Melbourne Sexual Health Centre Melbourne TREATMENT GUIDELINES Sexual Health Centre A part of Alfred Health WARTS and HPV INFECTION Genital infection with Human Papillomavirus virus (HPV) can result in anal or genital warts. Most HPV infection is asymptomatic. Most genital warts are caused by HPV types 6 & 11. The quadrivalent vaccine (Gardasil) provides excellent protection against these types, but to be most effective needs to be given prior to the commencement of sexual activity. Gardasil is licensed for use in females between the age of 10-45, and males between 9-26. The schedule is: 0.5 mLs IM at 0, 2, and 6 months (rapid course: 0, 1, 3 months). June 2012 Choice of treatment depends on: • number, size, and degree of keratinization of the warts • area affected • patient preference • pregnancy status No treatment is an option as the natural history of HPV infection is to resolve in 12-24 months. This may particularly be an option during pregnancy; genital warts often proliferate at this time but regress markedly postpartum. See MSHC treatment guideline on warts in pregancy. However, most patients request treatment. Approximate cost is $450 for the 3 doses. There is no reliable pre-vaccination test for the HPV types covered in the vaccines. In general, warts which are soft, mucosal, vulval or perianal, or are on or under the prepuce respond well to topical agents such as imiquimod and podophyllotoxin. Condoms offer some protection against infection with HPV but this is limited as infection is usually multi-focal and often involves skin not covered by the condom. Keratinized warts, or those which are long-standing, usually need ablative therapy such as cryotherapy. TREATMENT Asymptomatic infection (Pap smear cytology changes etc) cannot be treated. 80% of HPV infections resolve within 12 months. Genital warts See Wart Treatment video on MSHC website: http://www.mshc.org.au/OnlineEducation/Videos/ tabid/369/Default.aspx Options: • No treatment • Podophyllotoxin • Imiquimod • Cryotherapy • Surgery Cryotherapy • Liquid nitrogen cryospray • Cryoprobe Cryotherapy is well tolerated and unlikely to result in scarring. The only contraindication is cryoglobulinaemia. Few patients need local anaesthesia, although the application of 2% or 5% xylocaine jelly before using the cryoprobe may help diminish discomfort. Imiquimod Imiquimod 5% cream self-applied 1/3 to 1 sachet 3 times a week for 4 – 16 weeks Always give patients an instruction sheet and warn regarding potential local irritation. Review every 4 weeks. Disclaimer The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein. Page 1 Melbourne Sexual Health Centre TREATMENT GUIDELINES Melbourne Sexual Health Centre A part of Alfred Health WARTS and HPV INFECTION June 2012 Do not use imiquimod: • In pregnancy (Category B) or for lactating women • In patients under 18 (no studies done) • In patients with co-existing dermatitis • For intra-anal, vaginal or cervical warts Podophyllotoxin Podophyllotoxin 0.5% solution self-applied twice daily for 3 days then nothing for 4 days. Use for 4 weeks, then review. Warn patients regarding potential local irritation. Precautions: • Contraindicated in pregnancy • Do not use on vaginal or cervical warts or anal warts because solution can be difficult to apply carefully: use podophyllotoxin cream at these sites instead • Do not use on areas of skin affected by dermatitis Combined therapies Combined therapies may be used e.g., use imiquimod tode-bulk a large area of warts prior to cryotherapy, or vice versa Surgery Surgical removal of warts under anaesthesia may be considered for especially large warts where other treatments have failed or are not tolerated. However surgery will not remove HPV which ca result in recurrent warts after surgery. Page 2