Cryosurgery, electrosurgery, laser ablation, topical acids, retinoin, interferon, and conservative surgical excision have been used successfully. Laser vaporization is precise and effective therapy that causes little scarring. Topical therapy with immunomodulators may be effective if surface keratin is minimal. Risk assessment including age and immune status is also an important part of planning therapy. Other modalities used include Efudex, Condylox, Aldara®, and Podophyllin.

Treatment Options and Recurrence Rates: External Genital Warts

AGENT	ACTION	COST	HEALING	SCAR	CLEARANCE RATES	RECURRENCE
Cryosurgery more info	Surgical	Low	4 days-4 wks	Little	68% -90%	38%
Electrosurgery more info	Surgical	Low	2-6 wks	Possible
Laser Ablation more info	Surgical	High	2-4 wks	Little	27-82%	7-72%
Topical acids more info	Chemical/ Cytotoxic	Low	1-2 wks	Little	70-81%	NA
Podophyllin more info	Chemical/ Cytotoxic	Low	1-2 wks	Little	32-79%	27-65%
Pododphyllotoxin more info	Chemical/ Cytotoxic	Low	1-2 wks	Little	45-88%	31-60%
5-Fluorouracil more info	Chemical/ Cytotoxic				30%-50%
Interferon more info	Immuno- therapy	High	None	None	Intralesional 32-60% Systemic 17-21%	65-67% Not reported
Imiquimod (Aldara®) more info	Immuno- therapy	Low	2-3 wks	Rarely	72-84% (female)	5-19% (female)
Surgery more info	Surgical Excision (see also laser ablation)

***Post Laser Instructions

Apply ice for the first 12-24 hours. The ice should not be left in place throughout the entire 12-24 hour time period; instead it should be applied at 15-20 minute intervals with 1-2 hours between applications of ice packs.   Cool gel packs may be used instead of ice.

Take a sitz bath three times per day with warm water and instant ocean, sea salt or Epsom salts. The duration of the bath should be approximately 15-20 minutes per bath and not to exceed three baths per day. Two tablespoons of the salt solution should be placed in a bathtub that is half full.

Dry the area well thereafter with a hair drier set on low or pat the vulva dry with a soft cloth.

Apply Silvadene cream (not to be used if you have sulfa allergies), Carrington's gel, or Bacitracin afterwards.

Cleanse the area with salt-water solution after each void or bowel movement, if soiled. The salt-water solution to be used is 9% sodium chloride solution that is available at pharmacies or can be made by adding 1 tablespoon of salt to 1 quart of water, boiling the solution and cooling it prior to application.

For symptomatic relief, use warm teabags or lightly apply witch hazel in between the sitz baths. Tea tree oil and vitamin E applied to the skin also offer soothing relief.

Leave the vulva uncovered at night (no underwear) to allow adequate exposure to the air.

You will be given oral pain medication. At times, this can cause constipation; therefore, a stool softener may be needed. There are two over-the-counter stool softeners that are recommended, (Surfak and Colace).

Within 12-24 hours after laser surgery, redness and swelling on the vulva may occur. The worst pain may occur 2-5 days following the surgery. As the skin heals, it will begin to itch at times. Complete healing of the treated vulvar skin generally occurs within 4-6 weeks.

Small amounts of bleeding may occur. If you start soaking a pad with blood in an hour or two hours, you need to contact your health care provider. Also, if you develop extreme redness around the lasered area or a foul discharge or fever, please your health care provider.

At times, if laser is performed at the vaginal opening, skin friability may result and tearing may occur. Notify your health care provider if this occurs. Additionally, if the labia minora (small lips of the vulva) are lasered, they also can scar together and change the size of the vaginal opening. If these areas were lasered, separate them with gentle traction daily to keep them from attaching to each other.  Vaginal dilation may be required.  Avoid intercourse until the region is  healed and comfortable.

Long-Term Follow-Up Care and Prevention

Self-examination supplemented by periodic exams by health care providers are recommended to assess for recurrence of HPV disease on external areas.

If a patient does not respond to a given product by the fourth week, you should switch to another form of therapy and consider a biopsy to rule out other diseases.

Comparison of FDA-approved products for treatment of external genital warts

Product	Packaging	Dosing regimen	Mechanism of action	Treatment limitations by labeling	Margin of safety	Pregnancy category	Relative cost*
Imiquimod (Aldara®)	5% topical cream in 0.25-g sachets’ 12 sachets/box	tiw at night for < 16 weeks self-applied	Cytokine induction; immune response modifier	< 20 cm2	Wide	C	$-$$
Podofilox (Condylox™)	0.5% solution 3.5-mL vials; 0.5% gel in 3.5-g tubes	bid X 3 days consecutively, rest X 4 days	Antimitotic, locally inflammatory	< 10 cm2 and < 0.5 g/day	Wide	C	$-$$
Interferon-a: Leukocyte- Derived (Alferon-N™)	5 MIU/1.0 mL vial for injection	0.05 mL/wart intralesionally biw X < 8 weeks	Nonspecific antiviral Immuno-stimulatory (?)	< 5 MIU or < 20 warts	Moderate	C	$$$$
Recombinant (Intron-A™)	1.0 MIU/0.1 mL 0.5 or 1.0 mL vials for injection	0.1 mL/wart Intralesionally tiw X <3 weeks	Nonspecific antiviral Immuno-stimulatory (?)	< 5 MIU or < 5 warts	Moderate	C	$$$$

*"Relative cost" includes estimates of cost of office visits, cost of drug, primary efficacy, recurrence rates following complete clearance, and need for additional treatment with failure.

REFERENCES

1. Aynaud O, Buffet M, Roman P, Plantier F, Dupin N. Study of persistence and recurrence rates in 106 patients with condyloma and intraepithelial neoplasia after CO2 laser treatment.  European Journal of Dermatology. 2008;18(2):153-8.
2. Barr E, Sings HL. Prophylactic HPV vaccines: new interventions for cancer control. Vaccine. 2008;26(49):6244-57.
3. Cook K, Brownell I. Treatments for genital warts. Journal of Drugs in Dermatology: JDD. 2008;7(8):801-7.
4. Cox JT, Petry KU, Rylander E, Roy M. Using imiquimod for genital warts in female patients. Journal of Women's Health. 2004;13(3):265-71.
5. Einarson A, Costei A, Kalra S, Rouleau M, Koren G. The use of topical 5% imiquimod during pregnancy: a case series. Reproductive Toxicology. 2006;21(1):1-2.
6. Garland SM, Steben M, Sings HL, James M, Lu S, Railkar R, Barr E, Haupt RM, Joura EA.   Natural history of genital warts: analysis of the placebo arm of 2 randomized phase III trials of a quadrivalent human papillomavirus (types 6, 11, 16, and 18) vaccine.  Journal of Infectious Diseases. 2009;199(6):805-14.
7. Haidopoulos D, Diakomanolis E, Rodolakis A, Vlachos G, Elsheikh A, Michalas S. Safety and efficacy of locally applied imiquimod cream 5% for the treatment of condylomata acuminata of the vulva. Archives of Gynecology & Obstetrics.2004; 270(4):240-3.
8. Harper DM, Franco EL, Wheeler CM, Moscicki AB, Romanowski B, Roteli-Martins CM, Jenkins D, Schuind A, Costa Clemens SA, Dubin G. HPV Vaccine Study group. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised control trial. Lancet. 2006;367(9518):1247-55.
9. Kennedy CM, Boardman LA. New approaches to external genital warts and vulvar intraepithelial neoplasia. Clinical Obstetrics & Gynecology. 2008;51(3):518-26.
10. Kuehn BM. CDC panel backs routine HPV vaccination. JAMA. 2006;296(6):640-1.
11. Mayeaux EJ Jr, Dunton C. Modern management of external genital warts. Journal of Lower Genital Tract Disease. 2008;12(3):185-92.
12. Maw RD. Treatment of external genital warts with 5% imiquimod cream during pregnancy: a case report. BJOG: an International Journal of Obstetrics & Gynaecology. 2004;111(12):1475.
13. Scheinfeld N, Lehman DS. An evidence-based review of medical and surgical treatments of genital warts. Dermatology Online Journal. 2006;12(3):5.
14. Taner ZM, Taskiran C, Onan AM, Gursoy R, Himmetoglu O.   Therapeutic value of trichloroacetic acid in the treatment of isolated genital warts on the external female genitalia.   Journal of Reproductive Medicine. 2007;52(6):521-5.

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