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Genital Warts: Rapid Evidence Review

Richard W. Temple, MD
Jackeline C. L. Larker, DO, MS
Janelle M. Brus, DO

American Family Physician. 2025;111(2):156-162.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Genital warts (also referred to as anogenital warts and condyloma acuminatum) are caused by human papillomavirus types 6 and 11 in 90% of cases. They are transmitted primarily through anogenital contact and penetrative and non-penetrative sex. Transmission can be effectively prevented with vaccination. Current evidence regarding the effects of condom use on the prevalence of genital warts is conflicting. In the United States from 2013–2016, the prevalence of genital warts among individuals ages 18 to 59 years was 1.3% in men and 3.1% in women. The diagnosis is made clinically by the appearance of single or multiple lesions that may coalesce or be the same color as surrounding skin, cauliflower-like, flat, papular, or keratotic. Biopsy is indicated in some cases, such as for atypical lesions. Treatment may be patient- or physician-administered, with choice of treatment informed by shared decision-making. Treatment options may be limited by physician skills and clinic availability. Podofilox 0.5% solution is the most effective patient-administered therapy and carbon dioxide laser therapy, surgery, and electrosurgery are the most effective for wart removal at the end of treatment. All treatment strategies are associated with some recurrence, but most successfully treated warts do not recur. Use of podofilox, imiquimod, and sinecatechins should be avoided in pregnancy.

In the United States from 2013–2016, the prevalence of genital warts among individuals ages 18 to 59 years was 1.3% in men and 3.1% in women.1 Among the commercially insured US population, an estimated $127 million was spent on treatment of genital warts in 2019, for an average cost of $431 per patient.2 This article summarizes the best available evidence on the prevention, diagnosis, and treatment of genital warts.

WHAT'S NEW ON THIS TOPIC

Genital Warts
From 1999–2016, the prevalence of genital warts in US adults ages 18 to 59 years decreased from 4% to 1.4% in men and from 7.2% to 3.1% in women.
A meta-analysis that included data from 14 high-income countries showed that after 5 to 8 years of human papillomavirus vaccination programs, genital wart diagnoses decreased by 67%, 54%, and 31% among females ages 15 to 19 years, 20 to 24 years, and 25 to 29 years, respectively.
A systematic review and meta-analysis showed that male circumcision had no effect on rates of genital warts in males.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments
Routine HPV vaccination is recommended for all patients ages 11 to 12 years. Vaccination can be started at age 9 years. Catch-up vaccination is recommended for all patients through age 26 years.15,16 ASystematic reviews and meta-analyses with patient-oriented outcomes
Use of shared decision-making is recommended for patients ages 27 to 45 years who may benefit from vaccination based on individual risk factors for acquiring new HPV infection.16 CExpert consensus guidelines
HPV vaccination is recommended for clinicians with routine occupational exposure to HPV.17 CExpert consensus guidelines
Diagnosis of genital warts is based on clinical assessment. Biopsy is indicated in cases of uncertain diagnosis, lack of response to standard therapy, worsening of the condition during therapy, or presence of atypical lesions (eg, pigmented, indurated, affixed to underlying tissue, bleeding, ulcerated).33 CExpert consensus guidelines
When performing smoke-generating procedures on HPV-related lesions, physicians and staff should consider surgical smoke to be potentially infectious. Smoke vacuum, room ventilation, and full personal protective equipment, including N95-grade masks, should be used.38 CExpert consensus guidelines
Podofilox, imiquimod, and sinecatechins (Veregen) should not be used in pregnancy.5 CExpert consensus guidelines
Podofilox 0.5% solution is the most effective patient-administered treatment for genital warts.39–41 ASystematic reviews and meta-analyses with patient-oriented outcomes

HPV = human papillomavirus.

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 https://www.aafp.org/afpsort.

RICHARD W. TEMPLE, MD, is a clinical associate professor in the Departments of Family Medicine and Obstetrics and Gynecology at East Carolina University Brody School of Medicine, Greenville, North Carolina.

JACKELINE C. L. LARKER, DO, MS, is an obstetrician-gynecologist at WakeMed in Raleigh, North Carolina. At the time the article was written, she was a resident physician in the Department of Obstetrics and Gynecology at East Carolina University Health Medical Center, Greenville.

JANELLE M. BRUS, DO, is a resident physician in the Department of Family Medicine at East Carolina University Health Medical Center.

Address correspondence to Richard W. Temple, MD, at templer23@ecu.edu.

Author disclosure: No relevant financial relationships.

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