I’ve got genital warts, what are my treatment options?

gential warts no woman

Given how common they are, it is highly likely you have heard about genital warts, or perhaps you’ve even had them. They are small single or multiple bumps or growths on the skin. They occur in the genital and/or anal area, which includes the vulva, perineum, anal area, vagina, cervix, and urethra. Genital warts are caused by the Human Papilloma Virus (HPV) and it is the most common sexually transmitted viral infection in the world.1 Incidence is highest between the ages of 15-29 and the prevalence of genital warts is thought to be around 4%.2 However, the prevalence of HPV infection is much higher (around 50-80%) as most people are asymptomatic.3 So, you might have HPV but have no signs or symptoms, and normally this isn’t a problem as the body can fight off the infection by itself over time.

Certain HPV types are known to cause cancer however. Once HPV infects the skin, it can lead to a whole range of diseases of different severity depending on the strain of virus. HPV 6 and 11 cause benign genital warts, whereas HPV 16,18,31,35 and 45 are linked to anogenital cancers. This is why it is important to go for your cervical smear test, as this can pick up changes to the cells in the cervix before they develop into cancer.

HPV causing genital warts infects the cells of the skin that are exposed during sexual intercourse. Transmission can occur with just close contact as well sexual intercourse. Once the virus infects skin cells, it proliferates and results in the multiplication of certain skin cells leading to the formation of warts. The immune system has the ability to clear the virus in most people. However, the virus is slow to clear and is clever at evading our immune system which is why genital wart episodes can recur more than once in some people after the first infection. This is particularly so in those who have an impaired immune system.

Risk factors for contracting HPV include sexual activity from an early age, high number of sexual partners, unprotected intercourse, smoking, and immunosuppression. The median time between being infected with HPV type 6 or 11 and the occurrence of a genital wart episode is approximately 5-6 months, but it can occur as early as 3 weeks after being infected with HPV.4

Approximately one-third of genital warts will resolve spontaneously within the first four months of infection.5 The duration of each episode differs according to each individual. Unfortunately, the majority of genital warts will recur within three months of infection. Long-term persistence of warts is mainly due to an impaired immune system. Other factors include being of older age and being infected with high risk subtypes of HPV – 16 and 18 – which are also the viruses implicated in cervical cancer.6 Genital warts can recur on and off over a period of years even if you don’t have impaired immune system or a high risk sub-type of HPV. There will be people who cannot clear the virus for no apparent reason.

Management of genital warts

The diagnosis of warts usually requires a trained health professional, either a doctor or nurse, to look at them. You can either attend your GP practice or a sexual health clinic for an examination and treatment prescription. Treatment will only be given if warts are visible, and the medications suitable for genital warts are prescription only. You should see your doctor if the episode recurs as it could either be an old infection that has returned or a new infection.

There is no evidence that home remedies including tea tree oil, green tea, garlic, and apple cider vinegar are effective at getting rid of warts.7 Although warts may appear to get smaller, they cannot eradicate warts or the virus. It is important to note that putting these home remedies on delicate areas such as the vulva can cause irritation. They should not be placed inside the vagina.

Treatment options are directed at removing warts rather than clearing HPV. The treatments used however are not completely effective at eradicating warts long term. There is no one therapy that is gold standard and so treatment is dependent on factors such as the severity of the episode, patient background (immunosuppressed or pregnant), or if is a recurrence. The treatments available are detailed below.

Podophyllotoxin

Podophyllotoxin, often sold under the brand name Warticon, is an extract of the podophyllum plant which prevents the multiplication of cells that form warts. It also destroys the existing cells. The effect of this treatment can usually seen within a few days. It comes in a solution, gel, or cream form which can be self-administered. The cream or gel is more appropriate for vaginal or anal lesions. Clearance rates when using this treatment ranges between 45-77% and the recurrence rate is around 38%.8

Imiquimod cream

Imiquimod, often sold under the brand name Aldara, is thought to work by activating immune cells to try and clear the wart. The cream can be self-administered and clearance has been achieved in up to 56% of patients, with more of an effect seen in women. The median time for clearance is approximately eight weeks.9

Trichloroacetic acid

Trichloroacetic acid is a strong acid that essentially burns the wart away. It cannot be self-administered and requires a health professional to apply it onto the skin. The initial burning sensation once applied usually lasts for 5-10 minutes. Clearance rates are approximately 70-80% but with recurrence rates of 36%. Clearing of lesions can take between 2-5 months.10

Cryotherapy

Cryotherapy is essentially the freezing of skin tissue using agents such as nitrogen or nitrous oxide. It has to be carried out by a doctor who will administer the nitrogen from a canister. The freezing temperature causes damage to the skin cells and blood supply to the wart, and can result in a slight burning or stinging sensation while it is being administered. Clearance rates of 79-88% have been seen after the first three treatments with a recurrence rate between 25-40%.11 After the treatment the skin can take between 1-3 weeks to heal.12

Electrosurgery

Electrosurgery involves a metal probe being placed on the wart. An electric current passes through and burns the wart which can then be scraped off by a doctor. It is usually used for small warts rather than larger ones due to the risk of scarring. Clearance rates are as high as 94% at six weeks after treatment.13 It is comparable to cryotherapy in terms of long-term outcomes. As it can be quite painful, local anaesthetic is required and it usually takes 1-3 weeks for the area to heal.14

Laser therapy

Laser therapy uses carbon dioxide and infrared energy to vaporize wart tissue. Local anaesthetic is usually required. It is thought to be less effective in terms of treatment as clearance rates are slightly lower at 23-52%. Recurrence rates are also higher at 77%. It is usually a preferred method of treatment for immunosuppressed or pregnant patients who have not responded to cryotherapy or trichloroacetic acid.15

Surgical excision

This involves removal of the wart with a scalpel and local anaesthetic. This is rarely done today and is only really suitable for very large warts or if there is any suspicion that a wart may be cancerous. Remember, the HPV types linked to genital warts are not cancerous. However as with any wart, it does have the potential to become cancerous (very rarely).

Usually, sexual intercourse should be avoided until the warts have cleared. This is to allow the warts to heal. Condoms can help prevent viral spread during the episode but they should also be used for up to three months even after the warts have gone as the virus can still be transmitted.

It is important to comply with treatment, especially those treatments that require self-administration. If the warts have cleared up with the prescribed treatment, it is not necessary to see your doctor again. However, if you feel that the treatment is not working, then please do pay a visit.

References

  1. H. Patel et al., ‘Systematic review of the incidence and prevalence of genital warts’, BMC Infectious Diseases, vol. 13, no.39, 2013.
  2. K. A. Fenton et al., ‘Sexual behaviour in Britain: reported sexually transmitted infections and prevalent genital chlamydia trachomatis infection’, Lancet, vol. 358, no. 9296, 2001, pp.1851-1854.
  3. H. Cubie, ‘Diseases associated with human papillomavirus infection’, Virology, vol. 445, no.1-2, 2013, pp. 21-34.
  4. H. Patel et al., ‘Systematic review of the incidence and prevalence of genital warts’, 2013.
  5. V. Yanofsky et al., ‘Genital Warts: A comprehensive review’, Journal of clinical and aesthetic dermatology, vol. 5, no. 6, 2012, pp. 25-36.
  6. Ibid.
  7. Family Planning Association, ‘Genital Warts’, Help and Advice, [website], http://www.fpa.org.uk/sexually-transmitted-infections-stis-help/genital-warts, (Accessed 18 August 2017).
  8. V. Yanofsky et al., ‘Genital Warts: A comprehensive review’, 2012, pp. 25-36.
  9. Ibid.
  10. Ibid.
  11. Ibid.
  12. Family Planning Association, ‘Genital Warts’, Help and Advice, [website].
  13. V. Yanofsky et al., ‘Genital Warts: A comprehensive review’, 2012, pp. 25-36.
  14. Family Planning Association, ‘Genital Warts’, Help and Advice, [website].
  15. V. Yanofsky et al., ‘Genital Warts: A comprehensive review’, 2012, pp. 25-36.

Dr Shreya Patel MBBS MSc BSc DFSRH

Shreya is a London-based doctor specialising in Obstetrics and Gynaecology. Her passion in global and public health, family planning, and reproductive rights led her to pursue a masters in Public Health at Harvard. She is a strong believer that women should have easily accessible, accurate information about their health, to enable them to make decisions about their health that are right for them.

View more