The management of diYcult anogenital warts

Patients with anogenital warts present the healthcare professional with two major problems—recurrence and persistence. These problems occur because of persistence of human papillomavirus in keratinocytes, defective immune responses in individuals with persistence and recurrence of warts, and the lack of specific antiviral therapy. In this article, the discussion will be confined to the management of lesions visible to the naked eye and a scheme of management that I have found useful is shown in figure 1. The hyperplastic condylomata acuminata that have been present for less than 3 months, often clear quickly after treatment with podophyllin, podophyllotoxin, or cryotherapy. Podophyllotoxin appears to be more eVective than podophyllin in clearing warts and it has the added advantage that the patient can apply it. Recurrence, either at the site of the initial lesions or on adjacent skin or mucosa, is common, and probably indicates active viral activity in that area; therefore, repeated cycles of treatment are often necessary before there is complete eradication. As surrounding tissue necrosis may be a problem, I do not use podophyllin or podophyllotoxin on warts in the vagina, anal canal, or on the uterine cervix. As lesions at these sites often regress spontaneously, I generally leave vaginal and anal warts untreated unless there are associated symptoms such as anorectal bleeding or troublesome vaginal discharge. In my hospital, laser therapy is used less frequently in the treatment of intravaginal or ectocervical warts but, although ulceration can be a complication, I have found 5-fluorouracil cream (5%) useful in the treatment of the former. Loop diathermy for ectocervical warts has the advantage that histological examination for cervical intraepithelial neoplasia (CIN) is possible, and this is my treatment of choice. Scissor excision under local or general anaesthesia is my preferred treatment for intra-anal warts. Treatment with podophyllin or podophyllotoxin is less successful for sessile warts or lesions on dry skin surfaces, such as the shaft of the penis, and I prefer to treat these by ablative methods. Extensive hyperplastic anogenital warts are often refractory to podophyllin, podophyllotoxin, and cryotherapy and are best dealt with surgically or by the topical application of 5-fluorouracil cream, an agent that I have found particularly useful. Persistence at the same site for at least 6 months despite regular conventional treatment is common and, in only very few cases, is a feature of immunodeficiency. A special case, however, is that of pregnancy when, with limited treatment options, anogenital warts can be extensive and persistent. As regression often occurs within several weeks of delivery, treatment is usually unnecessary. Occasionally, however, the warts cause discomfort, and these may be treated with cryotherapy or trichloroethanoic acid (TCA). Conventional therapy is not uniformly successful in the treatment of warts in the immunocompromised patient, including HIV infected individuals, and immunotherapy is generally unsatisfactory; it is not, however, the purpose of this article to discuss this issue further. In deciding on treatment of persistent lesions, it is worth considering the following: Size and number of the lesions—Many individuals have a few warts that are less than 1 mm in diameter and reassurance that spontaneous regression will eventually occur, together with counselling about reducing the risk of sexual transmission, may be all that is necessary. In addition to the psychological morbidity, larger and more numerous warts, however, can cause discomfort, and, particularly at the urethral meatus and in the perianal region, they may bleed and become secondarily infected. How the patient perceives his or her infection— Many patients seek some form of treatment because the presence of even the smallest wart causes considerable anxiety. Sometimes I find that talking with the patient about the following is all that is required: + the benign nature of the lesions + feelings of guilt about having acquired a sexually transmitted infection and allaying these + the natural history of human papillomavirus infection + treatment that is not curative + the possible adverse eVects of treatment of small lesions; there may be damage to surrounding, latent virus-containing tissue with the subsequent growth of warts at that site (Koebner phenomenon). Many patients, however, are not satisfied by this approach. What treatment, then, can be oVered to the individual with persistent warts?