CHAPTER 19
External Genital Condyloma
Alex Ferenczy
KEY POINTS
The lifetime risk of developing external genital warts (EGWs)
is 10%.
The vast majority of EGWs as well as recurrent respiratory
papillomatoses are caused by human papillomavirus (HPV)
types 6 and 11.
Although most EGWs are sexually transmitted, those affecting
the upper respiratory tract in children are acquired while passing
through the birth canal of mothers with EGWs.
When EGWs present atypically or are resistant to therapy,
biopsy is indicated to rule out precancer/cancer or condylomata
mimics.
There are no evidence-based data to suggest that a given type
of therapy for EGWs is superior to another.
Therapy should be based on a mutual decision between
the healthcare provider and the patient following an informed
consent.
Both provider-administered and patient-administered
therapies can be used as either first-line or second-line therapies,
depending on the patients preference, providers experience,
and number and location of EGWs.
In general, multiple therapeutic sessions with a single form or
multiple forms of therapy are required to achieve complete
clearance of EGWs.
In new relationships or in couples who are not monogamous,
constant and correct use of latex condoms will reduce but not
eliminate the risk of HPV transmission and the development
of EGWs.
Mass and universal prophylactic HPV vaccination
programs with HPV types 6/11containing vaccines are
likely to significantly reduce the burden of disease in at-risk
populations.
EPIDEMIOLOGY
Most studies on prevalence and incidence of external genital
warts (EGWs) have been conducted in selected populations
such as women attending colposcopy clinics or those
attending university sexually transmitted infection (STI)
clinics. Until recently, the general population has not been
extensively studied. Earlier estimates showed approxi-
mately 1% of sexually active populations in the United
States have EGWs.1 The prevalence of EGWs in university
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students was 1.5%, whereas in a health maintenance
organization in Washington State, it was 0.8% in women
aged 21 to 29 years and 0.6% in those aged 30 to 39 years.
Understandably, in those who attend STI clinics, the
prevalence of EGWs is the highest, ranging from 4%
to 13%, with both men and women having similar rates.
In four Nordic countriesDenmark, Iceland, Norway,
and Swedena random sample of 70,000 women
between the ages of 18 and 45 years who completed self-
administered questionnaires found a 10.6% lifetime
prevalence of EGWs.2 The history of EGWs correlated with
the number of sexual partners, STIs, use of oral contra-
ceptives, and use of condoms, as well as smoking and
level of education.
The cumulative incidence of EGWs in a cohort of 898
Norwegian females aged 16 to 24 years was 10.7% at 48
months of follow-up.3 Approximately 22% of women with
HPV types 6 or 11 developed EGWs. Among those with
HPV types 6 or 11 and 16 or 18, 29% developed EGWs
within 4 years of follow-up. The relative risk for developing
EGWs has been estimated to be five times higher in HPV-
positive versus HPV-negative women.
TRANSMISSION/ACQUISITION
The vast majority of HPV infections, including EGWs, are
sexually transmitted either via intercourse or, less fre-
quently, through genital skin-to-skin contact without pene-
trative sex.4 This explains why self-declared virgins may still
be found with EGWs. In addition, such individuals test HPV
negative in their vaginal and cervical samples, supporting
the concept of direct skin-to-skin contact for HPV transmis-
sion and acquisition. In one of the rare prospective studies
carried out in the 1950s, 60% of women whose male part-
ners returned from the Korean War with EGWs developed
genital warts.5 In the Oriel et al. study, periods of incuba-
tion of EGWs ranged from 3 weeks to 18 months with an
average of 3 months, whereas most lesions in children
develop between 1 and 20 months.6 In rare instances, auto-
inoculation from one site to another or heteroinoculation
may be the mechanism of transmission. For example, in
381
 Colposcopy, Principles and Practice
heterosexual individuals with perianal condylomata,
approximately one half to two thirds of intra-anal lesions
are believed to be the result of HPV transferred
by anodigital insertions rather than receptive intercourse.7
Oral and laryngeal warts may rarely occur in adults
practicing frequent oral sex and in children 2 to 5 years
old delivered by mothers with vaginal warts, respectively.8
Although anogenital warts in children can be acquired at
any age as a result of sexual abuse, the majority of them
are a result of nonsexual vertical or horizontal transmission
of HPV.8 Children may also develop nongenital verruca
vulgaris in their perianal and/or vulvar skin caused by
HPV type 2 from their own finger warts or from those found
on their parents or guardians hands.6 Typically, the lesions
are found at some distance from the pigmented, perianal
squamous epithelium.
CLINICAL SIGNIFICANCE AND
VIRAL CORRELATES
As mentioned previously, the vast majority (90%) of EGWs
are caused by low-risk HPV type 6 and, less often, type 11.
Recent epidemiologic viral correlation studies showed geo-
graphic variations in HPV 6/11/prevalence of EGWs.9
Although in the United States 95% of EGWs are caused
by HPV 6/11, in Latin America the rate is only 75%. The
reason(s) for the differences is not clear. Typically, HPV type
6 and 11 have almost no potential for viral integration into
host cell DNA and, consequently, carcinogenic transforma-
tion of 6/11-positive EGWs is a very rare phenomenon.1
The very rare, well-differentiated verrucous squamous cell
carcinoma of the external anogenital skin (formerly giant
condyloma of Buschke-Lowenstein) has been found to carry
HPV type 6, subtype 6b. In immunocompetent individuals,
histologically-verified EGWs have little, if any, cancer poten-
tial. Furthermore, despite the fact that there is an increased
association of EGWs and anogenital precancer and cancer
in individuals with cell-mediated immunosuppression, the
carcinogenic transformation of EGWs is not increased.10,11
These patients, such as those with lymphoproliferative
disorders, organ transplants, acquired immune deficiency
syndrome (AIDS), and aplastic (Fanconi) anemia are prone
to multiple low- and high-risk types of HPV infections.12,13
In such patients, development of invasive squamous cell
cancers from preinvasive lesional epithelium as a result
of high-oncogenic-risk HPV types occurs alongside the devel-
opment of EGWs as a result of low-risk HPV infection.
The approximately fourfold relative risk of cervical cancer
in patients with EGWs is explained by susceptibility of
these individuals to be infected by high-oncogenic-risk HPV
types.13
From a practical point of view, the main significance of
EGWs is that they are cosmetically and psychosexually unac-
ceptable and are a source of infection to new sexual partners
and, as previously mentioned, rarely to the neonate.
382
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CLINICAL EVALUATION
Condylomata acuminata are sessile, papular, papillary, cauli-
flower-type lesions with warty or verrucous surfaces. They
are found mainly on the nonhairy skin of the external geni-
tals (Figures 19-1 and 19-2). Those that develop in mucosal
surfaces (e.g., introitus, anal canal, inner surface of prepuce,
meatus, upper respiratory tract, conjunctiva) are soft and
whitish to pink in color, and each papillae has a double-
looped feeding capillary (Figure 19-3). Surface keratiniza-
tion is moderate to absent. Condylomata of the hairy
genital skin tend to be firm with often a prominent layer
of surface keratinization (hyperkeratosis) (Figure 19-4).
Acuminate condylomata should be distinguished from their
mimics (Table 19-1).
Micropapillomatosis labialis (MPL) is one of the condi-
tions most often confused for condylomata acuminata.
Unlike acuminate condyloma in which multiple papillae
converge toward a single base, in MPL each fingerlike papil-
lomatous projection has its own base (Figure 19-5). Most
patients with MPL have no symptoms or have a history of
recurrent candidiasis, Trichomonas, or Chlamydia infections.
HPV is no more prevalent in the epithelium of MPL than
in normal labial epithelium.14,15 The condition is regarded
as an exaggerated variant of an otherwise physiologic vulvar
skin.
A somewhat analogous condition called pearly penile
papules is seen in one third of male penises. Pearly penile
papules develop after puberty and consist of small papules
arranged in linear fashion along the corona glandis and
on each side of the frenulum. Ferenczy et al. failed to detect
HPV deoxyribonucleic acid (DNA) by polymerase chain
reaction technology in any of the 13 cases of pearly penile
papules studied.16
Molluscum contagiosum (MC) presents as multiple
papules with often depressed centers (umbilication), cover-
ed by a yellowish membrane. On microscopy, the depres-
sion can be seen to be filled with pox virus particles
(Figure 19-6). MC tends to aggregate in the pubic and thigh
regions; however, it can involve the external anogenital
skin as well and be associated with classic condylomata
acuminata.
Pigmented mole(s) of the intradermal type and skin
tags (acrochordon) are warty variants of vulvar intraepi-
thelial neoplasia (Figure 19-7) and verrucous carcinoma
(Figure 19-8) and are not infrequently mistaken for acumi-
nate condylomata. Another condyloma mimic is secondary
syphilis or condylomata lata. Unlike the warty surface of con-
dyloma acuminatum, condyloma latum has a shiny, smooth
surface and a sharp, demarcated contour (Figure 19-9).
HPV infections are often multicentric, and about one
third of individuals with EGWs also have HPV-related
changes on the cervix and, less often, in the vagina and ure-
thral meatus.17 Most cervical lesions are low-grade cervical
intraepithelial lesions (CIN 1). High-grade CIN 2,3 is found
only in 2% of women, typically in those 25 years or older.17
Therefore in practices where colposcopy is readily available,
 Chapter 19 External Genital Condyloma

Figure 19-1 Condylomata acuminata. A, Multiple lesions involving both the hairy and nonhairy skin of the vulva and perianal epithelium. B, Histology of
condyloma acuminatum. Papillary growth pattern with club-shaped papillae and surface keratinization as well as elongated (acanthotic) rete pegs
extending to the base of the lesion. (A, From Ferenczy A. External genital human papillomavirus infections. Curr Obstet Gynaecol 1995;5:98106.)

Figure 19-3 Condylomata acuminata. Multiple lesions devoid of surface

Figure 19-2 Condylomata acuminata. Lesions seen on the clitoris and
subclitoral mucous membrane of the labia minora. (From Richart RM,
Ferenczy A, Meisels A, et al. Condyloma virus and cervical cancerhow
strong a link? Contemp Ob Gyn 1984;23:210224.)
keratinization obscure the foreskin and glans of the penis. (From Ferenczy A.
Management strategies for genital HPV infection in men. Contemp Urology
1990;(Sep-Oct):1022; and A. Ferenczy. Epidemiology and clinical
pathophysiology of condylomata acuminate. Am J Obstet Gynecol
1995;13311339.)
383

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 Colposcopy, Principles and Practice

it may be appropriate to examine the cervix and vagina in

individuals with EGWs. However, if unavailable, a cytologic
sample taken from a clinically normal-appearing cervix is
sufficient. In the authors experience, about 10% of women
and 80% of homosexual men with perianal condylomata
who had engaged in anoreceptive intercourse have intra-anal
involvement of condyloma. Therefore in practices where
colposcopy is readily available, it may be appropriate to
examine these patients with high-resolution anoscopy, the
anal equivalent of vaginal colposcopy. Lesional involvement
is usually located at or below the anorectal junction (i.e.,
about 3 cm from the anal orifice). Meatal involvement by
HPV infection manifests as acuminate- or papular-
type condylomata, and the lesions are located in the fossa
navicularis in more than 90% of cases. Urethrocystoscopy
is only indicated if the condylomatous lesions are beyond
colposcopic view.
Histologic evaluation of typical condylomata acuminata
is optional. However, lesions should be histologically veri-
fied whenever the patient is treated with surgical techniques
(e.g., electrosurgery, laser) or has atypical lesions where
intraepithelial neoplasia or cancer is suspected (see Figure
19-7) or has lesions unrelated to HPV infections (e.g., mollus-
cum contagiosum, nevi, skin tag, seborrheic keratosis) or
invasive disease (Figure 19-10). In the surgically treated
group, histologic evidence of disease serves as proof that the
treatment was indicated or serves to identify noncondyloma-
tous lesions that are treated differently from typical warts. In
two large randomized, controlled trials determining the effi-
cacy of the prophylactic HPV 6/11/16/18 vaccine (Gardasil),
the agreement between a central laboratory and a panel of
experts in gynecologic pathology was 80%, with a higher
prevalence of HPV 6/11 in condylomatous lesions diagnosed
by the panel (90%) compared with that of the central labora-
Figure 19-4 Condylomata acuminata. Hyperkeratotic, cauliflower-like
lesions on the hairy skin of the vulva and perianal skin. tory (p < 0.001).18
Colposcopy of the external anogenital skin is indicated
in two situations: (1) to localize small papular or acuminate
lesions that may be hidden in the hairy genital skin, allow-
ing all lesional tissue to be included in the treatment field
(see Figure 19-1, A, and 19-2); and (2) to explain the origin
of a positive cytologic smear in patients whose cervix and
Table 19-1 Genital Condylomata Mimics vagina are devoid of lesional tissue by colposcopy, histol-
ogy, and endocervical curettage. In such cases of a verified
Epidermal inclusion cysts (mainly scrotum)
cytologic diagnosis, the epithelium of the introitus, labia
Giant condyloma of Buschke-Lowenstein minora, or both often contain HPV-related subclinical
Herpes simplex virus
macules (see Figure 19-5). In such cases, the exfoliated cells
are carried presumably by antiperistalsis cephalad in the
Human papillomavirusrelated, basalo-verrucous VIN vagina and recovered at the cervix level.
Hypertrophy of sebaceous glands
Intradermal nevi, seborrheic keratosis, skin tag (achrochordon) THE MALE PARTNER
Micropapillomatosis labialis
Molluscum contagiosum Because external genital HPV infections are sexually trans-
mitted, some recommend evaluating their male sexual part-
Pearly penile papules ners.19,20 However, in the authors opinion the compulsive
Syphilis, chancre tracing of contacts is not cost-effective for the current rela-
tionship because her partner already has subclinical HPV
Vulvar intraepithelial neoplasia
infection that has already spontaneously regressed or will
384

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 Chapter 19 External Genital Condyloma

Figure 19-5 Condyloma mimic. A, The entire hymenal ring and labia minora contain confluent, micropapillary epithelium. This is an example of MPL.
The patient complained of cyclic vulvitis, and vaginal culture showed Candida glabrata. B, Detailed view of MPL with each fingerlike projection having its own
base compared with acuminate condylomata. (A, From Ferenczy A. Epidemiology and clinical parhophysiology of condylomata acuminate. Am J Obstet
Gynecol 1995; 172:13311339, B, from Richart RM, Beutner K, Ferenczy A. Current management of genital warts. Contemp Obstet Gynecol 1997;(Nov):74103.)

regress within a relatively short period of time, or the male
partner carries latent HPV without lesional epithelium and
is simply not the source of EGWs in his current partner.21
This philosophy is in agreement with the latest recommen-
dations of the Centers for Disease Control and Prevention
in which examination of sex partners is not recom-
mended.22 Exceptions to this practice are the following:
1. Men with suspected condylomata acuminata
2. Symptomatic patients with pruritus and/or burning of
the penis
3. Examination specifically requested by the patient
In the first two instances, evaluation of the external ano-
genital skin is often followed by therapy. In the third instance
(in the absence of finding visible lesions), information on the
natural history of HPV infection may be helpful in relieving
anxiety, guilt, or both and may result in the modification of
sexual practices, including consistently using condoms or
engaging in long-term, mutual monogamy. Indeed, most
agree with the concept that a womans cervical cancer risk
depends not as much on her own sexual behavior but rather
on that of her male sexual partners. Although the use of con-
doms has not been shown to prevent all HPV infections, they
can substantially reduce (but not eliminate) the risk of HPV
transmission.19,20 The evidence on treatment results of
women with vulvar warts suggests that in long-term, mutual
monogamous sexual relationships, the untreated male part-
ner does not represent a reservoir of reinfection.11 In one
study, only 23% of couples had the same HPV type in their
genital specimens21; another study found that only 37% of
partners were infected by the same HPV type.20 One retro-
spective study comparing treated to untreated male patients
failed to demonstrate a decrease in the post-treatment recur-
rence/failure rate for EGWs in the female partners.23
Table 19-2 contains the authors experience with 108
steady male sexual partners (6 months and longer) with
penile HPV infections whose female partners had been trea-
ted for EGWs. The men were randomized to either surgery
385

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 Colposcopy, Principles and Practice

Figure 19-6 Condyloma mimic. A, Multiple papules with smooth surface and umbilicated center, typical of molluscum contagiosum. B, Detailed view
of molluscum contagiosum. (B, From Ferenczy A, Kohn T, Shore M. Evaluating male partners of condyloma patients. Contemp Ob Gyn 1983;22:183196.)

(CO2 laser vaporization) or loop electrosurgical excision
procedure (LEEP) and condom use (55 patients) or no ther-
apy and no condom use (53 patients), and the entire cohort
was followed for a minimum of 6 weeks to a maximum of
24 weeks (mean 12 weeks). The results clearly show that
recurrence rates for women whose male partners were treated
versus those whose partners were not treated are similar.
The results are consistent with the concept that partners in
stable sexual unions do not reinfect each other; rather,
post-therapy recurrence is a reflection of later activation of
latent HPV DNA that is present in the normal epithelium
adjacent to previously treated fields in a large proportion of
cases (Figure 19-11).
The author also questions the clinical benefit of remov-
ing subclinical lesions that coexist with clinically overt
condylomata. Earlier reports suggested improved cure rates
for EGWs (87%) and decreased number of repeat ablative
procedures when both the subclinical macules and condylo-
mata are treated using the so-called extended CO2 laser
vaporization technique. However, subsequent experience
with extended laser vaporization for EGWs yielded only
40% cure rates, certainly not better than those reported
386
without extended laser therapy.23 Also, extended laser ther-
apy is often associated with more pain and delayed healing.
Finally, a recent cross-sectional study of heterosexual couples
found that the majority of flat, subclinical, penile lesions
regressed simply with the use of condoms.20
THERAPY
General Considerations
There have been no new significant breakthroughs in the
treatment of EGWs in the last 10 years. Treatment regimens
continue to be numerous and are testimony of our failure to
guarantee cure, at least with a single treatment session.
Indeed, there is no evidence to suggest that any treatment modal-
ity is significantly superior to another, nor is there evidence indi-
cating that the currently available treatments eradicate or affect
the natural history of HPV infection. The removal of warts
may or may not decrease infectivity. If left untreated, visible
genital warts may resolve on their own in 20% to 30% of
cases, remain unchanged, or increase in size or number.

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 Chapter 19 External Genital Condyloma

Figure 19-7 Condyloma mimic. A, The entire nonhairy skin of the labia minora is replaced by confluent, hyperkeratotic, warty lesions resembling
condylomata acuminata. B, Histology of warty vulvar intraepithelial neoplasia. Papillary, hyperkeratotic surface and pleomorphic, poorly differentiated,
neoplastic squamous cells. Arrow points to a corps ronds, and there are several abnormal mitotic figures (lower middle). (A and B, From Ferenczy A.
Intraepithelial neoplasia of the vulva. In: Coppleson M (ed). Gynecologic Oncology, vol 1, ed 2. London: Churchill-Livingstone, 1992, pp 447452; and
Ferenczy A. Epidemiology and clinical pathophysiology of condylomata acuminata. Am J Obstet Gynecol 1995;172:13311339. A, Also from Ferenczy A.
Using lasers to treat condylomas and VIN. Contemp Obstet Gynecol 1982;(20):5775.)

The treatment of visible warts does not decrease the risk
of developing cervical cancer.22 It is important to inform the
patient that treatment often requires multiple (the average
number is 5 sessions) rather than a single session of therapy,
and recurrences are frequent (30% or more). Fortunately, the
majority of patients experience sustained disease-free peri-
ods within 3 months and recurrences are relatively infre-
quent 6 months after the last successful treatment.24
In general, favorable response to therapy is much more
likely in patients aged 20 years or younger regardless of
extent of lesions; other good response predictors are lesions
less than 10 cm2 in total volume, lesions less than 4 months
in duration and those in immunocompetent women.
Most patients in private practice have less than 10 genital
warts, with a total wart area of 5.0 cm2 or less that are
responsive to most treatment modalities (Table 19-3).
In contrast, in referral centers, many patients have EGWs
between 20 and 50 cm2 in total wart area. These patients
often require longer treatment sessions and surgical rather
than medical-type therapies. In general, factors that might
influence selection of treatment in addition to patient pref-
erence include wart size, wart number, anatomic site of
warts, wart morphology, the cost of treatment, convenience,
adverse effects, and provider experience. Having a treatment
plan is important because most patients are likely to require
multiple therapeutic sessions. EGWs with little or no kerati-
nization located on moist surfaces and/or in intertriginous
areas generally respond better to topical treatment (e.g., tri-
chloroacetic acid [TCA], podophyllin, 0.5% podofilox, 5%
imiquimod) than do their keratinized counterparts on drier
surfaces (Figure 19-12). The differential in therapeutic suc-
cess rates is likely due to enhanced product absorption
into HPV-infected keratinocytes.
A given treatment modality may be changed after four to
six weekly provider-administered treatments or if warts have
not completely cleared after eight weekly treatments. The
387

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 Colposcopy, Principles and Practice

Figure 19-8 Condyloma mimic. A, Voluminous, confluent, exophytic lesions obscuring the anogenital skin. B, Histologically, confluent, club-shaped rete
pegs extend superficially into the dermis, consistent with verrucous squamous cell carcinoma of vulva.

exception to this rule is the use of the immune system mod-
ulator, 5% imiquimod cream (Aldara), and the recently Food
and Drug Administration (FDA)-approved pro-apoptotic
polyphenon-E 15% ointment, both of which can be used
for as much as 16 weeks of therapy. Using these treatment
modalities, a substantial number of patients (about an addi-
tional 20%) may experience complete clearance between the
eighth and sixteenth weeks of therapy.24,25 In intractable,
standard treatment-resistant cases, therapies that combine
topical cytotoxins or immunomodulators with ablative/
excisional methods may be indicated. Topical, off-label
1% cidofovir gela broad-spectrum antiviral agenthas
also been shown to be successful in about 40% of recurrent
EGWs in a small group of immune-suppressed, human
immunodeficiency virus (HIV)-positive patients.26
When treatments for warts are employed properly, com-
plications are rare. Patients should be warned that scarring
in the form of persistent hypopigmentation or hyperpigmentation
is common with ablative treatment modalities. Depressed
or hypertrophic scars are rare but can occur, especially
if the patient has had insufficient time to heal between
treatments. Rarely, treatment can result in disabling chronic
pain syndromes (e.g., vulvodynia, hyperesthesia of the
treatment site).
388
In couples who are not in long-term, mutually monogamous
sexual unions, treatment results are enhanced and recurrences
prevented by the consistent and correct use of condoms prior to
and during intercourse, as well as the practice of genital hygiene.
Ultimately, the universal use of the prophylactic HPV vac-
cine containing HPV types 6 and 11 (Gardasil) is likely to
provide the most successful preventive measure against
most cases of EGWs.
Table 19-3 presents the summary data on provider-
administered and patient-applied treatment results. It is
impossible to compare one method with another because of numer-
ous variables, all of which can influence therapeutic results. The
most common confounding factors are age of patient (i.e.,
younger patients respond better than their older counter-
parts), number and size of EGWs, gender, treatment regimen,
diagnostic ascertainment (histology versus clinical inspec-
tion), duration of EGWs (longer outbreaks are associated
with a less-favorable response than shorter outbreaks), length
of follow-up, and method of assessment of recurrences.
It should be realized that treatment results obtained under
perfect experimental conditions (per-protocol cohort) tend
to be superior to intent-to-treat protocols that reflect real-
life practices. Furthermore, in most reports recurrences are
reported separately and not included in failure rates,

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 Chapter 19 External Genital Condyloma

Figure 19-9 Condyloma lata. A, Multiple, raised, sharply demarcated, smooth-surfaced lesions mimicking condylomata. Both serology and histology
were consistent with secondary syphilis in this sexually abused 7-year-old girl. B, Histology of acanthotic rete pegs and marked, chronic inflammatory
exudate in subepithelial, papillary dermis.

whereas in real life the reason that the patient still has warts
(recurrence or treatment failure) is not relevant. As a result,
to assess the true overall cure rate, one should only consider com-
plete responders as cured and include recurrences in the group of
those who failed to respond.
Provider-Applied Therapies
Provider-applied therapies include the following:
1. Podophyllin: This is one of the oldest cytotoxic agents
(podophyllotoxin). It is applied topically at
concentrations ranging from 8% to 25% in compound
tincture of benzoin. It interferes with mitosis of infected
cells by paralyzing the mitotic spindle.
Application: Once a week for as long as 6 weeks over
total wart area of less than 10 cm2 per application. It
should be washed off with soap within 4 to 6 hours.
Treatment results: Complete clearance is obtained in
about 50%; however, recurrences are in the order of 40%.27
It is ineffective on large, hyperkeratotic, dry lesions of the
hairy skin of the lower genital tract (i.e., scrotum, labia
majora, base of penis). Overall, the use of podophyllin
has limited therapeutic value.
Adverse effects: Pruritus, burning pain, erythema
and edema. Podophyllin has the potential for
massive systemic absorption that may result in bone
marrow depression or coma. It should not be used in
pregnant women because it contains mutagenic
substances.22,27
2. Trichloroacetic (TCA) or bichloroacetic acid (BCA):
These are keratolytic and keratinocytic chemo-coagulating
agents. TCA and BCA are the most commonly used topical
agents by North American gynecologists.
Application: Once a week for as long as 8 weeks at a
50% to 90% concentration in 70% ethanol solution.
Once TCA/BCA dries, a white frost develops on the
surface of EGWs (Figure 19-13). This should not be
washed off for at least 4 four hours. Burning discomfort
may be reduced by topical perilesional application of 5%
EMLA anesthetic cream or 25% benzocaine gel or by
neutralizing TCA with sodium bicarbonate (baking
soda).
Treatment results: Better than podophyllin, particularly
for EGWs on moist genital epithelium. No data are available
as to whether TCA is superior to BCA or vice versa.
Recurrences are as high as 36%.27
389

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 Colposcopy, Principles and Practice

Figure 19-11 Koebner phenomenon. In this patient, multiple acuminate

Figure 19-10 Invasive squamous cell carcinoma of vulva. This mid-adult
organ transplantee has been treated for recurrent condylomata acuminata
for a number of years. At the margin of previously treated area, a sharply
demarcated, ulcerative lesion developed, which on excision was found to
be invasive cancer. (From Ferenczy A. External genital human papillomavirus
infections. Curr Obstet Gynaecol 1995;5:98106.)
Adverse effects: Same type of skin reactions as for
podophyllin; however, overapplication may produce
excessive pain, ulcerations, and scarring. TCA/BCA are not
absorbed into the systemic circulation and can be safely
used during pregnancy.
3. 5-Fluorouracil (5-FU) cream (Efudex): This is an
antimetabolite interfering with nuclear DNA and
lesions developed peripherally to previous treatment sites (vitiligoid
epithelium). They are believed to represent complications due to activation
of latent HPV.
ribonucleic acid (RNA) synthesis; it is a sort of DNA
splitter. In current practice, its use is limited to meatal
warts. The therapeutic response is difficult to evaluate. It
should not be used in pregnancy and generally has
limited application.
4. Cryotherapy: This is the most commonly used means to
treat EGWs by North American dermatologists and
genitourinary medicine clinics in the United Kingdom.28
Liquid nitrogen is the most common refrigerant used by
dermatologists, and nitrous oxide is the most common
refrigerant used by gynecologists. Regardless of cryogen

Table 19-2 Role of the Male Sexual Partner in Treatment Results of Vulvar/Anal Condylomata

Male Partners** Recurrence of Vulvar Warts*

Number of Patients Percent (%)
CO2 laser/LEEP condom (n 55) 92 58
No therapy/no condom (n 53) 98 62
Total: 108 160 100
LEEP, Loop electrosurgical excision procedure.
*After single CO2 laser therapy or LEEP.
**With clinical/subclinical lesions.
390

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 Chapter 19 External Genital Condyloma

Table 19-3 External Genital Warts: Summary Data of Treatment Results by Therapeutic Methods

Therapy Complete Clearance (%) Recurrence Rates (%)

Provider Applied
Podophyllin 2280 2165
BCA/TCA 6480 36
Cryotherapy, Electrosurgery, CO2 laser 7096 2539
Excision 7294 2551
Interferons: 7297 649
Systemic 8993 19-22
Intralesional 782 23
Topical 3652 2125
33 N/A
Patient Applied
Podofilox (Condyline) 6888 1634
Imiquimod (Aldara) 50 1319
Polyphenon-E (Veregen) 59 10.5
Adapted from K. Beutner and A. Ferenczy, Am J Med 1997;102:29, and A. Ferenczy, J SOGC Dec 1999:1307.
BCA, Bichloracetic acid; TCA, trichloracetic acid; N/A, data not available.

Figure 19-12 Condylomata acuminata. A, Nonkeratinizing lesions in vestibular epithelium. B, The vestibular epithelium is completely devoid of lesional
epithelium 8 weeks after home therapy with imiquimod 5% cream. 391

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 Colposcopy, Principles and Practice

Figure 19-13 Topical trichloroacetic acid therapy. A, 80% TCA solution must be shaken to obtain a turbid fluid prior to application. B, Soon after
application, the salt oxidizes, producing chemocoagulation of condylomata and 2 mm of the adjacent epithelium.

used, the cryo-coagulative effect is particularly noticeable on
small and keratinized lesions.
Application: Therapy is delivered once a week for as
long as 8 weeks using a modified cotton-tipped
applicator or spray by dermatologists or cryoprobe by
gynecologists. To optomize treatment results, it is
important to double- or triple-freeze with appropriate thaw
periods (30 seconds) and extend the ice ball 2 to 5 mm
beyond the margin of the lesion being treated (Figure 19-14).
Treatment results: Clearance rates as high as 80% are
obtained; however, recurrences may be as high as 21%.27,28
Adverse effects: The most frequent complaint is pain
during therapy; however, the pain is generally only mild
to moderate in severity and of short duration. In the case
of severe discomfort, local anesthesiaeither topical 5%
EMLA cream or subepithelial injection of 2% lidocaine
solutionmay be used at treatment sites. Cryotherapy
can safely be used during pregnancy.
5. CO2 laser therapy: Heat generated by CO2 laser light is
selectively absorbed by intra- and intercellular water,
resulting in instant vaporization of genital warts. Under
magnification, the laser light is delivered with precision,
392
preventing excessive removal of normal tissues adjacent
to lesional tissues. With appropriate depth control, healing
occurs without scarring.
Application: The laser beam is best delivered either
using a micromanipulator or handheld device at
magnification (using colposcopy) (Figure 19-15). The
procedure requires either local or general anesthesia
depending on the extent and anatomic location of
disease. CO2 laser therapy is indicated for extensive disease
and that which has failed to respond to other forms of therapy.
Its major pitfall is the high cost of the equipment and its
maintenance. The technique requires hands-on training
and a relatively high volume of cases to acquire and
maintain expertise.
Treatment results: Success rates are 50% including
recurrences after a single session and 70% to 80% after
multiple treatments.27 Due to the coagulative property
of the CO2 laser beam, vaporization has been used
for treating heavily vascularized EGWs during pregnancy.
The lowest recurrence rates are observed when
treatment is given during the last trimester (i.e., 3234
weeks).29

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6. Electrosurgery: This technique uses high- (radio)
7. Surgical excision: This is probably the best and least
Figure 19-14 Cryotherapy. Cryogen in the form of nitrous oxide gas is
delivered onto warts by a cryoprobe.
8. Interferons (IFNs): Both natural and recombinant
Figure 19-15 CO2 laser vaporization. Laser light is delivered a handheld
device, and a suction hose (upper left) is kept within 1 inch of the operative
field to adequately remove the plume of smoke.
Adverse effects: Using appropriate technique, the
cosmetic results are excellent (Figure 19-16). Poor depth
control may lead to delayed healing, pain, scarring,
perforations, and hyper- or depigmentation (vitiligo).
The laser beam may ignite rectal gases in inappropriately
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Chapter 19 External Genital Condyloma
prepared patients to whom laser therapy is delivered for
intra-anal warts. Adequate evacuation of the plume of
smoke is critical to prevent inhaling allergens,
carcinogens, and HPV DNA.
frequency alternating current to electroexcise, desiccate,
or fulgurate EGWs. Electrosurgery generates less smoke
than the CO2 laser surgery.
Application: Electrosurgery is performed under
local or general anesthesia. Loop-shaped and ball-
type electrodes are used for excision and fulgura-
tion, respectively. The thermocoagulated eschar is
removed by a wet cotton-tipped applicator or a
curette (Figure 19-17).
Treatment results: After considering recurrences,
complete clearance rates are similar to those obtained by CO2
laser photovaporization, in the order of 50%.23 Cure rates can
be improved with repeated laser sessions. The advantages of
electrosurgery over laser therapy are the lower cost of the
equipment and maintenance and easier depth control
when electrofulguration is used.
Adverse effects: Electroexcision with either loop or
needle-shaped electrodes may cause deep cuts into dermis
that may lead to intraoperative bleeding and require suturing.
Electrofulguration or desiccation that extends to the deep
dermis or subcutaneous fat may result in hypertrophic
scarring.
costly option for a limited number (<10) of warts and
may also be used for recurrent and large or extensive
acuminate warts.
Application: Local or general anesthesia is required.
Excisions are performed using either scissors or cold or hot
knife (Figure 19-18). Another advantage of surgical
excision is that it provides specimens for histologic
evaluation. Bleeding sites from extensive excisions are
sutured, whereas those from smaller sites are treated with
topical Monsels paste or electrofulguration.
Treatment results: After considering recurrences,
complete clearance rates are in the order of 70% to 80% after
one session and 90% after repeat excisions.27
Adverse effects: In unskilled hands, intraoperative
bleeding due to poor depth control, postoperative
pain, and delayed healing with or without scarring may
occur.
IFNs have antiproliferative, immunomodulating, and
antiviral effects although they have not been shown to
clear HPV DNA.22,27 Prospective, randomized, placebo-
controlled studies have shown that when IFNs are
administered systemically (subcutaneous or
intramuscular) at a site distant to the EGWs, they are
ineffective.30 Currently, only IFN-a produced by virus-
infected lymphocytes/lymphoblasts is approved by the FDA
for intralesional use in the treatment of EGWs in the
United States.
Application: The treatment protocol consists of
sublesional (not intralesional) injections of recombinant
393
 Colposcopy, Principles and Practice

Figure 19-16 CO2 laser vaporization. A, Extensive confluent lesions (seen on right labia minora) are vaporized to a depth of subepithelial stroma (first
surgical plane). B, Complete re-epithelialization without scarring of treatment fields occurs by the eighth week after laser vaporization. (From Ferenczy A,
Behelak Y, Wright TC, et al. Treating vaginal and external anogenital condylomas with electrosurgery vs CO2 laser ablation. J Gynecol Surg 1995;11:4243.)

IFN-a2b three times a week for 3 weeks; for natural IFN-
a, injections are given twice a week for 8 weeks. Results
following topically applied IFNs (in the form of cream)
are not better than placebo. Another therapeutic
approach uses IFN as an adjunct to conventional
therapy.
Treatment results: Intralesional IFNs produce two
to four times better clearance rates than the placebo; however,
the overall efficacy and recurrence rates are comparable to
other forms of therapy31 (see Table 19-1).
Adverse effects: Patients frequently complain of
flulike symptoms, fever, and pain at injection sites and
require frequent office visits. For example, with IFN-a2b,
only five EGWs can be treated in one sitting, whereas
with natural IFNs, treatment is total dose limited.
Additionally, IFN therapy is expensive (U.S. $9001200
per month) and long-term therapy may result in
leukopenia. Because of the shortcomings of IFN therapy,
it is rarely used as a treatment of EGWs and then only as a
last resort.
394
Patient-Applied Therapies
Patient-applied therapies have been developed primarily to
improve patient compliance with therapy and reduce costs
related to provider-administered therapies. They are avail-
able in liquid solution and solid (gel, cream, or ointment)
formulations and include the following:
1. Podophyllotoxin: This is the main cytotoxic lignin of
podophyllin resin, also referred to as podophyllotoxin.
Unlike podophyllin, in which the concentration of
podophyllotoxin is high and nonstandardized (825%),
in podofilox the concentration is low and standardized
to 0.5%. This results in a lower concentration of systemic
podofilox, and it is therefore safer to use than
podophyllin. Podofilox has been homologated
worldwide and is available under the names of
Condylox, Condyline, and Wartec.
Application: Podofilox is available as a 0.5% solution
(3.5 ml), a 5% gel (3.5 g), and a 0.15% cream. Regardless
of presentations, they are applied topically twice a day, three

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 Chapter 19 External Genital Condyloma

Figure 19-17 Electrosurgery. A, Larger lesions are electroexcised using small, square-shaped electrodes (mini-debulking). B, Smaller lesions are treated
by electrofulguration with a ball-shaped electrode using coagulating power output. (From Ferenczy A, Behelak Y, Wright TC, et al. Treating vaginal and
external anogenital condylomas with electrosurgery vs CO2 laser ablation. J Gynecol Surg 1995;11:4243.)

days per week for as long as 3 weeks. If a partial response
is obtained by 3 weeks, treatment may be continued as
off-label use for as long as 8 weeks. The solution is
applied with cotton-tipped applicators, and the gel/
cream formulations are applied with a finger. Total wart
area treated should not exceed 10 cm2. It is important to
demonstrate the appropriate application technique to
the patient in the office and indicate the location of
EGWs to be treated.
Treatment results: Several comparative clinical trials
showed better and faster therapeutic response with
podofilox than podophyllin or placebo.32 Therapeutic
response to solution is similar to gel formulation (3070%);
unfortunately, 35% to 90% of patients with wart clearance
experience recurrences.
Adverse effects: Moderate to severe reactions occur
usually within the first 2 weeks of treatment and include
burning pain (59%), erythema (40%), and erosions
(30%) at treatment sites.32 Although the concentration
of podophyllotoxin is low, podofilox should not be
prescribed to pregnant women, as it has teratogenic and
embryotoxic effects (FDA pregnancy category C).
2. Imiquimod 5% cream (Aldara): Imiquimod destroys
HPV-infected keratinocytes by stimulating the cell-mediated
immune system. Imiquimod is a potent pro-inflammatory
cytokine inducer in both animal models and humans.
The main cytokines are IFN-a; interleukin-1, -6, and
-8; and tumour necrosis factor. Induction of cytokines is
rapid (8 hours after cream application) and sustained for
1 to 3 days.33 Importantly, virus-presenting Langerhans
cells (decreased CD-1), T cells (increased CD-4 and 8),
and T-cell activation (increased CD-29) are all stimulated
by imiquimod at wart sites. Paralleling the increase in
intralesional IFNs, HPV DNA L1 and E7 genes decreased
dramatically from baseline value. The results indicate
that imiquimod has powerful but nonspecific antiviral
activity.
Application: Imiquimod is available in packets
(sachets), each containing 0.25 g of 5% imiquimod
vanishing cream. The cream is rubbed into the warts with
a finger followed by handwashing. It is applied in thin
layers at bedtime three times a week for as long as 16 weeks.
The treatment sites are washed the next morning.
Imiquimod is dispensed for a period of 4 weeks at a
395

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 Colposcopy, Principles and Practice

Figure 19-18 Excisional therapy. A, Fine, iris-type scissors are placed on the base of the wart and gently closed and pulled to cut. B, The depth of
excision is shallow. Hemostasis is provided by Monsels paste, which is then removed to prevent scarring of treatment sites.

time, and the patient is examined at the end of each
month of therapy.
Treatment results: In a prospective, multicenter,
randomized vehicle-controlled, double-blind study of
209 patients, 50% experienced total clearance of their EGWs
compared with 11% for the placebo group (intent-to-treat
analysis).24 More women (72%) than men (33%)
responded favorably to imiquimod, presumably because
of differences in bioavailability of the active agent,
shorter outbreak, and younger age of female than male
patients. Indeed, men had more keratinizing warts and
longer outbreak (>6.5 months) and were older (>29
years) than their female counterparts. In addition to
the total clearance rates, the majority of patients
experienced a 50% or greater reduction (partial response) of
the total wart area. Partial therapeutic response was
observed in most patients by the fourth week of
treatment, and close to 50% of patients were cleared of
EGWs by the eighth week of therapy. The most attractive
feature of imiquimod was its association with a low recurrence
rate (13%), similar to that experienced by the placebo
group (10%).
Adverse reactions: These are mainly limited to
application site reactions such as burning (22%), pruritus
(13%), pain (6%), erythema (61%), erosion (30%), and
excoriation (32%). Most local skin reactions are mild to
moderate and resolve spontaneously.24 Patients,
particularly those with fair skin complexions, may be
hypersensitive to imiquimod and should be warned to
apply imiquimod only once or twice a week. More
frequent applications may be associated with severe local
skin reactions including burning pain, severe erythema,
and erosions.
Systemic IFN-like side effects are rare with
imiquimod. It has not been clinically tested in
pregnancy, although no complications (abortion or
premature delivery) were observed in five pregnant
patients treated with imiquimod (personal observation).
Experimentally, imiquimod is not mutagenic,
cytotoxic, teratogenic, or carcinogenic. Although it
is classified as FDA pregnancy category B (no known
fetotoxic effects), whether it may be used in pregnancy
remains to be determined. Imiquimod should not be used
on open wounds, erosions due to infections or inflammatory

396

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reactions, or as postsurgical therapy for EGWs or
genital ulcers.
3. Polyphenon-E ointment 15% (Veregen) has recently
received FDA approval for home therapy for EGWs
(www.bradpharm.com). The active ingredient in
polyphenon-E is a mixture of catechins extracted from
green tea. Catechins are antioxidants and have possible
anticarcinogenic, anti-inflammatory, antimicrobial, and
antiviral activities.34
Application: Three times a day (up to 250 mg) until
clearance or 12 weeks maximum.
Treatment results: In a prospective phase II/III,
pivotal, randomized, controlled trial with placebo on
125 male and 117 female patients with EGWs, complete
clearance of pre-existent and post-baseline (new) warts was
59% versus 37.3% in the placebo group.25 Partial clearance
(>50% total wart area) occurred in 54.5% of the active
treatment group versus 51.8% for placebo. Recurrence
rates were 10.6% and 10.3% in the active and placebo-
treated groups, respectively. The median time to
clearance was 16 weeks both in the active and placebo
treatment groups.
Adverse effects: These occurred in 8% of the subjects;
most were related to local application site reactions and
occurred more frequently in the 15% ointment group
versus placebo. Local reactions occurred after 2 weeks
of treatment and decreased gradually over the
remaining study period. Only three patients
discontinued participation in the study because of
allergic dermatitis. Systemic adverse events were not
encountered. No information is available as to its safety
in pregnant patients.
Therapies for Intractable Disease
The management of EGWs, particularly in immunosup-
pressed patients including HIV-infected individuals, is
frustrating because failure and recurrence rates are very
high. Theoretically, imiquimod could be an attractive
choice of therapy for this population because it boosts
cell-mediated immunity. Unfortunately, in one rando-
mized, controlled trial of 100 patients, complete response
rates were only 11% versus 6% in the placebo group,
whereas the partial response rate was 38% versus 14%.35
Similarly, response rates have been lower (31%) in 75
highly active antiretroviral therapy (HAART)-treated HIV-
positive subjects compared with 50 HIV-negative control
subjects (62%). Nevertheless, overall 55% of the HIV-positive
patients had either complete or partial response with 20% recur-
rence rates, findings that are highly acceptable considering the
difficulties in treating this subset of the population.36
Cidofovir 1% gel has been tried in desperate cases. It is
given once a day at bedtime for five consecutive days for a
maximum of 6 cycles, with 1 week off between treatment
cycles. Cidofovir is a nucleotide analogue with a broad-
spectrum antiviral (DNA) activity. Cidofovir therapy causes
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Chapter 19 External Genital Condyloma
necrosis of EGWs. It should only be used on external lesions, as
its absorption through nonkeratinized, internal mucous mem-
branes may lead to nephrotoxicity. In one study of 10 patients,
40% complete response occurred within 2 weeks of treat-
ment and 30% of patients had 50% or greater total wart
reduction.26
Several off-label treatment combinations may be considered
for intractable EGWs either simultaneously or concomitantly.
These include simultaneous application of 80% to 90%
TCA and podophyllin solutions; surgical ablation followed
by topical application of either 85% TCA solution/1% cido-
fovir daily, or imiquimod 5% on newly recurrent lesions.
Topical therapy may be replaced by systemic IFN ther-
apy.3739 The author often uses 85% TCA solution to
remove surface keratin layer on keratinized warts. This
is then followed by home therapy with 5% imiquimod
cream or polyphenon-E ointment. In open-labeled, non-
controlled clinical trials in HIV-positive men, electroful-
guration or laser vaporization followed by application of
intra-anal imiquimod suppositories reduced recurrences of
intra-anal condylomata and viral load by 50%.40 Laser
vaporization followed by intramuscular injection of IFN
has been standard therapy for juvenile onset of recurrent
respiratory papillomatosis (JORRP) with relatively good
results in reducing recurrent disease.8 More recently, IFN
therapy has been replaced by the phytochemical indole-3-
carbinole (I-3-C). I-3-C is extracted from vegetables such
as cabbage and broccoli and has a potent, direct antiproli-
ferative effect in both estrogen-dependent and independent
tumor cell lines by inducing a G1 cell cycle arrest and
increasing p53-independent apoptotic response.41 I-3-C is
administered orally, has little side effects compared with
IFN therapy, and reduces recurrences to the same magni-
tude as IFN therapy. Adjuvant IFN-a2b therapy has also
been assayed after cryosurgery and CO2 laser vaporization
delivered for refractory EGWs. The results have been mixed;
one controlled trial found no increased efficacy of cryo-
therapy combined with subcutaneous injection of IFN,42,43
whereas others reported increased efficacy with systemic
IFN-a prior to cryotherapy44 as well as IFN-a prior to CO2
laser vaporization.40 In one study, better complete response
rates (67%) were reported with intralesional IFN combined
with podophyllin versus 42% with podophyllin alone.
However, recurrence rates were the same: 67% and 65%,
respectively.38 Lower recurrences have been obtained when
intralesional IFN was used as an adjunct to either CO2 laser
or 5-FU therapy (27%) compared with those without IFN
therapy (24%).39
PROSPECT FOR HUMAN PAPILLOMAVIRUS
VACCINES
Because EGWs are HPV induced, prevention by using pro-
phylactic HPV vaccination in HPV 6/11-nave individuals
is the best approach. The recently FDA-approved
397
 Colposcopy, Principles and Practice

quadrivalent HPV 6/11/16/18 L1-VLP (Gardasil) has been

shown in multiple, large, randomized control trials (RCTs) to Clinician and patient
have a 95% to 99% efficacy of preventing HPV 6 or 11positive decide on treatment
EGWs.44 However, the impact of universal mass vaccination
programs to reduce substantially EGWs will take several
years, and parallel to prophylactic vaccination, it may be Non-pregnant
appropriate to develop therapeutic HPV vaccines to treat patients
existing disease. Unfortunately, clinical trials published to date
fail to show cure rates any better, and sometimes even less favor-
able, than those existing with conventional medical or surgical Provider-administered Patient-applied
treatment modalities.45 therapies therapies
Whereas prophylactic vaccination depends on the secre-
tion of neutralizing antibodies against HPV (humoral
immunity), induction of cell-mediated immunity including TCA Imiquimod cream 5%
cytotoxic cells that are needed to regress anogenital warts is Cryotherapy Podofilox gel 0.5%
Scissors excision Polyphenon-E ointment 15%
much more difficult.46 In general, the target molecules of Electrosurgery
interest have been the HPV E6 and E7 gene products. So Laser therapy
far, several phase I and II RCTs have been conducted using
a variety of therapeutic vaccine designs including recombi-
nant viruses, synthetic peptides, and dimeric virus-like parti- Failure/Recurrence
cles. Despite induction of an adequate immune response,
therapeutic vaccination that uses fusion protein of L2
and E7 from HPV type 6 (HPV L2/E7) and ASO2A adjuvant
fail to increase the efficacy of conventional therapies for Patient-applied Provider-administered
EGWs.45 In another uncontrolled study on 14 patients Imiquimod cream 5% TCA
using HPV-16 E7 protein fused to heat-shock protein 65 Podofilox gel 0.05% Cryotherapy
(Hsp65) from mycobacterium bovis, 3 of 14 (28%) patients Polyphenon-E ointment 15% Scissors excision
Electrosurgery
completely cleared their EGWs.46 However, this clearance
Laser surgery
rate is not greater than that reported in patients receiving
placebo and might be due to a nonspecific effect of
Figure 19-19 Treatment protocols for external genital warts. Flow chart to
Hsp65.24 illustrate various therapeutic alternatives used for treating EGWs in
The failure of therapeutic vaccines may be due to (1) nonpregnant patients. (Adapted from Ferenczy A. External anogenital warts:
using a weak antigen such as L2 as opposed to a more old and new therapies. J SOGC 1999;(Dec):13051313.)
potent inducer of both neutralizing antibodies and cell-
mediated immunity such as L; (2) E7 may be expressed
choice depends on volume, distribution, and type of lesion
too late in the viral cycle as opposed to E2 or E4; and (3)
as well as the patients preference and financial resources.
E7 protein may be masked from immunocytes by L2,
A given treatment(s) should be discontinued if no response is
which is the predominant part in the L2E7-HPV-6 vaccine.
obtained by 4 weeks or only partial response is observed at 8 weeks
Many more and larger RCTs are needed to refine HPV
of therapy. Alternate therapies are to be instituted. Exception
research aimed at the development of effective therapeutic
to the rule is 5% imiquimod cream and 15% polyphenon-E
vaccines.
ointment, both of which are associated with a substantial
rate of complete clearance if used for as long as 16 weeks.
Most single use of therapeutic agents or interventions result
CONCLUSIONS in an approximately 50% wart clearance, and recurrence rates
range from close to 10% and 90% with an average of 30%.
Genital warts are mostly caused by the low-risk HPV types 6 Patients have to be informed about the need for multiple applica-
and 11. They represent a major burden of disease with tions of single or combined therapies and possible adverse effects
a 10% lifetime risk of developing lesions and high medical, associated with wart treatments. Overall, approximately 80% of
financial, and psychological costs. Both external and internal patients will experience clearance of their warts within 1 year
genital warts need treatment because persistent lesions are a after multiple therapeutic attempts; the remaining 20% will
source of infection to sexual partners and rarely to newborn need further therapies on a relatively long-term basis or follow-
infants. Treatment strategies should be discussed with the up without therapy. Short of efficacious HPV vaccines, the
patient and be instituted after obtaining a mutual (patient best preventive action is to practice long-term, mutual
healthcare provider) agreement on the choice(s) of therapy monogamy or the consistent and correct use of condoms.
(Figures 19-19 and 19-20). The ultimate solution will likely be provided by universal,
Provider-administered and patient-applied therapies are mass, prophylactic vaccination with HPV 6/11-containing
appropriate either as first-line or second-line treatments. Their vaccines.
398

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Clinician and patient
decide on treatment
Pregnant patients
TCA
Cryotherapy
Electrosurgery
Laser therapy
Failure/Recurrence
Repeat treatment
Figure 19-20 Treatment protocols for external genital warts. Flow chart to
illustrate therapeutic alternatives, all of which are considered safe for both
the pregnant patient and the fetus. In cases of recurrence, focus on
vaginal and introital lesions that are potentially infectious to the baby
during delivery, rather than attempting to remove all anogenital lesional
tissue. (Adapted from Ferenczy A. External anogenital warts: old and new
therapies. J SOGC 1999;(Dec):13051313.)
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Chapter 19 External Genital Condyloma
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