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Guidelines for anogenital wart management

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Anogenital warts are caused by the human papillomavirus (HPV), of which over 100 genotypes have been identified.

Anogenital warts are benign epithelial skin tumours. They may be single or multiple. Those on the moist, non-hair bearing skin tend to be soft and non-keratinised and those on the dry, hairy skin, are firm and keratinised.

Lesions may be broad based or pedunculated and some are pigmented. Many patients are asymptomatic.

MANAGEMENT

Patients should be given a detailed explanation of their condition. This should be reinforced by offering clear and accurate written information. Treatment choice depends on the morphology, number, and distribution of warts and patient preference. Treatment decisions should be made after discussing the appropriate options with the patient.

Treatment options recommended by the British Association for Sexual Health and HIV (BASHH) in their UK national guidelines on the management of anogenital warts include self-applied treatments (podophyllotoxin 0.5% solution or 0.15% cream, imiquimod 5% cream and sinecatechin leaf extract 10%) and ablative methods (cryotherapy, excision, trichloroacetic acid and electrocautery).

Sinecatechin (Camellia sinensis) leaf extract 10% ointment is a self-administered topical treatment for external genital and perianal warts. In two randomised controlled trials involving a total of 1 005 adults, sinecatechin extract 10% ointment was two-fold more effective than vehicle (placebo) ointment in terms of complete clearance of all baseline and new warts over a maximum treatment duration of 16 weeks. Genital, anal, and oral sexual contact should be avoided while the ointment is on the skin.

A diagnosis of anogenital warts can cause anxiety and distress. For some patients the psychological impact of warts is the worst aspect of the disease. Where psychological distress is apparent, referral for counselling may be appropriate. Current partners of patients with anogenital warts should be offered clinical assessment for the presence of warts along with education and advice about HPV infection and screening for other sexually transmitted infections.

Review is recommended at the end of a treatment course to monitor response and assess the need for further therapy. Patients frequently overestimate their response to treatment and those whose original lesions have responded well to treatment, but in whom new lesions are developing, can continue with the current regimen. Where there is no response, or only a partial response, by the end of the standard treatment duration, it is suggested that a second modality of treatment is applied.

A change in therapy is indicated if either the patient is not tolerating the current treatment, or there is less than a 50% response to the current treatment by four to five weeks (8-12 weeks for Imiquimod). Relapses should be treated as appropriate to the lesion types.

References available on request.

 

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