An evidence-based review of medical and surgical treatments of genital warts.

Genital human papillomavirus (HPV) infection is the most common sexually transmitted disease. Each year 1 million new cases of genital warts are diagnosed, two thirds of which are in women. The estimated prevalence rate in the US population is 15 percent. HPV infects keratinocytes. Such infection can manifest clinically as warts. Treatment options for genital warts are numerous, well established, and effective. Topical treatments include podophyllin resin, imiquimod, trichloroacetic acid, and podophyllotoxin. Surgical or destructive therapies include carbon dioxide laser, surgical excision, loop excision, cryotherapy, and electrodessication. Interferon can be injected locally or administered systemically to treat genital warts. Evidence of efficacy in the treatment of genital warts is drawn from randomized blind-controlled trials, prospective studies, and retrospective cohort studies. Evidence of efficacy appears to be good, but more head-to-head studies and comparisons of combination therapies versus monotherapy need to be done. Treatment of choice depends on the number, size, and location of lesions. There is little certainty that any approach is more effective than another, however costs differ. It would seem that the first line destructive treatment is cryotherapy, but surgery and electrodesiccation are more effective. The first line topical treatments appear to be podophyllotoxin and imiquimod. Interferon is too expensive and trichloracetic acid is too inconsistent to be recommended as primary treatment. It is unclear if combinations of therapies are more effective than monotherapy. Side effect profile, cost, effectiveness and convenience (ability to attend physician's office or to undertake protracted home treatment) define the choice of therapy.