Cryosurgery
Cryotherapy can be used to treat condyloma of the vulva. It can be performed with either a nitrous oxide (N₂O) unit fitted with a suitable probe, with cotton-tipped applicators submerged in liquid nitrogen, or with a commercial liquid nitrogen spray.

The mechanism of action of these methods is cell lysis by rapid change in temperature across cell margins.

Electrosurgery
Once the most popular methods of treating genital warts, electrosurgery almost disappeared from use after laser vaporization became popular.  In contrast to laser, the equipment required for electrosurgery is relatively inexpensive. There is reduced ability to control depth of burn when compared with laser ablative therapy.

Laser Ablation
During the 1980s, laser was the mainstay for treatment of external genital warts and intraepithelial lesions throughout the lower genital tract.

It is best for the treatment of multiple or large external lesions.

Topical acids
Trichloroacetic acid (TCA)
Bichloroacetic acid (BCA)

Inexpensive, useful, and popular agents for treating vulvar, peri-anal, and penile warts, as well as vaginal, intra-anal, and urethral meatal warts. The solution can be prepared in concentrations of between 50-85% in 70% alcohol. The 85% solution is usually well tolerated and most effective.

The treatment may need to be repeated in 1 to 2 weeks. Before the application, consider treatment with 5% lidocaine/prilocaine (EMLA) cream, ELAMAX cream or 20% benzocaine to make sure they will tolerate the therapy. Shallow ulcers may occur after the wart sloughs off, and usually heals within a matter of one to three weeks. These agents are safely used in pregnancy.

Podophyllin
Podophyllin was once a popular agent, but inconsistent results and variable toxicity due to non-standardized production techniques and instability of the product has greatly reduced its use.

The patient should be instructed to wash the treated area four to six hours after treatment (or sooner if significant discomfort occurs).

Podophyllin should not be used in the vagina, in the urethra, or on the cervix, nor during pregnancy.

Podophyllotoxin
Podophyllotoxin is a purified lignan (1% podophyllotoxin, Condylox) derived from the same plant root (Podophyllum peltatum and P. emodi, or May apple) as podophyllin. Mechanism of action includes anti-mitosis, inhibition of nucleoside transport, damage to vessels within the wart, and stimulation of macrophage proliferation and production of interleukin-1 and 2.

The medication is supplied as a 0.5% solution and a 0.15% cream.

Both are applied twice a day for three days, followed by four treatment-free days for treatment duration of four weeks. If partial response is obtained, a repeat of the 4-week cycle for a maximum of 8 weeks may be given.

50% in 12-week follow-up. In local follow-up, some recurrence rates were even higher. Podophyllin was once a popular agent, but inconsistent results and variable toxicity due to non-standardized production techniques and instability of the product has greatly reduced its use.

The patient should be instructed to wash the treated area four to six hours after treatment (or sooner if significant discomfort occurs).

Podophyllin should not be used in the vagina, in the urethra, or on the cervix, nor during pregnancy.

5-Fluorouracil
5-Fluorouracil (5-FU) cream (Efudex) has been used particularly for the treatment of vaginal lesions. It is available in 20 g tubes of 3 and 5% concentration.  5-FU is a DNA antimetabolite.

No standard treatment guidelines have ever been adopted for 5-FU use in the mucosal areas of the lower genital tract, and its use in these areas has always been “off-label”. It has been associated with severe vaginal scarring.

Interferon
When used intramuscularly:  Interferon 2B -1 million units IM twice a week for 2 weeks, then 3 times a week for 6 weeks.

Fever, muscle aches, and other generalized "flu-like" symptoms are common and are dose-related.

Check EKG if the patient has cardiac disease prior to starting this medication. Check CBC, plts and differential prior to starting treatment, then weekly for the first 3 to 4 weeks, then every 2-4 weeks.  Check LFTs prior to starting, then q 3 to 4 weeks, unless clinically indicated to monitor more frequently. 

Imiquimod (Aldara)
Imiquimod 5% cream is applied by the patient three days of each week, such as Monday, Wednesday, and Friday. It needs to be rubbed in well. It should be left on the skin for 6-10 hours (place at bedtime), then washed off well with soap and water using a wash cloth. The medicine is supplied in boxes of 12 sachets, with each sachet intended for single use. However, the cream does not degenerate once opened, and cream remaining in a sachet can be applied on subsequent treatment days, significantly increasing the cost-effectiveness of this treatment modality. Clearing can occur as early as several weeks and averages eight to 10 weeks. Erythema, excoriation, flaking, and edema can develop, prompting a “rest period” of a few days until the symptoms abate.

This drug is not recommended for an area larger than 20 cm (2).

Surgery
Surgical treatments include electrosurgery and scissor excision. One valuable surgical method is to use a fine tip bovie to debulk extensive condyloma prior to lasering.

Treatment of genital warts must include education and emotional support to lessen the psychological impact of having a sexually transmitted disease (STD).

There may be no single “best” treatment, and in many patients a combination may be appropriate, depending on site, extent of disease, response, patient choice, and other factors.