Question 2 - Anogenital Warts Question Bank

A 23-year-old cisgender man is evaluated in a sexual clinic for perianal and buttock warts. He first noticed the lesions a few months prior and denies any pain or bleeding. He is sexually active with men and rarely uses condoms. Recent testing for HIV and syphilis was negative. Physical examination reveals a cluster of verrucous lesions in the perianal area and gluteal folds (Figure 1). The lesions are hypopigmented without induration, bleeding, or ulceration. He does not want to come back to the clinic for treatment and states he is comfortable with self-applied treatment.

Which one of the following would be the most appropriate patient-applied topical option for the management of anal warts in this man?

Betamethasone dipropionate 0.05% ointment applied to affected area daily for 14 days

Trichloroacetic acid (TCA) applied to affected area once weekly for up to 12 weeks

Imiquimod 5% cream applied to affected area once at bedtime three times weekly for up to 16 weeks

Tretinoin 0.05% cream applied to affected area once at bedtime nightly for up to 12 weeks

Figure 1. Warts in Gluteal Fold

This image shows multiple anogenital warts clustered bilaterally in the gluteal fold region.

Photograph credit: Negusse Ocbamichael, PA; Public Health—Seattle & King County Sexual Health Clinic

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Question Last Updated
August 10th, 2022

Table 1. 2021 STI Treatment Guidelines: Anogenital Warts
Treatment of External Anogenital Warts

External anogenital warts include penis, groin, scrotum, vulva, perineum, external anus, and perianus*

Recommended for PATIENT-APPLIED Therapy

Imiquimod 3.75% cream

Tradename:Zyclara

Apply the 3.75% cream once at bedtime, every night consecutively for up to 8 weeks.

The treatment area should be washed with soap and water 6-10 hours after the application.

Note: The imiquimod cream might weaken condoms and vaginal diaphragms.

Recommended for PATIENT-APPLIED Therapy

Imiquimod 5% cream

Tradename:Aldara

Apply the 5% cream once at bedtime, three times a week for up to 16 weeks.

The treatment area should be washed with soap and water 6-10 hours after the application.

Note: The imiquimod cream might weaken condoms and vaginal diaphragms.

Recommended for PATIENT-APPLIED Therapy

Podofilox 0.5% solution or gel

Tradename:Condylox

Apply podofilox solution (using a cotton swab) or podofilox gel (using a finger) to anogenital warts twice a day for 3 days, followed by 4 days of no therapy. Repeat the cycle, as necessary, for up to four cycles.

The total wart area treated should not exceed 10 cm², and the total volume of podofilox should be limited to 0.5 mL per day.

Recommended for PATIENT-APPLIED Therapy

Sinecatechins 15% ointment

Tradename:Veregen

Apply three times daily (0.5 cm strand of ointment to each wart) using a finger to ensure coverage with a thin layer of ointment until complete clearance of warts is achieved. This product should not be continued for longer than 16 weeks.

Do not wash off after use.

Note: Sinecatechins might weaken condoms and vaginal diaphragms.

Recommended for PROVIDER-ADMINISTERED Therapy

Cryotherapy with liquid nitrogen or cryoprobe

Tradename:

Local anesthesia (topical or injected) might facilitate therapy if warts are present in many areas or if the area of warts is large.

Note: Health care providers should be trained on the proper use of this therapy because over- and under-treatment can result in complications or low efficacy.

Recommended for PROVIDER-ADMINISTERED Therapy

Surgical removal either by tangential scissor excision, tangential shave

Tradename:

After local anesthesia is applied, anogenital warts can be physically destroyed by electrocautery, in which case no additional hemostasis is required. Alternatively, the warts can be removed either by tangential excision with a pair of fine scissors or a scalpel, by carbon dioxide (CO2) laser, or by curettage.

Note: Surgical therapy has the advantage of eliminating most warts at a single visit, although recurrence can occur. Surgical removal requires substantial clinical training, additional equipment, and sometimes a longer office visit.

Recommended for PROVIDER-ADMINISTERED Therapy

Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% solution

Tradename:

A small amount should be applied only to the warts and allowed to dry (i.e. develop white frost on tissue) before the patient sits or stands.

If pain is intense or an excess amount of acid is applied, the area can be covered with sodium bicarbonate (i.e., baking soda), washed with liquid soap preparations, or be powdered with talc to neutralize the acid or remove unreacted acid. TCA or BCA treatment can be repeated weekly if necessary.

Note: TCA solution has a low viscosity comparable with that of water and can spread rapidly and damage adjacent tissues if applied excessively.

*Persons with external anal or perianal warts might also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.

Source: Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. Human papillomavirus (HPV) infection: anogenital warts. MMWR Recomm Rep. 2021;70(No. RR-4):1-187. [2021 STI Treatment Guidelines]

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Which one of the following would be the most appropriate patient-applied topical option for the management of anal warts in this man?

Table 1. 2021 STI Treatment Guidelines: Anogenital Warts
Treatment of External Anogenital Warts

Imiquimod 3.75% cream

Imiquimod 5% cream

Podofilox 0.5% solution or gel

Sinecatechins 15% ointment

Cryotherapy with liquid nitrogen or cryoprobe

Surgical removal either by tangential scissor excision, tangential shave

Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% solution

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Questions in Topic

Which one of the following would be the most appropriate patient-applied topical option for the management of anal warts in this man?

Table 1. 2021 STI Treatment Guidelines: Anogenital WartsTreatment of External Anogenital Warts

Imiquimod 3.75% cream

Imiquimod 5% cream

Podofilox 0.5% solution or gel

Sinecatechins 15% ointment

Cryotherapy with liquid nitrogen or cryoprobe

Surgical removal either by tangential scissor excision, tangential shave

Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% solution

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Table 1. 2021 STI Treatment Guidelines: Anogenital Warts
Treatment of External Anogenital Warts