Recurrence of Warts with Different Treatments
Frederick R. Jelovsek MD
"I've been diagnosed with having HPV (genital warts). I've had them for over 2 years and since I've known I had them, I haven't had one day without them. No treatment seems to work. The cryosurgery works but as soon as they kill 5, 10 more pop up. What can I do? Is there any way to stop this? Is there something I can do to help?
I'm 20 years old and I'm on no meds. ". Sara
Genital warts are caused usually by HPV virus subtypes 6 and 11. We do not know entirely the life cycle of the virus but we know it can sometimes cause a warty growth on the skin while at other times it can lie dormant and inactive in skin cells for many years at a time. We do not know why the virus can be reactivated sometimes after many years either. The immune system of the body plays a major role in suppressing the virus from causing warts to grow or even ridding the body of warts if it is strong; if the immune system is weak, it seems to allow more warts and faster growth, and more recurrence of new warts after treatment.
With HPV genital lesions, it is very difficult to tell whether a new wart growth is a recurrence or whether it is due to new exposure and infection by a different subtype of HPV. Although subtypes 6 and 11 are the most common associated with genital warts, there are over 80 subtypes described and others can cause the same appearing lesion. HPV is predominantly transmitted by physical contact with the virus. It can be by touching with hands that have come in contact with the virus or sexual contact of genital or perianal skin or even pubic hair that has the virus. In either case, growth or first appearance of the lesions may not be very proximate to the physical skin contact.
If Left Untreated
What is the natural history of condyloma accuminata (genital warts) untreated?
In order to know how effective a treatment is at getting rid of the warts, we need to know how often the warts go away on their own without any treatment. We can learn that from the few studies that have be done in which patients did not receive any treatment for years and years. Also the studies which have been performed using a placebo control can indicate how often the lesions go away over the short term.
- In children followed for a long time with condyloma accuminata, over 50% regress by 5 years.
- In men who did not have treatment for genital warts, it took an average of about 15 months for 50% of them to have spontaneous regression of their lesions.
- In a placebo controlled trial of 16 weeks of condyloma treatment in women, only 11% of lesions cleared spontaneously.
How often do the warts recur after treatment?
Depending upon the treatment used, different recurrence rates have been noted. The most common treatment currently used is a self-applied, 5% imiquimod cream (Aldara®) that stimulates the immune system to fight off the virus and lesions. It seems to have a genital wart recurrence rate of about 13-19%.
Sometimes large condyloma are just cut off under local anesthesia with a knife or scissors. This seems to have a recurrence rate of about 21%. In a study using self-applied podofilox gel, the cure rate was low at only 51% but the recurrence rate was only about 10%. With respect to the cryotherapy you describe, the recurrence rate is quite high at the level of 73% without any supplemental treatment being given to the cryotherapy. Thus while you may have failed other treatments, the current cryotherapy treatment you are receiving seems to be the least efficacious.
What are the risk factors associated with recurrence?
Any disease or medication that suppresses the immune system will increase the risk of genital warts in someone who was previously exposed to the virus. Human immunodeficiency virus (HIV) a major immune suppressing disease but hepatitis, drug use and chemotherapy for other medical conditions can also suppress it.
One study looking at risk of recurrence found that having 5 or more sexual partners within the past 5 years not only was associated with an initial episode of genital warts, but also with recurrences after clearing. That same study also found that a history of previous sexually transmitted diseases, a history of oral herpes and a history of allergies were also associated with recurrences. Interestingly, in that study, smoking and oral contraceptive use were not associated with recurrences. Other studies, however, do find that smoking is a risk factor at least for the first occurrence and for progression of the size of the condyloma accuminata.
Minimize Recurrence Of Warts
What is the best way to minimize recurrence of warts?The best treatment results and lowest recurrence rates are associated with use of the imiquimod cream (5%) which stimulates your own immune system to suppress the HPV virus. Whether you have the warts frozen off (cryotherapy), or cut off with a laser, cautery or knife, I think that use of the self-applied imiquimod cream for 4 months in addition or by itself will be the best way to minimize the chance of the warts returning. Also, you should stick with one or no sexual partners and use condoms and avoid orogenital sex. This can decrease the viral load to the perineal area. Your partner should also be treated with Aldara® cream since there is a fairly high chance (67%) that he also has lesions.
If you are a smoker, this would be a good reason to stop. I would also say that any vulvar procedures such as piercing the labia should be avoided so that the virus is not introduced to the tract of the piercing. Use of a generalized immune system stimulant such as the herbal preparation of echinacea should not hurt this infection and possibly may help against the virus. Finally, be sure to have blood tests for HIV and hepatitis B and C if you are having constant recurrences of these genital warts in spite of treatment for over two years.
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Dr. Jelovsek, I'm confused. You wrote that the recurrence rate for Aldera alone is 13-19%, while the recurrence rate for cryotherapy alone is 73%. However, I found a controlled trial (1), that said, "No statistically significant difference was observed regarding the recurrence rate between the two groups (P = 0.138)." Furthermore, that study says, "Cryotherapy was more effective, as 86.7% of patients showed 100% improvement compared with 68.6% of patients in the imiquimod group. On the contrary, 17.1% of the imiquimod group did not show any signs of improvement, compared with 2.2% of the cryotherapy group (P = 0.017)." What do you make of this, and how do you reconcile it with your numbers? The reason I ask is that I have been treated with cryotherapy for about 6 sessions (with various doctors). My dermatologist strongly encouraged me to use Imiquimod cream (5%) instead, because he says it reduces the chance of scarring and sensation loss, compared to cryotherapy. However, I couldn\'t find any research to substantiate his claim. Do you agree with him? I find the cryotherapy much, much, much more tolerable than the Imiquimod (I've tried the latter for about a week, in total, thus far). The itchiness from the Imiquimod is horrible. However, if it reduces the chance of scarring and sensation loss, compared to cryotherapy, then I will continue trying it. Thanks, John (1) Stefanaki C, Katzouranis I, Lagogianni E, Hadjivassiliou M, Nicolaidou E, Panagiotopoulos A, Anyfantakis V, Bethimoutis G, Rallis E, Antoniou C, Katsambas A. Comparison of cryotherapy to imiquimod 5% in the treatment of anogenital warts. Int J STD AIDS. 2008 Jul;19(7):441-4. PubMed PMID: 18574113.