Human Papillomavirus (HPV) Organism-Specific Therapy

Treatment of human papillomavirus (HPV) infection is directed to the macroscopic (ie, genital warts) or pathologic (ie, precancerous) lesions caused by infection. ^{[1, 2]} Genital HPV infection can clear spontane­ously; therefore, specific antiviral therapy is not recom­mended. In the absence of lesions, treatment is not recommended for subclinical genital HPV infection.

Treatment also is not recommended for cervical intraepithelial neoplasia 1 (CIN1). For CIN2 or greater, refer to the American Society for Colposcopy and Cervical Pathology (ASSCP) ^[3] and American Congress of Obstetricians and Gynecologists (ACOG) guidelines for evaluation and management. ^{[1, 2, 4]}

External genital warts

Genital warts are commonly asymptomatic but, depending on the size and location, may be painful or pruritic. Primary treatment should be targeted at symptomatic relief and removal of warts. Therapy may be applied by the patient or by the provider. There is no evidence that any one treatment is superior to the others. A treatment response is usually seen within 3 months.

Patient-applied therapy is as follows:

• Podofilox 0.5% solution applied with a cotton swab or podofilox gel applied with a finger to genital warts BID for 3 days, followed by 4 days of no therapy; repeated as needed for up to 4 cycles (total wart area treated should not exceed 10 cm², and total volume of podofilox should be limited to 0.5 mL/day) or

• Imiquimod 5% cream applied at bedtime 3 times weekly for up to 16 weeks; the treatment area should be washed with soap and water 6-10 hours after the application or

• Sinecatechins 15% ointment applied with a finger (0.5-cm strand of ointment to each wart) TID to ensure coverage with a thin layer of ointment until complete clearance of warts, but not for >16 weeks; the medication should not be washed off after use; sexual (genital, anal, or oral) contact should be avoided while the ointment is on the skin

Provider-administered therapy is as follows:

• Cryotherapy with liquid nitrogen or cryoprobe every 1-2 weeks or

• Podophyllin resin 10%-25% in a compound tincture of benzoin every 1-2 weeks as needed or

• Trichloroacetic acid (TCA) or bichloracetic acid (BCA) 80%-90% every 1-2 weeks as needed or

• Surgical removal by tangential scissor excision, tangential shave excision, curettage, or electrosurgery

Vaginal warts

Treatment for vaginal warts is as follows:

• Cryotherapy with liquid nitrogen (the use of a cryoprobe in the vagina is not recommended because of the risk of vaginal perforation and fistula formation) or

• TCA or BCA 80%-90% applied to warts, repeated weekly if necessary; a small amount should be applied only to warts and allowed to dry, at which time a white frosting develops; if an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid

Urethral meatus warts

Treatment for urethral meatus warts is as follows:

• Cryotherapy with liquid nitrogen or

• Podophyllin 10%-25% in compound tincture of benzoin, repeated weekly if necessary; the treatment area and adjacent normal skin must be dry before contact with podophyllin; the safety of podophyllin during pregnancy has not been established; data are limited on the use of podofilox and imiquimod for treatment of distal meatal warts

Anal warts

Treatment for vaginal warts is as follows:

• Cryotherapy with liquid nitrogen or

• TCA or BCA 80%-90% applied to warts, repeated weekly if necessary; a small amount should be applied only to warts and allowed to dry, at which time a white frosting develops; if an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid; or

• Surgical removal

Prevention

HPV vaccines have been demonstrated to protect against diseases and precancerous conditions cause by the HPV types contained in each vaccine in individuals who have not previously been infected with those particular HPV types.

Depending on the HPV type, vaccination offers protection against the HPV types that cause 70% of cervical cancers (ie, types 16 and 18). One HPV vaccine is available in the United States to decrease the risk of certain cancers and precancerous lesions in women and men. The nonavalent HPV vaccine covers types 6, 11, 16, 18, 31, 33, 45, 52, and 58. ^{[5, 6, 7, 8, 9]} Cervarix (2vHPV) and Gardasil (4vHPV) were discontinued in the United States in October 2016. The FDA-approved indications for Gardasil 9 (9vHPV) are listed below (see Table 1).

Table 1. HPV Vaccine (Open Table in a new window)

A 3-dose series is standard administration for the vaccine. In children and young adolescents, a 2-dose regimen is approved for the nonavalent vaccine (see Table 2).

Table 2. HPV Vaccine Dose Schedules ^[10] (Open Table in a new window)

Counseling considerations for patients diagnosed with HPV infection

Within an ongoing sexual relationship, both partners are usually infected at the time when one of them is diagnosed with HPV infection, even though signs of infection might not be apparent.

A diagnosis of HPV in one sex partner is not indicative of sexual infidelity in the other.

Treatments are available for the conditions caused by HPV (eg, genital warts), but not for the virus itself.

HPV does not affect a woman’s fertility or ability to carry a pregnancy to term.

Correct and consistent male condom use might lower the chances of transmitting genital HPV, but such use is not fully protective, because HPV can infect areas that are not covered by a condom.

Sexually active persons can lower their chances of getting HPV by limiting their number of partners; however, HPV is common and often goes unrecognized, and persons with only one lifetime sex partner can have the infection.

Genital warts commonly recur after treatment, especially in the first 3 months.

Persons with genital warts should inform current sex partner(s) because the warts can be transmitted to other partners; they should refrain from sexual activity until the warts are gone or removed.