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Anogenital warts

Definition
Anogenital warts, also known as condylomata acuminata, are a STI caused by certain strains of the HPV, primarily HPV genotypes 6 and 11.
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Pathophysiology
The pathophysiology of anogenital warts involves the transmission of HPV through sexual contact, leading to the infection of squamous epithelial cells in the anogenital region. The virus causes these cells to proliferate excessively, resulting in the formation of warts.
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Epidemiology
The incidence of anogenital warts is estimated at 160-289 per 100,000 person-years worldwide.
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Disease course
Clinically, anogenital warts present as growths on the skin or mucous membranes of the anogenital area. They can vary in size and shape, ranging from flat to raised, small to large, and singular to multiple. Some warts may be asymptomatic, while others can cause symptoms such as itching, discomfort, or bleeding.
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Prognosis and risk of recurrence
The prognosis of anogenital warts is generally good as they are usually benign. However, they can recur after treatment, and certain high-risk HPV strains can lead to malignancies, such as SCC.
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Key sources
The following summarized guidelines for the evaluation and management of anogenital warts are prepared by our editorial team based on guidelines from the International Union Against Sexually Transmitted Infections (IUSTI 2020).
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Guidelines

1.Diagnostic investigations

Physical examination: perform a physical examination using a good light source.
B
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  • Screening for STIs

  • Screening for cervical cancer

  • Assessment of sexual partners

2.Diagnostic procedures

Colposcopy: consider magnification with a lens or colposcope for small lesions.
C

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  • Proctoscopy

  • Biopsy

3.Medical management

First-line patient-applied therapy
Offer one of the following medications as first-line patient-applied therapy:
podophyllotoxin 0.5% solution self-applied to lesions BID for 3 days, followed by 4 rest days, for up to 4 or 5 weeks
A
podophyllotoxin 0.15% cream self-applied to lesions BID for 3 days, followed by 4 rest days, for up to 4 or 5 weeks
B
imiquimod 5% cream self-applied directly to the warts thrice weekly before normal sleeping hours and washed off with soap and water between 6 and 10 hours later, until wart clearance, or for up to 16 weeks
A
sinecatechins 10% or 15% ointment self-applied TID until complete clearance, or for up to 16 weeks
A
Use podophyllotoxin cream in patients with vulvar and perianal warts, as clinical experience suggests that for ease of application the cream formulation is preferable for warts at these sites.

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  • Trichloracetic acid

  • 5-FU

  • Intralesional interferon injections

  • Podophyllin

4.Nonpharmacologic interventions

Smoking cessation: advise smoking cessation for general health benefit, acknowledging that there is no evidence that smoking cessation improves outcomes of wart treatment.
B

5.Therapeutic procedures

Photodynamic therapy: insufficient evidence to support photodynamic therapy for the management of patients with anogenital warts.
I

6.Surgical interventions

First-line clinician-applied therapy: offer one of the following surgical methods as clinician-applied first-line therapy:
surgical excision
cryotherapy
electrosurgery and electrocautery
laser surgery (CO2 and neodymium:yttrium aluminium garnet laser)
A
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  • Combination therapies

7.Specific circumstances

Management of internal involvement: treat patients with vaginal warts with either cryotherapy, trichloracetic acid or any surgical treatment modality.
B
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  • Pregnant patients

8.Patient education

Patient education: provide patients with a detailed explanation of their condition, including advice about onward transmission.
B
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9.Follow-up and surveillance

Follow-up: follow-up patients at regular intervals, for example, every 4 weeks, until warts have resolved, and switch of treatments if an inadequate response is observed.
B

10.Quality improvement

Local treatment algorithms: develop local treatment algorithms that address the needs of the given patient population and are deliverable with the resources available to the service.
B

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