HPV Management

Spontaneous regression of genital warts can occur in up to 30% of affected patients. Regression, however, does not necessarily lead to viral clearance, as viral genomes can be detected in normal epithelium for months to years following clearing of visible disease. In immunocompetent women, however, the cell-mediated immunity that resulted in lesion regression most likely controls latent HPV infection. Disease recurrence is, therefore, less likely. Immunosuppression, on the other hand, does not confer the same protection. Women at increased risk of developing HPV-related manifestations include those receiving long-term corticosteroid therapy or chronic immunosuppressive treatment, as well as immunosuppressed women with HIV infection. Antiviral chemotherapies are particularly critical for these populations, if disease recurrences are to be minimized (Stanley, 2003).

The majority of currently available treatment options for genital warts, however, are not targeted antiviral therapies. The goal in general has been physical destruction or removal of visible disease, not eradication of HPV infection, as evidenced by the currently recommended treatment regimens for external genital warts. These include both patient-applied medications as well as provider-administered therapies.  Patient applied treatments include podofilox 0.5% solution or gel, imiquimod  5% cream, and sinecatechins 15% ointment. The newest of these treatments, sinecatechin ointment, is a green-tea extract with an active product (catechins). Provider-administered therapies include cryotherapy, podophyllin resin 10%-25%, trichloroacetic or bichloroacetic acid 80%-90%, surgical removal and laser therapy (CDC, 2010; see Table). Such therapies have been the mainstay of treatment. Local irritation (e.g., pain, burning and soreness), erythema, edema and, at times, ulceration can result from the use of any of the medications. Careless or excessive use can result in extensive burning of the epithelium, with resultant scar formation. Surgical excision or laser vaporization should be reserved for patients with extensive disease.

Alternative regimens include treatment options that might be associated with more side effects and/or less data on efficacy. These treatments are not recommended for first line therapy in treating either warts or vulvar intraepithelial neoplasia (VIN). These alternative regimens include intralesional interferon (Stanley, 2003), photo-dynamic therapy, and topical cidofovir (CDC STD Treatment Guidelines 2010).

Treatment Options and Recurrence Rates: External Genital Warts