Treating visible warts
The primary treatment goal is the removal of symptomatic lesions. Therapy may reduce but probably does not eradicate infection. In most patients, treatment can induce wart-free periods. If left untreated, warts may remain unchanged, increase in size and number, or resolve on their own. The following recommendations are based largely on the 2002 Centers for Disease Control STD Treatment Guidelines.9
Clinicians should have available and be knowledgeable about one provider-applied and one patient-applied treatment. Patients should be cautioned about the potential of hypo- and/or hyperpigmentation changes to the integument following therapy and the rare complications of depressed scarring and chronic pain syndromes. Avoiding the application of any therapy to nonhealed or ulcerated skin may decrease the likelihood of these complications.
The type of therapy used should be based on lesion size, number, site, and morphology. Other influences include patient preference, resources available, cost of treatment, adverse effects, and provider experience. There is no evidence that any one regimen is superior to another. Patients with less than 10 warts in an area 0.5-1.0 cm2 will usually respond to most treatments. Alternatively, observation may be all that is needed because of the uncertainty of transmission and possibility of spontaneous resolution.9
As a general rule, warts on dry skin surfaces do not respond as well to therapy as those on moist surfaces. If no improvement is noted after three provider treatments and resolution is not observed after six treatments, the modality should be changed. Many patients will require more than one application. Follow-up may be useful several weeks into therapy to determine appropriateness of medication and response.Recurrence is usually seen within the first three months, so a three-month follow-up may be offered.
In pregnant patients, lesions may proliferate and become friable. Some experts recommend removal of lesions during pregnancy because HPV types 6 and 11 have been implicated in the rare complication of respiratory papillomatosis. The preventive value of a cesarean section is unknown; this procedure is not recommended unless lesions obstruct the birth canal or excessive bleeding occurs. The warts may resolve spontaneously after delivery.9
In HPV patients with HIV or other immunodeficiencies, responses to therapy are often disappointing. There may be frequent recurrences after treatment. SCC is more likely to arise in or resemble warts, so biopsy confirmation may be necessary.9
In women with a history of genital warts, frequency of Pap smear screening does not have to change.9 However, SCC in situ and Pap smear abnormalities should be followed in conjunction with a specialist.
While some epidemiologic studies have demonstrated lower rates of HPV infection among condom users, most have not. The relationship between condom use and HPV infection is difficult to ascertain because of the transient nature of the virus (often intermittently detectable) and because it is difficult to tell how many detected infections are new or previously existing. Many available studies were not designed or conducted in ways that allow for accurate measurement of condom effectiveness against HPV infection.4,9
A number of studies, however, do show an association between condom use and a reduced risk of HPV-associated diseases, including genital warts, cervical dysplasia, and cervical cancer.13 The reason for lower rates of cervical cancer among condom users is unknown.
Although condom use has not been proven to prevent HPV infection, latex condoms may protect against the development of genital warts, as well as cervical dysplasia and cervical cancer.13 Since HPV is passed easily through skin-to-skin contact and the condom covers only the shaft of the penis, the true benefit of condoms is not known.4,8,9
More research is needed to assess the degree of protection latex condoms provide for both HPV infection and HPV-associated disease.
Primary prevention in the form of vaccines for genital HPV infection is under investigation. In a number of studies, inoculation of animals with HPV-like particles resulted in protective immunity against subsequent infection.14 In one promising pilot study, women were inoculated with an HPV-like particle vaccine. The results demonstrated a reduced incidence of HPV-16 infection and related cervical changes.15 Expansion of the vaccine to include HPV types 6, 11, and 18 is under way. Although the availability of these vaccines is years away, the results at this point are promising.