Management of External Genital Warts



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Am Fam Physician. 2014 Sep 1;90(5):312-318.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.

  Patient information: See related handout on genital warts, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Genital warts affect 1% of the sexually active U.S. population and are commonly seen in primary care. Human papillomavirus types 6 and 11 are responsible for most genital warts. Warts vary from small, flat-topped papules to large, cauliflower-like lesions on the anogenital mucosa and surrounding skin. Diagnosis is clinical, but atypical lesions should be confirmed by histology. Treatments may be applied by patients, or by a clinician in the office. Patient-applied treatments include topical imiquimod, podofilox, and sinecatechins, whereas clinician-applied treatments include podophyllin, bichloroacetic acid, and trichloroacetic acid. Surgical treatments include excision, cryotherapy, and electrosurgery. The quadrivalent human papillomavirus vaccine is active against virus subtypes that cause genital warts in men and women. Additionally, male circumcision may be effective in decreasing the transmission of human immunodeficiency virus, human papillomavirus, and herpes simplex virus.

Genital warts are benign manifestations of human papillomavirus (HPV) that can cause discomfort and significant patient distress.1 Treatment options abound, and recurrence is common. Patient preferences, available resources, cost, and clinician experience should guide treatment selection.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Treatment of genital warts should be guided by patient preference, available resources, cost, and the experience of the physician.

C

2

Pregnant women should not be treated with podophyllin, and the safety of imiquimod (Aldara), sinecatechins (Veregen), and podofilox (Condylox) in pregnancy has not been established.

C

2

Administration of the quadrivalent human papillomavirus vaccine (Gardasil) in male and female adolescents prevents external genital warts.

A

40

Male circumcision may decrease the transmission of human immunodeficiency virus, human papillomavirus, and herpes simplex virus in heterosexuals.

A

25, 42, 43


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Treatment of genital warts should be guided by patient preference, available resources, cost, and the experience of the physician.

C

2

Pregnant women should not be treated with podophyllin, and the safety of imiquimod (Aldara), sinecatechins (Veregen), and podofilox (Condylox) in pregnancy has not been established.

C

2

Administration of the quadrivalent human papillomavirus vaccine (Gardasil) in male and female adolescents prevents external genital warts.

A

40

Male circumcision may decrease the transmission of human immunodeficiency virus, human papillomavirus, and herpes simplex virus in heterosexuals.

A

25, 42, 43


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Epidemiology

Genital warts are clinically present in 1% of the sexually active U.S. population, with an estimated lifetime risk of about 10%.3 Prevalence varies with age; the highest prevalence is in sexually active women 20 to 24 years of age and in men 25 to 29 years of age.3 A study of privately insured patients found an average cost of $436 over three office visits for treatment of an episode of genital warts.4

Clinical Presentation

Genital warts vary from small, flat-topped papules to large, cauliflower-like lesions on the anogenital mucosa and surrounding skin (Figures 1 through 3). Lesions range from barely visible and asymptomatic (Figure 4) to large plaques that can interfere with toileting and sexual intercourse (Figure 5). Large warts are not associated with a higher risk of malignancy.

Figure 1.

External genital warts at the coronal sulcus.

Copyright © Richard P. Usatine, MD

View Large


Figure 1.

External genital warts at the coronal sulcus.

Copyright © Richard P. Usatine, MD


Figure 1.

External genital warts at the coronal sulcus.

Copyright © Richard P. Usatine, MD

Figure 2.

Large external

The Authors

JONATHAN B. KARNES, MD, is a faculty member at Maine Dartmouth Family Medicine Residency in Augusta and assistant clinical professor of family and community medicine at the Geisel School of Medicine at Dartmouth College, Hanover, N.H. At the time the article was written, he was an assistant professor of family and community medicine at the University of Texas Health Science Center at San Antonio.

RICHARD P. USATINE, MD, is a professor of family and community medicine and a professor of dermatology at the University of Texas Health Science Center at San Antonio.

Address correspondence to Jonathan B. Karnes, MD, MDFMR Dermatology Services, 55 Middle St., Augusta, ME 04330 (e-mail: jonathan.karnes@mainegeneral.org). Reprints are not available from the authors.

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