Warts and HPV infection

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Genital infection with Human Papillomavirus virus (HPV) can result in anal or genital warts. Ninety percent of these are caused by HPV 6 and 11, and most HPV infection is asymptomatic.

PREVENTION


The quadrivalent vaccine (Gardasil) provides excellent
protection against HPV 6 and 11, but needs to be given prior to commencement of sexual activity to be most effective

Condoms offer some protection against HPV infection, but this is limited as infection is usually multi-focal
and often involves skin not covered by condoms.

DIAGNOSIS 

Diagnosis is usually clinical on visual Inspection. However, biopsy should be considered for

  • Atypical looking warts
  • Warts not responding to standard treatment
  • For all cervical warts to exclude HGSIL
TREATMENT 

Asymptomatic infection, as seen on pap smears, cannot be treated. However 80% of HPV infections resolve within 12 months.


Genital warts
See Wart Treatment video on MSHC website:

 

Options:

  • No treatment
  • Patient applied
      - Podophyllotoxin
      - Imiquimod
  • Clinicial applied
      - Cryotherapy
      - TCA
      - Surgery

Choice of treatment depends on:

  • Number, size, and degree of keratinization of the warts
  • Area affected
  • Patient preference
  • Pregnancy status

Treatment is to ameliorate symptoms and is not curative. No treatment is an option as the natural history of
HPV infection is to resolve in 12-24 months. This may particularly be an option during pregnancy; genital warts often proliferate at this time but regress markedly postpartum. See MSHC treatment guideline on warts in pregancy.

However, most patients request treatment.

In general, warts which are soft, mucosal, vulval or perianal, or are on or under the prepuce respond well to topical agents such as imiquimod and podophyllotoxin.

Keratinized warts, or those which are long-standing, usually need ablative therapy such as cryotherapy.

Patient applied 

Podophyllotoxin

0.5% solution (Condyline paint)
0.15 % cream (Wartec cream)
self-applied twice daily for 3 consecutive days then nothing for 4 days. Use for 4 weeks, then review. Warn patients regarding potential local irritation.

Precautions:

  • Contraindicated in pregnancy
  • Do not use on vaginal or cervical warts. 
  • Take care when treating anal warts because solution can be difficult to apply accurately. Consider partner-applied application or use podophyllotoxin cream instead
  • Do not use on areas of skin affected by dermatitis

Imiquimod

Imiquimod 5% cream self-applied 1/3 to 1 sachet 3 times a week for 4 – 16 weeks

Always give patients an instruction sheet and warn regarding potential local irritation.
Review every 4 weeks.

  • Do not use imiquimod:
  • In pregnancy (Category B) or for lactating women
  • In patients under 18 (no studies done)
  • In patients with co-existing dermatitis
  • For vaginal or cervical warts, and intra-anal warts at the dentate line. Warts involving the squamous epithelium of the distal anal canal can be treated with imiquimod. 

Generic 5% Imiquimod cream has recently become available, making this treatment very competitive in price now.

Cryotherapy

  • Liquid nitrogen cryospray
  • Cryoprobe

Cryotherapy is well tolerated and unlikely to result in scarring. The only contraindication is cryoglobulinaemia.

Few patients need local anaesthesia, although the application of 2% or 5% xylocaine jelly before using the cryoprobe may help diminish discomfort.

  • Tricloroacetic acid (TCA) 85%. Clinician applied to warts, (mainly used in pregnancy)

A small amount of TCA is applied to the wart, and after this a small amount of 5 % xylocaine gel is applied. The patient then is advised to wash the area with saline solution and keep the area dry. This treatment can be repeat weekly.


Combined therapies
Combined therapies may be used e.g., use imiquimod tode-bulk a large area of warts prior to cryotherapy, or vice versa


Surgery
Surgical removal of warts by laser, diathermy or excision under general anaesthesia may be considered for especially large warts where other treatments have failed or are not tolerated. However surgery will not remove HPV which can result in recurrent warts after surgery.

COMPLICATIONS

Long term complications are very rare and include

  • hypo or hyper pigmentation
  • Vulvodynia after surgery for extensive warts

Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.

Last Updated October 2014