This document discusses genital warts management. It covers causes (HPV types 6 and 11 cause most warts), symptoms (often asymptomatic but can cause pain or itching), types (flat, papular, etc.), treatment sites on the body, diagnostic methods (visual inspection and sometimes biopsy), and various treatment options. Treatments discussed include patient-applied options like podofilox and imiquimod creams as well as provider-applied cryotherapy, podophyllin, and surgical removal. Factors influencing treatment choice and potential complications are also outlined.

1. Genital warts management
CDC, 2010
Aboubakr elnashar
Benha university Hospital, Egypt
Aboubakr Elnashar

2. Causes
I. 90%:
HPV 6 or 11.
2. Occasionally:
HPV types 16, 18, 31, 33, and 35: usually as
coinfections with HPV 6 or 11
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3. Symptoms
Asymptomatic: usually
Pain or pruritis: depending on the size and site
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4. Types
1. Flat
2. Papular
3. Pedunculated
4. Cauliflower
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5. Sites
1. Cervix
2. Vagina
3. Around the introitus
4. Urethra
5. Perineum
6. Perianal skin
7. Intra-anal
Aboubakr Elnashar

6. Filamentous projections
cervical condyloma are
present on this large ectopy
with evidence of other low-
grade HPV effect on the
columnar epithelium.
A cobblestone appearance
is noted in this patch of
vaginal warts found in the
cul de sac of a woman with
low-grade squamous
intraepithelial lesion (LSIL)
on Pap smear and a
colposcopically normal
cervix. Aboubakr Elnashar

7. Pigmented papules were
present over much of the labia
majora bilaterally in this young
woman with an abnormal Pap
smear and flat vaginal (HPV)
lesions. These are most likely
due to HPV type 16, although
other high-risk types could also
induce increased melanin
production. Although a biopsy
of these lesions often would be
read as high-grade, treatment
options utilized for other
external genital HPV-induced
lesions will usually clear these
lesions as well.
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8. Dome shaped lesion on
keratinized skin above clitoris
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9. A filamentous genital
wart is present in the
urethra
Cauliflower-like
condyloma acuminata
are seen on the
perineum, adjacent
posterior fourchette,
and right lower labia
majora. Aboubakr Elnashar

10. Perianal condyloma
acuminata are present, but
their morphology is smoother.
Keratinized flat warts are
present in the junction
between the introitus and
the perineum. Keratin
produces the strikingly white
appearance.
Aboubakr Elnashar

11. Micropapillations are normal single-
filament projections on the inner
labia minora that can often be
confused with genital warts. The
single filament of each projection
differentiates this normal finding
from HPV induced genital warts.
The umbilicated center of a typical
molluscum contagiosum differentiates
HPV-induced lesions from molluscum.
However, some molluscum lesions do
not have an umbilicated center and
are more difficult to differentiate. When
in doubt, probing a papular lesion with
a 25- to 30-gauge needle will elicit a
central core if the lesion is a
molluscum.
Aboubakr Elnashar

12. Diagnosis
Visual inspection.
Confirmation
Biopsy
indicated if
-Lesion
1) uncertain
2) atypical
3) pigmented, indurated, fixed, bleeding, or ulcerated.
4) do not respond to therapy
5) worsens during therapy
6) -Patient has
comprised immunity
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13. Tests
HPV DNA testing:
not recommended {test results would not alter clinical
management of the condition}.
Acetic acid test (3%–5%) :
causes skin color to turn white
not a specific test for HPV infection.
routine use is not recommended.
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14. Treatment
If left untreated:
1. Resolve on their own
2. Remain unchanged
3. Increase in size or number.
Objective:
1. Amelioration of symptoms
2. Relieving cosmetic concerns
3. Removal of the warts.
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15. Results:
1. Wart-free periods.
2. Reduce, but do not eradicate, HPV infectivity.
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16. Forego treatment and wait for spontaneous
resolution:
acceptable alternative for some persons
{ 1. No evidence that the presence of genital warts or
their treatment is associated with the development
of cervical cancer.
2. Effect of treatment on future transmission of
HPV: uncertain
3. Possibility of spontaneous resolution}
Aboubakr Elnashar

17. Factors that influence selection of treatment:
1. Wart
Size
Number
Site
Morphology
2. Treatment
Cost
Convenience
Adverse effects
3. Provider experience.
4. Patient preference
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18. Factors that might affect response to therapy:
Most genital warts respond within 3 months of therapy.
1. Presence of immunosuppression
2. Compliance with therapy:
single treatment or complete course of treatment.
3. Lesions on moist surfaces or in intertriginous areas
respond best to topical treatment.
Aboubakr Elnashar

19. Complications:
1. Persistent hypopigmentation or
hyperpigmentation {ablative modalities or
imiquimod}.
2. Depressed or hypertrophic scars: uncommon
{insufficient time to heal between treatments}.
3. Rare:
a. Ch pain syndromes (e.g. vulvodynia and
hyperesthesia of the treatment site)
b. In anal warts: painful defecation or fistulas.
c. Systemic effects {podophyllin and interferon}
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20. Types of regimens:
1. Provider-applied modalities.
2. Patient-applied modalities
Follow-up visits are important
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21. I. Patient applied
1. Podofilox: (Condylox)
Antimitotic drug that destroys warts
Advantages:
Relatively inexpensive
Easy to use
Safe
Self-applied.
Disadvantages:
1. Pain: Mild to moderate or local irritation
2. Safety during pregnancy: not established.
Aboubakr Elnashar

22. Method of application:
1. Applied with a cotton swab, or podofilox gel with a
finger, to visible genital warts twice a day for 3 d,
followed by 4 d of no therapy.
2. This cycle can be repeated, as necessary, for up to
4 cycles.
3. The total wart area treated should not exceed 10
cm2, and the total volume of podofilox should be
limited to 0.5 mL/d.
4. If possible, the health-care provider should apply
the initial treatment to demonstrate the proper
application technique and identify which warts
should be treated.
Aboubakr Elnashar

23. 2. Imiquimod cream: (Aldara)
Topically active immune enhancer that stimulates
production of interferon and other cytokines.
Method of application:
1. Applied once daily at bedtime, three times a week
for up to 16 w
2. The treatment area should be washed with soap
and water 6–10 h after the application.
Aboubakr Elnashar

24. Disadvantages:
1. Local inflammatory reactions: redness, irritation,
induration, ulceration/erosions, and vesicles
2. Hypopigmentation
3. Weaken condoms and vaginal diaphragms.
4. Safety during pregnancy: not established.
Aboubakr Elnashar

25. 3. Sinecatechin ointment:
Green-tea extract with an active product (catechins)
Method of application:
1. Applied 3 times daily (0.5-cm strand of ointment to
each wart) using a finger to ensure coverage with
a thin layer of ointment until complete clearance of
warts.
2. Should not be continued for longer than 16 w
3. Should not be washed off after use.
4. Sexual contact should be avoided while the
ointment is on the skin.
Aboubakr Elnashar

26. Side effects:
1. Erythema, pruritis/burning, pain, ulceration,
edema, induration, and vesicular rash.
2. Weaken condoms and diaphragms.
3. Efficacy or safety during pregnancy: Not available
4. Not recommended for HIV-infected persons,
immunocompromised persons, or persons with
clinical genital herpes{safety and efficacy has not
been established}.
Aboubakr Elnashar

27. II. Provider-applied
1. Cryotherapy
Destroys warts by thermal-induced cytolysis.
Local anesthesia: (topical or injected) facilitate
therapy if warts are present in many areas or if the
area of warts is large.
Complications:
1. Over- and under treatment: complications or low
efficacy.
2. Pain after application of the liquid nitrogen:
necrosis and sometimes blistering
Aboubakr Elnashar

28. 2. Podophyllin resin:10%–25%
Mode of application:
1) Application should be limited to <0.5 mL of
podophyllin or an area of <10 cm2 of warts/
session
2) The area to which treatment is administered
should not contain any open lesions or wounds.
3) The preparation should be thoroughly washed off
1–4 h after application to reduce local irritation.
4) Allow air-dry before the treated area comes into
contact with clothing
5) The treatment can be repeated weekly, if
necessary.
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29. Disadvantages:
1. Overapplication or failure to air dry: local
irritation {spread of the compound to adjacent
areas}.
2. Safety during pregnancy: not established.
3. The shelf life and stability: unknown.
Aboubakr Elnashar

30. 3. TCA and BCA
Caustic agents that destroy warts by chemical
coagulation of proteins.
Mode of application:
1. A small amount should be applied only to the
warts and allowed to dry before the patient sits or
stands, at which time a white frosting develops.
2. If pain is intense: acid can be neutralized with
soap or sodium bicarbonate.
3. If an excess amount of acid is applied: treated
area should be powdered with talc, sodium
bicarbonate (baking soda), or liquid soap
preparations to remove unreacted acid.
4. Treatment can be repeated weekly, if necessary.
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31. Disadvantages:
Damage adjacent tissues.
{TCA solutions have a low viscosity comparable with
that of water: spread rapidly if applied excessively}
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32. 4. Surgical therapy
Suitable for:
1. Patients who have a large number or area of
genital warts.
2. Both carbon dioxide laser and surgery:
Extensive warts or
Intraurethral warts, particularly for those persons who
have not responded to other treatments.
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33. Advantage:
usually eliminating warts at a single visit.
Disadvantages:
1. Requires
substantial clinical training
additional equipment
longer office visit.
2. {most warts are exophytic} procedure: wound that
only extends into the upper dermis.
Aboubakr Elnashar

34. Method:
A. Electrocautery
1. local anesthesia
2. Visible genital warts: destroyed by electrocautery
3. Care must be taken to control the depth of
electrocautery to prevent scarring.
4. Hemostasis by:
Electrocautery
Chemical styptic (aluminum chloride solution).
5. Suturing is neither required nor indicated in most
cases if surgical removal is performed properly.
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35. B. Tangential excision with a pair of fine scissors or
a scalpel
C. Laser
D. Curettage.
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36. Alternative Regimens
Treatment options that might be associated with
more side effects and/or less data on efficacy.
Intralesional interferon
Photodynamic therapy
Topical cidofovir.
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37. Aboubakr Elnashar

38. Aboubakr Elnashar

39. Aboubakr Elnashar

40. Aboubakr Elnashar

41. Aboubakr Elnashar

42. Aboubakr Elnashar

43. Aboubakr Elnashar

44. Pregnancy
Contraindicated TT:
1. Imiquimod
2. Sinecatechins
3. Podophyllin
4. Podofilox
Effect of pregnancy on wart:
Genital warts can proliferate and become friable
Effect of removal of warts during pregnancy:
resolution might be incomplete or poor until
pregnancy is complete.
Aboubakr Elnashar

45. Effect of wart on pregnancy:
Rarely, HPV types 6 and 11 can cause respiratory
papillomatosis in infants and children, although the
route of transmission (transplacental, perinatal, or
postnatal) is not completely understood.
Effect of CS on prevention of respiratory
papillomatosis in infants and children:
unclear:
CS should not be performed solely to prevent
transmission of HPV infection to the newborn.
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46. Indication of CS:
1. Genital warts obstructing pelvic outlet
2. Vaginal delivery would result in excessive
bleeding.
Pregnant women with genital warts should be
counseled concerning the low risk for warts on the
larynx (recurrent respiratory papillomatosis) in their
infants or children.
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47. HPV infection does not induce infertility.
Juvenile-onset RRP (JORRP) is a rare condition
that is associated with high morbidity and is
thought to be due to low-risk HPV types. The
risk for conveying RRP to progeny is low;
prevalence estimates range from 1 in 400 births
[Shah, 1986] and 0.36 (95% CI, 0.12–1.13) and
1.1 (95% CI, 0.58–2.13) per 100,000 resident
children aged !18 years [Armostrong et al, 1999;
Armostrong, 2000].
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48. To avoid exposure to the virus, delivery by
cesarean section has been proposed by some
[Shah, 1998], however, only a very limited cost-
benefit analysis has been performed, and the true
effectiveness of this procedure is
unknown [Bishai et al, 2000]. In addition, the
morbidity associated with cesarean section is
significant and, when conservative estimates
are used, the risks associated with cesarean
section are greater than the risk of rearing a child
with JORRP [van Ham, 1997; Armostrong et al,
1999; Armostrong, 2000].
Thus,cesarean section is not recommended for
prevention of JORRP (Wiley et al, 2002).
Aboubakr Elnashar

49. Counseling
• Genital HPV infection is very common.
Many types of HPV are passed on through
sexual contact: vaginal, anal or oral
• Most sexually active adults will get HPV at some
point in their lives, though most will never know it
because HPV infection usually has no signs or
symptoms.
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50. • In most cases, HPV infection clears
spontaneously, without causing any health
problems.
Nevertheless, some infections do progress to
genital warts, precancers, and cancers.
• The types of HPV that cause genital warts are
different from the types that can cause anogenital
cancers.
• Within an ongoing sexual relationship, both
partners are usually infected at the time one person
is diagnosed with HPV infection, even though signs
of infection might not be apparent.
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51. • A diagnosis of HPV in one sex partner is not
indicative of sexual infidelity in the other partner.
• Treatments are available for the conditions
caused by HPV (e.g., genital warts), but not for the
virus itself.
• HPV does not affect a woman’s fertility or ability to
carry a pregnancy to term.
• Correct and consistent male condom use might
lower the chances of giving or getting genital HPV,
but such use is not fully protective, because HPV
can infect areas that are not covered by a condom.
Aboubakr Elnashar

52. • Sexually active persons can lower their chances
of getting HPV by limiting their number of partners.
However, HPV is common and often goes
unrecognized; persons with only one lifetime sex
partner can have the infection.
For this reason, the only definitive method to avoid
giving and getting HPV infection and genital warts
is to abstain from sexual activity.
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53. • Tests for HPV are now available to help providers
screen for cervical cancer in certain women.
These tests are not useful for screening adolescent
females for cervical cancer, nor are they useful for
screening for other HPV-related cancers or genital
warts in men or women.
HPV tests should not be used to screen:
– men
– partners of women with HPV
– adolescent females or
– for health conditions other than cervical cancer.
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54. • HPV vaccines: 2 are available
Protection:
1. Against the HPV types that cause 70% of
cervical cancers (16 and 18)
2. Quadrivalent vaccine (Gardasil) also protects
against the types that cause 90% of genital warts (6
and 11).
Most effective when all doses are administered
before sexual contact.
Recommended for
1. 11- and 12-year-old girls
2. females aged 13–26 ys who did not receive or
complete the vaccine series when they were
younger.
3. males aged 9–26 years to prevent genital warts.Aboubakr Elnashar

55. •The Gardasil vaccine
which has been approved for use in males and females
aged 9–26 years, protects against the HPV types that
cause 90% of genital warts (types 6 and 11).
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56. • Genital warts are not life threatening.
If left untreated, genital warts might go away, stay the
same, or grow in size or number.
Except in very rare and unusual cases, genital warts will
not turn into cancer.
• It is difficult to determine how or when a person
became infected with HPV
Genital warts can be transmitted to others even when no
visible signs of warts are present, even after warts are
treated.
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57. • It is not known how long a person remains contagious
after warts are treated.
It is also unclear whether informing subsequent sex
partners about a past diagnosis of genital warts is
beneficial to the health of those partners.
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58. • Genital warts commonly recur after treatment,
especially in the first 3 months.
• Women should get regular Pap tests as recommended,
regardless of vaccination or genital wart history.
Women with genital warts do not need to get Pap tests
more often than recommended.
• HPV testing is unnecessary in sexual partners of
persons with genital warts.
• If one sex partner has genital warts, both sex partners
benefit from getting screened for other STDs.
Aboubakr Elnashar

59. • Persons with genital warts should inform current sex
partner(s) because the warts can be transmitted to other
partners.
In addition, they should refrain from sexual activity until
the warts are gone or removed.
• Correct and consistent male condom use can lower the
chances of giving or getting genital warts, but such use
is not fully protective because HPV can infect areas that
are not covered by a condom.
Aboubakr Elnashar

60. Thanks
Aboubakr Elnashar
Benha university Hospital, Egypt
Aboubakr Elnashar