Condyloma: Medical Treatment Options
Updated: Jul 18, 2021
C
ondyloma acuminata (CA), also called external genital warts (EGW), is one of the most commonly occurring sexually transmitted diseases [1]. According to an estimation, 500,000 to one million new cases are diagnosed per year in the United States. The fiscal burden of human papillomavirus (HPV) in 2004 was reported to be four billion dollars for the management of genital warts. [2, 3]
Human papillomavirus types 6 and 11 are, in most cases, responsible for genital warts. HPV can remain dormant in epithelial cells for extended periods while not showing any clinical signs and symptoms. It is referred to as subclinical HPV infection. [4]
The lesions of genital warts occur on the moist tissues of the anogenital area. However, they can also occur in the mouth or throat after an oral contraction of the virus through sexual contact [5]. The appearance of the CA lesion ranges from dome-shape, cauliflower shape, pedunculated or flat [6]. Even though the lesion can present individually, it is typically found in large clusters. They can begin as 1-2 mm small papules and either remain the same throughout the infection period or increase in size to as much as a few inches in diameter. [7] The risk factors of CA include early onset of sexual activity, multiple sexual partners, poor hygiene and unsafe sexual practices. [8]
Herein, we are going to discuss the management of CA as backed by evidence.
Management Of Condyloma Acuminata
Diagnosis
Proper diagnosis of genital warts is made by a thorough clinical history and physical examination. Generally, the infection is asymptomatic; however, patients are mainly concerned about the lesion and may present with bleeding, pain and pruritus. [9]
Adequate management of CA does not necessitate the identification of the type of HPV [10].
Biopsy for CA is recommended in the following conditions:
Lesions unresponsive to the initial phase of therapy
When malignancy is suspected. [11]
Discoloured warts
Warts fixed to underlying structures
Patient’s physical examination is done by bright light and magnification as the recommended approach.
Treatment Options
The primary aim of CA therapy is to remove genital warts that can cause physical symptoms or emotional misery. It is not definite that the available treatments at present will cure the primary HPV infection. Although therapy may clear genital warts, HPV infection can still be present in the body. If left untreated, CA lesions may reduce, remain unaffected, or multiply, but they rarely become malignant.
1. Topical Treatment
The first three months of CA treatment consist of topical applications which is the most common treatment option used for CA. These include:
Podophyllotoxin 0.5% solution or 0.15% cream – applied two times a day for three days, followed by a gap of four days. Lesions expected to resolve within four weeks.
Imiquimod 5% cream – applied thrice a week, alternate days with resolution expected in 16 weeks. It is associated with comparatively lesser rates of recurrence.
Imiquimod 3.75% cream
Sinecatechins 15% ointment
Podophyllin
5-fluorouracil (5-FU)
Trichloroacetic acid (TCA) 80 to 90% - applied once in a week for 8 to 10 weeks on smaller lesions of genital warts. This will result in the formation of a small ulcer which will heal without scarring. Interferons are not generally recommended for primary care treatment. [12]
2. Surgical treatment
Cryotherapy – it is less expensive, less painful, and safe for pregnant women. This procedure includes the application of liquid nitrogen on the margins of warts lesions 3 to 5 times a day for 20 seconds during each application. The application process is repeated every week for a period of 6 to 10 weeks.
In the case of unresponsive lesions and severe complication, surgical excision is recommended, which include:
Electrosurgery
CO2 laser
Scissor excision and curettage [9]
5-aminolevulinic acid-photodynamic therapy (ALA-PDT) – Application of 5-ALA PDT is an upcoming therapy with promising results for genital warts. Its benefits include greater effectiveness, simplicity of the procedure, and lower recurrence rates as compared to CO2 laser treatment. 5-ALA PDT is considered to be a valuable adjunct therapy to the standard treatment modalities. [13]
Which therapy will be the treatment of choice for a patient varies diversely, depending upon the physical and psychosocial condition as well as the availability of medical facilities. Other factors such as the extent of the lesion, anatomical location, nature of genital warts, and the existence of any comorbidity also play a crucial role in the type of treatment option used. [14]
References:
1. Fleischer AB, Jr., et al. Condylomata acuminata (genital warts): patient demographics and treating physicians. Sex Transm Dis. 2001;28(11):643–647. [PubMed] [Google Scholar]
2. Cates W., Jr. Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. American Social Health Association Panel. Sex Transm Dis. 1999;26(4 Suppl):S2–S7. [PubMed] [Google Scholar]
3. Markowitz LE, et al. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep. 2007;56(RR-2):1–24. [PubMed] [Google Scholar]
4. Baken LA, et al. Genital human papillomavirus infection among male and female sex partners: prevalence and type-specific concordance. J Infect Dis. 1995;171(2):429–432. [PubMed] [Google Scholar]
5. Batista CS, et al. 5-FU for genital warts in non-immunocompromised individuals. Cochrane Database Syst Rev. 2010(4):CD006562. [PMC free article] [PubMed] [Google Scholar]
6. Mougin C, et al. [Epidemiology of cervical papillomavirus infections. Recent knowledge] Presse Med. 2001;30(20):1017–1023. [PubMed] [Google Scholar]
7. Oriel JD. Natural history of genital warts. Br J Vener Dis. 1971;47(1):1–13. [PMC free article] [PubMed] [Google Scholar]
8. Benjamin M et al. Condylomata acuminata: A retrospective analysis on clinical characteristics and treatment options, Heliyon. 2020;6(3). doi: 10.1016/j.heliyon.2020.e03547. http://www.sciencedirect.com/science/article/pii/S2405844020303923
9. Pennycook KB, McCready TA. Condyloma Acuminata. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547667
10. Eriad Yunir P, Mochtar CA, Hamid AR, Sukasah CL, Umbas R. Surgical Management of Giant Genital Condyloma Acuminata by Using Double Keystone Flaps. Case Rep Urol. 2016;2016:4347821. doi:10.1155/2016/4347821
11. Scheinfeld N., Lehman D. S. An evidence-based review of medical and surgical treatments of genital warts. Dermatology Online Journal. 2006;12(3, article 5) [PubMed] [Google Scholar]
12. Yanofsky VR, Patel RV, Goldenberg G. Genital warts: a comprehensive review. J Clin Aesthet Dermatol. 2012;5(6):25-36.
13. Lee, Wen-Linga,b; Lee, Fa-Kungc; Wang, Peng-Huid,e,f,g,* Management of condyloma acuminatum, Journal of the Chinese Medical Association: August 2019 - Volume 82 - Issue 8 - p 605-606. doi: 10.1097/JCMA.0000000000000127
14. Beutner K. R., Wiley D. J., Douglas J. M., et al. Genital warts and their treatment. Clinical Infectious Diseases. 1999;28(supplement 1):S37–S56. doi: 10.1086/514722. [PubMed] [CrossRef] [Google Scholar]