Genital Warts - Selection of a Treatment Strategy
Frederick R. Jelovsek MD
It has been estimated that over 70% of sexually active women have evidence by DNA testing of having been exposed to the human papilloma virus, HPV, which is the cause of genital warts. The virus that causes these fleshy skin growths can lie dormant for many years and just cause vulvar, vaginal or cervical lesions when a women's immune system is suppressed. When lesions start forming, they can spread and recur quite quickly. The lesions are not harmful and they are primarily treated for cosmetic reasons. Since they can be so difficult to treat because of persistent and recurrent growth, the treatment strategy can be quite varied depending upon circumstances.
A recent article, Broekhuizen FF: Genital warts: A treatment strategy. OBG Management July 1999:25-32, offers some strategies for treating genital warts from an experienced physician.
Common Questions About Wart Treatment
If I get treated early as soon as I see some genital warts, will that prevent more warts from forming?
At the time of a first episode of genital warts, lesions can form very quickly and there is a high viral replication rate. Treatment is often unsuccessful during this phase so many doctors recommend waiting until the rate of growth and new occurrence slows down. This may take 2-6 weeks. Many women do not want to wait this long to begin treatment but there is good reason to wait because the treatment may be less effective for lasting relief. If the lesions are growing rapidly or spreading widely, treatment may need to be started immediately just because an extensive area of lesions may be too difficult to treat later if its area is not arrested at an early stage. Thus treating early is not really an advantage unless it is just to prevent an extensive area of lesions.
Do warts need to be biopsied?
Most of the time genital warts, condyloma accuminata, have a characteristic appearance and do not need to be biopsied to distinguish them from precancerous or cancerous lesions. However sometimes they are not so characteristic and biopsy is the only way to make sure the lesions are benign warts. When a woman is closer to menopause, say over 40 and certainly over age 50, doctors have heightened concerns about precancerous lesions such as vulvar dysplasia, so biopsy is recommended. Also, lesions that fail to respond to treatment after several courses of therapy should also be biopsied even in younger women.
What is the best treatment for genital warts?
Treatments for genital warts are usually based either on the principle of destroying the lesions or the principle of stimulating a woman's own immune system to keep lesions from forming and to breakdown lesions already present. Destructive forms of therapy include topical applications of trichloroacetic acid (TCA) or a podofilox gel. Lesions can also be frozen with cryotherapy or removed with a surgical or laser excision. Larger lesions (over 1 cm/0.5 inches) are best removed by excision. The immune stimulation, a 5% imiquimod cream (Aldara®), takes up to 4 months to clear lesions but is especially suited for a large area of lesions or ones that are difficult to identify.
Treatments of either injecting the lesions with 5-flurouracil (5-FU) or topical applications (Effudex®) cream are not used very much any more because the local side effects are much more common and annoying than other equally sucessful treatments.
What if the treatments do not get rid of the warts?
Agents that suppress the immune system should be evaluated to see if they can be altered. Smoking, alcohol abuse, HIV positivity, as well as steroid use and chronic antibiotics can be a factor. Any chronic illness or immunological illness may also delay clearing.
If topical treatments do not cure or significantly reduce the lesions in 3 or 4 applications or self-applied imiquimod cream used over 4 months, then surgical or laser therapy needs to be considered. Because a woman can have residual pain and scarring from damage of the subdermis from laser, cautery or surgery, these treatments should not be used unless there is first a failure to topical medical therapy.
Are the warts contagious? Do I need to use condoms to prevent spreading it?
Once the warty lesions start breaking out, both partners who have been having sexual relations have already been extensively exposed to the virus. Thus it is of no benefit to use condoms with your current sexual partner. Condoms should be used however with any future different sexual partner.
When a breakout of genital warts occurs, a woman cannot always assume that she contracted the virus from her current partner although that is the most likely event. The virus can have been dormant for many years. We occasionally see elderly widows who have not had sexual intercourse for many years have a breakout of genital warts on the vulva or even showing up on Pap smears. Once you have been exposed to the virus, it is harbored in your body forever. This is true of almost all viruses such as herpes (HSV), chickenpox (herpes zoster) and many others.
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