine (Gardasil®) is now available to help prevent infection with four types of HPV (types 6, 11, 16, and 18), which in turn can prevent most cases of cervical cancer and genital warts. The vaccine was proven to be safe and effective in several large clinical trials [9,10]. A topic review is available that discusses the HPV vaccine. (See "Patient information: Human papillomavirus (HPV) vaccine".)

Sexual contact — Avoiding contact with infected individuals is one way to reduce the risk of becoming infected or transmitting HPV. However, from a practical standpoint this is difficult, as many people are infected and do not have any visible warts. Condoms do not provide complete protection; contact (hand to genitals or genitals to genitals) involving areas not covered by the condom may allow HPV to be spread from one person to another.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Cervical cancer screening
Patient information: Human papillomavirus (HPV) vaccine

Professional Level Information:
Anal intraepithelial neoplasia: Diagnosis, screening, and treatment
Carcinoma of the penis: Epidemiology, risk factors, and clinical presentation
Clinical features, staging, and treatment of anal canal cancer
Clinical presentation and diagnosis of human papillomavirus infections
Clinical trials of human papillomavirus vaccines
Condylomata acuminata (anogenital warts)
Epidemiology of human papillomavirus infections
Recommendations for the use of human papillomavirus vaccines
Treatment and prevention of human papillomavirus infections
Treatment of vulvar and vaginal warts
Virology of human papillomavirus infections and the link to cancer

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Cancer Society

      (www.cancer.org, search for HPV)

• National HPV and Cervical Cancer Public Education Campaign

      Telephone: 1-866-280-6605
      (www.cervicalcancercampaign.org)

• National Institute of Allergy and Infectious Diseases

      (www.niaid.nih.gov/factsheets/stdhpv.htm)

• Center for Disease Control and Prevention

      (www.cdc.gov/std/HPV/STDFact-HPV.htm)

• American Social Health Association

      (www.ashastd.org/hpv/hpv_learn.cfm)

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