Anogenital warts guide: Treatment and follow-up

This guide focuses on the assessment and management of external anogenital warts (AGW) caused by human papillomaviruses (HPV). HPV vaccination and HPV-related cancer screening recommendations are beyond the scope of this guide.

Management and treatment

Patient education is an important component of providing care to individuals diagnosed with anogenital warts (AGW).

Advise people diagnosed with AGW that:

Determining when HPV may have been acquired is difficult because HPV is very common, readily transmissible through sexual activity (including by individuals without apparent AGW) and has a long incubation period^{Footnote 1}^{Footnote 2}^{Footnote 3}.
AGW may increase in size and number or may spontaneously regress and resolve over a period of months^{Footnote 1}^{Footnote 2}^{Footnote 3}.
With or without treatment, recurrence of AGW is common^{Footnote 1}^{Footnote 2}^{Footnote 3}.
Most AGW are caused by HPV types that are low risk for and only rarely associated with cancer^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 4}^{Footnote 5}^{Footnote 6}^{Footnote 7}^{Footnote 8}.
Co-infection with multiple types of AGW is common^{Footnote 1}^{Footnote 3}^{Footnote 8}^{Footnote 9}^{Footnote 10}^{Footnote 11}^{Footnote 12}^{Footnote 13}^{Footnote 14} and individuals with AGW should follow cancer screening guidelines^{Footnote 1}^{Footnote 6}.
The risk of acquiring other types of HPV may be reduced through HPV vaccination and other prevention measures, such as the consistent and correct use of barrier protection^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 5}^{Footnote 7}^{Footnote 15}^{Footnote 16}^{Footnote 17}^{Footnote 18}^{Footnote 19}^{Footnote 20}^{Footnote 21}.
During pregnancy, warts may recur, expand, or become friable, and are generally less responsive to treatment^{Footnote 2}^{Footnote 19}.
For people who are pregnant, there is a low risk of perinatal transmission, which can lead to recurrent respiratory papillomatosis in infants or children^{Footnote 2}^{Footnote 19}^{Footnote 22}^{Footnote 23}^{Footnote 24}.
Medical follow-up is indicated for sexual partners who find wart-like lesions on self-examination, and who would benefit from screening for other STBBI, cancer screening and/or HPV vaccination^{Footnote 2}.

A diagnosis of AGW can have significant psychosocial impacts^{Footnote 1}^{Footnote 2}^{Footnote 5}^{Footnote 8}^{Footnote 22}^{Footnote 25}^{Footnote 26}. Patients may benefit from supportive counselling and care.

Treatment indications

The goals of treating external AGW are wart removal and symptom relief, including relief of psychological distress^{Footnote 1}^{Footnote 2}^{Footnote 3}. Treatment does not eradicate HPV or prevent recurrences^{Footnote 1}^{Footnote 2}^{Footnote 3}. Without treatment, AGW may resolve on their own, stay the same, or increase in size or number^{Footnote 1}^{Footnote 2}^{Footnote 3}. Treatment may reduce the risk of transmission, but likely does not eliminate it^{Footnote 2}. Understanding the limitations, costs and potential consequences of treatment and the natural history of AGW, some people may choose to forgo or delay treatment^{Footnote 1}^{Footnote 2}^{Footnote 22}.

Treatments may be self- or clinician-applied^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 19}^{Footnote 22}.

The choice of treatment should be guided by^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 19}^{Footnote 22}:

size, shape, number, and site of lesions
person's preference
available resources
cost
convenience
potential adverse effects
clinician experience.

Treatments vary in terms of their effectiveness, cost, side-effect profiles and dosing schedules/ duration of treatment^{Footnote 3}. AGW located in moist or intertriginous areas may respond best to topical treatment^{Footnote 1}^{Footnote 2}. Emerging evidence suggests that a combination of treatments may reduce AGW recurrence rates^{Footnote 19}.

Treatment

Self-applied treatments may be preferred by some patients. In considering their suitability, clinicians should assess if the person will be able to reach and treat all AGW and follow instructions for use^{Footnote 19}. Self-applied treatments should always be used under the guidance of a healthcare professional^{Footnote 2} because they can cause localized and systemic reactions^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 19}.

Urethral meatus, vaginal, cervical and intra-anal warts

Treatment options for urethral meatal warts are limited to cryotherapy or surgical removal^{Footnote 2}. Treatment options for vaginal warts, cervical warts, and intra-anal warts are limited to cryotherapy, surgical removal, or trichloroacetic acid (TCA) or bichloroacetic acid (BCA)^{Footnote 2}.

Cervical and intra-anal warts should be managed in consultation with relevant specialists^{Footnote 2}. Referral to an experienced colleague or specialist is also indicated when AGW are atypical in presentation, the affected area is extensive and when recommended treatments are not effective^{Footnote 1}^{Footnote 2}^{Footnote 22}.

Adolescents

Imiquimod and sinecatechins have not been studied and are not approved in Canada for those younger than 18 years of age^{Footnote 27}^{Footnote 28}^{Footnote 29}.

Pregnant persons

During pregnancy, cryotherapy and trichloroacetic acid are preferred treatment options^{Footnote 19}. Podophyllotoxin^{Footnote 2}^{Footnote 3} and sinecatechins^{Footnote 2}^{Footnote 3}^{Footnote 29} are contraindicated during pregnancy. Imiquimod should be avoided until more data is available^{Footnote 2}^{Footnote 27}^{Footnote 28}. Caesarian section is indicated in the case of obstructing warts, or if they pose a risk of excessive bleeding during vaginal delivery^{Footnote 2}^{Footnote 19}^{Footnote 22}.

People who are immunocompromised

There is a lack of safety and efficacy data for imiquimod and sinecatechins for people who are immunocompromised^{Footnote 27}^{Footnote 28}^{Footnote 29}. Imiquimod should be used with caution in individuals who are immunocompromised. Sinecatechins should not be used for individuals receiving immunsuppressive therapy^{Footnote 29}.

For people living with HIV, consider shared follow-up with an experienced colleague, given:

AGW among people living with HIV may be more numerous, larger, and recalcitrant to treatment;^{Footnote 2}
People living with HIV are at increased risk for cervical intraepithelial lesions (CIN), anal intraepithelial lesions (AIN) and HPV-related cancers^{Footnote 2}^{Footnote 30}^{Footnote 31}^{Footnote 32}.

Clinician-applied treatment

These are the recommended clinician-applied treatments for external anogenital warts (AGW) located on the pubis, penis, scrotum, groin, vulva, perineum, perianal area, or buttocks.

Consult product monographs for information and instructions on use, adverse effects, contraindications, and precautions.

Table 1. Recommended clinician-applied treatments for external AGW
Treatment	Dosage	Additional Information
Cryotherapy [A-I]^{Footnote 1}^{Footnote 2}^{Footnote 19}^{Footnote 33}^{Footnote 34}^{Footnote 35}	Every 1-4 weeks for up to 16 weeks Apply freezing for up to 15 seconds Create 1-2 mm halo around the lesion(s) 1-3 freeze-thaw cycles per session	Causes thermal-induced cytolysis Cryotherapy can be administered as: liquid nitrogen via cotton applicator or spray gun carbon dioxide as dry ice dimethyl ether propane as Histofreeze nitrous oxide via cryoprobe Safe during pregnancy and lactation Destruction of the skin is usually limited to the epidermis or squamous mucous membranes May cause pain, necrosis and blistering May cause hypo/ hyperpigmentation Aggressive treatment can lead to scarring
Bi – or tri- chloroacetic acid (BCA or TCA) [A-I/ B-II]^{Footnote 2}^{Footnote 3}^{Footnote 19}^{Footnote 22}^{Footnote 33}^{Footnote 34}	Every 1 – 3 weeks for up to 16 weeks Apply a small quantity using a toothpick or fine tip swab Avoid surrounding skin Allow to dry Does not need to be washed off If an excess is applied, neutralize by covering the area with sodium bicarbonate (baking soda) or talc powder, or by washing with liquid soap	Causes chemical destruction 50 – 90% solutions in 70% alcohol are most effective Safe during pregnancy and lactation More suitable for small or papular AGW than lager keratinised lesions May produce blisters and ulcerations

Self-applied treatment

These are the recommended self-applied treatments for external anogenital warts (AGW) located on the pubis, penis, scrotum, groin, vulva, perineum, perianal area, or buttocks.

Consult product monographs for information and instructions on use, adverse effects, contraindications, and precautions.

Table 2. Recommended self-applied treatments for external AGW
Treatment	Dosage	Additional Information
Imiquimod 3.75% cream [A-I]^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 19}^{Footnote 27}^{Footnote 36}	Apply a thin layer daily at bedtime for up to 8 weeks Wash off with mild soap and water after approximately 8 hours	Immune modulator Insufficient data on safety during pregnancy and lactation Not studied or approved for use in those younger than 18 Can cause local skin reactions, including erythema, pain, burning, pruritis, erosions May cause hypo/ hyperpigmentation Primary cure rates are lower, but side effects are reduced, compared with imiquimod 5% cream
Imiquimod 5% cream [A-I]^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 19}^{Footnote 22}^{Footnote 28}	Apply a thin layer 3 times a week at bedtime, with 1-2 days between treatments, for up to 16 weeks Wash off with mild soap and water after 6-10 hours	Immune modulator Insufficient data on safety during pregnancy and lactation Not studied or approved for use in those younger than 18 Can cause local skin reactions, including erythema, pain, burning, pruritis, erosions May cause hypo/ hyperpigmentation Adherence may be lower than with imiquimod 3.75% due to long treatment schedule
Podophyllotoxin / Podofilox 0.5% solution [A-I] [Not licensed or available in Canada at the time of publication of this document in 2023]^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 19}^{Footnote 22}	Apply solution using a cotton swab or apply gel using a finger every 12 hours for 3 days, followed by 4 days without treatment, for up to 4 weeks Avoid surrounding skin Allow to dry Wash hands before and after each application Daily dose should not exceed 0.5 ml Treated area should not exceed 10 cm2	Anti-mitotic agent, causes wart necrosis Use with caution near urethral meatus Consider alternate treatment if response is suboptimal after 4 cycles Contraindicated during pregnancy and lactation Commonly causes pain, pruritis, inflammation and eruptions at application sites
Sinecatechins 10% or 15% ointment [A-I] [Only a 10% ointment was available in Canada at the time of publication of this document in 2023]^{Footnote 1}^{Footnote 2}^{Footnote 3}^{Footnote 19}^{Footnote 22}^{Footnote 29}^{Footnote 37}	Apply a 0.5 cm strand using a finger three times per day for up to 16 weeks Daily dose should not exceed 250 mg Does not need to be washed off between applications	Anti-inflammatory, anti-proliferative, anti-apoptotic and anti-viral properties May be more effective on keratinized AWG than other topical treatments Not studied or approved for use in those younger than 18 May stain light-coloured garments and linens Can cause erythema, pain, pruritis, irritation, ulceration, vesicular rash at application sites

Follow-up

For self-applied treatments, follow-up after several weeks of treatment enables health professionals to answer questions about use, address any side effects and assess response to treatment.

When the affected area is extensive or treatment is not effective, combined therapy or referral to an experienced colleague or specialist can be considered^{Footnote 1}^{Footnote 3}^{Footnote 19}^{Footnote 22}. Biopsy and/ or referral may be indicated to confirm the diagnosis for warts that are refractory to treatment^{Footnote 1}^{Footnote 22}.

Reporting and partner notification

National/provincial/territorial notification

AGW are not a nationally notifiable condition in Canada.

Partner notification

Encourage individuals with AGW to discuss their diagnosis with current partners^{Footnote 1}^{Footnote 2}^{Footnote 19}. The consistent use of barrier protection may reduce AGW transmission^{Footnote 1}^{Footnote 18}^{Footnote 20}^{Footnote 21}^{Footnote 26}^{Footnote 38}.

Sexual partners may wish to consult a health professional for HPV vaccination, STBBI screening, cancer screening per guidelines, and assessment and care if they find wart-like lesions on self-examination^{Footnote 1}^{Footnote 2}^{Footnote 19}.

References

References:

Footnote 1

Steben M, Garland SM. Genital warts. Best Pract Res Clin Obstet Gynaecol 2014;28(7):1063-1073.

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Footnote 2

Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021 07 23;70(4):1-187.

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Footnote 3

Yanofsky VR, Patel RV, Goldenberg G. Genital warts: A comprehensive review. J Clin Aesthetic Dermatol 2012;5(6):25-36.

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Footnote 4

Brianti P, De Flammineis E, Mercuri SR. Review of HPV-related diseases and cancers. The new microbiologica 2017;40(2):80-85.

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Footnote 5

Chelimo C, Wouldes TA, Cameron LD, Elwood JM. Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. J Infect 2013;66(3):207-217.

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Footnote 6

Public Health Agency of Canada. Human papillomavirus (HPV) vaccines: Canadian Immunization Guide For health professionals. 2017. Available at: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-9-human-papillomavirus-vaccine.html.

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Footnote 7

Steben M, Tan Thompson M, Rodier C, Mallette N, Racovitan V, DeAngelis F, et al. A Review of the Impact and Effectiveness of the Quadrivalent Human Papillomavirus Vaccine: 10 Years of Clinical Experience in Canada. J Obstet Gynaecol Can 2018;40(12):1635-1645.

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Footnote 8

Trottier H, Franco EL. The epidemiology of genital human papillomavirus infection. Vaccine 2006;24(SUPPL. 1):S4.

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Footnote 9

Aubin F, Prétet J-L, Jacquard A-C, Saunier M, Carcopino X, Jaroud F, et al. Human papillomavirus genotype distribution in external acuminata condylomata: A large French national study (EDiTH IV). Clin Infect Dis 2008;47(5):610-615.

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Footnote 10

Ball SL, Winder DM, Vaughan K, Hanna N, Levy J, Sterling JC, et al. Analyses of human papillomavirus genotypes and viral loads in anogenital warts. J Med Virol 2011;83(8):1345-1350.

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Footnote 11

Chan PKS, Luk ACS, Luk TNM, Lee K-F, Cheung JLK, Ho K-M, et al. Distribution of human papillomavirus types in anogenital warts of men. J Clin Virol 2009;44(2):111-114.

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Footnote 12

Liaw K-L, Hildesheim A, Burk RD, Gravitt P, Wacholder S, Manos MM, et al. A prospective study of human papillomavirus (HPV) type 16 DNA detection by polymerase chain reaction and its association with acquisition and persistence of other HPV types. J Infect Dis 2001;183(1):8-15.

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Footnote 13

Rousseau M-C, Pereira JS, Prado JCM, Villa LL, Rohan TE, Franco EL. Cervical coinfection with human papillomavirus (HPV) types as a predictor of acquisition and persistence of HPV infection. J Infect Dis 2001;184(12):1508-1517.

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Footnote 14

Thomas KK, Hughes JP, Kuypers JM, Kiviat NB, Lee S-, Adam DE, et al. Concurrent and sequential acquisition of different genital human papillomavirus types. J Infect Dis 2000;182(4):1097-1102.

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Footnote 15

Burchell AN, Tellier P-, Hanley J, Coutlée F, Franco EL. Human papillomavirus infections among couples in new sexual relationships. Epidemiology 2010;21(1):31-37.

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Footnote 16

Drolet M, Bénard É, Pérez N, Brisson M, Ali H, Boily M-C, et al. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet 2019;394(10197):497-509.

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Footnote 17

Forcier M, Musacchio N. An overview of human papillomavirus infection for the dermatologist: Disease, diagnosis, management, and prevention. Dermatol Ther 2010;23(5):458-476.

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Footnote 18

Nielson CM, Harris RB, Nyitray AG, Dunne EF, Stone KM, Giuliano AR. Consistent condom use is associated with lower prevalence of human papillomavirus infection in men. J Infect Dis 2010;202(3):445-451.

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Footnote 19

O'Mahony C, Gomberg M, Skerlev M, Alraddadi A, de las Heras-Alonso ME, Majewski S, et al. Position statement for the diagnosis and management of anogenital warts. J Eur Acad Dermatol Venereol 2019;33(6):1006-1019.

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Footnote 20

Pierce Campbell CM, Lin H-Y, Fulp W, Papenfuss MR, Salmerón JJ, Quiterio MM, et al. Consistent condom use reduces the genital human papillomavirus burden among high-risk men: The HPV infection in men study. J Infect Dis 2013;208(3):373-384.

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Footnote 21

Winer RL, Hughes JP, Feng Q, O'Reilly S, Kiviat NB, Holmes KK, et al. Condom use and the risk of genital human papillomavirus infection in young women. New Engl J Med 2006;354(25):2645-2654.

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Footnote 22

Karnes JB, Usatine RP. Management of external genital warts. Am Fam Phys 2014;90(5):312-318.

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Footnote 23

Park H, Lee SW, Lee IH, Ryu HM, Cho AR, Kang YS, et al. Rate of vertical transmission of human papillomavirus from mothers to infants: Relationship between infection rate and mode of delivery. Virol J 2012;9.

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Footnote 24

Smith EM, Ritchie JM, Yankowitz J, Swarnavel S, Wang D, Haugen TH, et al. Human Papillomavirus Prevalence and Types in Newborns and Parents: Concordance and Modes of Transmission. Sex Transm Dis 2004;31(1):57-62.

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Footnote 25

Maw RD, Reitano M, Roy M. An international survey of patients with genital warts: Perceptions regarding treatment and impact on lifestyle. Int J STD AIDS 1998;9(10):571-578.

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Footnote 26

Tyros G, Mastraftsi S, Gregoriou S, Nicolaidou E. Incidence of anogenital warts: epidemiological risk factors and real-life impact of human papillomavirus vaccination. Int J STD AIDS 2021;32(1):4-13.

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Footnote 27

Bausch Health Canada Inc. Product Monograph: Vyloma (imiquimod) Cream, 3.75% w/w. 2019; Available at: https://pdf.hres.ca/dpd_pm/00052002.PDF. Accessed April 18, 2023.

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Footnote 28

Bausch Health Canada Inc. Product Monograph: Aldara P (imiquimod) Cream, 5%. 2019; Available at: https://pdf.hres.ca/dpd_pm/00052002.PDF. Accessed April 18, 2023.

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Footnote 29

Paladin Labs. Veregen Sinecatechins Ointment, 10% (w/w). 2016; Available at: https://pdf.hres.ca/dpd_pm/00034236.PDF. Accessed April 5, 2023.

Return to footnote 29 referrer

Footnote 30

International Agency for Research on Cancer Working Group. Human papillomaviruses (HPV). IARC Monographs 2007;90.

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Footnote 31

Machalek DA, Poynten M, Jin F, Fairley CK, Farnsworth A, Garland SM, et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: A systematic review and meta-analysis. Lancet Oncol 2012;13(5):487-500.

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Footnote 32

Palefsky JM, Rubin M. The Epidemiology of Anal Human Papillomavirus and Related Neoplasia. Obstet Gynecol Clin North Am 2009;36(1):187-200.

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Footnote 33

Abdullah AN, Walzman M, Wade A. Treatment of external genital warts comparing cryotherapy (lipuid nitrogen) and trichloracetic acid. Sex Transm Dis 1993;20(6):344-345.

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Footnote 34

Godley MJ, Bradbeer CS, Gellan M, Thin RNT. Cryotherapy compared with trichloroacetic acid in treating genital warts. Sex Transm Infect 1987;63(6):390-392.

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Footnote 35

Simmons PD, Langlet F, Thin RNT. Cryotherapy versus electrocautery in the treatment of genital warts. Sex Transm Infect 1981;57(4):273-274.

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Footnote 36

Baker DA, Ferris DG, Martens MG, Fife KH, Tyring SK, Edwards L, et al. Imiquimod 3.75 cream applied daily to treat anogenital warts: Combined results from women in two randomized, placebo-controlled studies. Infect Dis Obstet Gynecol 2011;2011.

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Footnote 37

Tatti S, Swinehart JM, Thielert C, Tawfik H, Mescheder A, Beutner KR. Sinecatechins, a defined green tea extract, in the treatment of external anogenital warts: A randomized controlled trial. Obstet Gynecol 2008;111(6):1371-1379.

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Footnote 38

Wen LM, Estcourt CS, Simpson JM, Mindel A. Risk factors for the acquisition of genital warts: Are condoms protective? Sex Transm Infect 1999;75(5):312-316.

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Date modified:: 2024-03-07

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