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May 01, 2022
Genital warts (HPV) treatments: options,
effectiveness, and cost
What to expect in this article?
This article summarizes and compares genital warts treatment options. It should help someone with genital warts make an informed, practical treatment decision.
We’ll begin with a short overview of genital warts, including their transmission, diagnosis, and disease course, which should help you better understand the discussion of treatment that follows.
This article is written by STD expert Dr. Slava Fuzayloff from STDcenterNY (the busiest STD testing and treatment center in NYC).
Contents
This article is about free or low-cost STD testing and treatment options in New York, NY. Here we will summarize and compare different options that New Yorkers and our city's guests have when they need free STD testing or treatment.
The article contains all the practical information that's necessary to make an informed decision on free or low-cost STD testing in New York City.
Let's begin!
What are genital warts?
Genital warts - official name Condylomata acuminata - are caused by human papilloma virus (HPV).
Only a small number of people (10%) infected with HPV get visible genital warts.
The chance of transmission of HPV with unprotected sex is 70% (if partner has visible warts)
Over 200 types of HPV have been identified, and more than 40 of them can be transmitted genitally.
How common are genital warts?
HPV is the most common sexually transmitted disease in the world.
- At least 75% of sexually active adults in the United States have been infected with at least one genital HPV type at some point.
- The estimated chance that an unvaccinated person has HPV is about 10%-20%. An HPV vaccination significantly reduces the chances of getting the disease.
- Over 3 million sexually active people in United States, or 1% of the population, get genital warts each year.
Long-term risk of genital warts
HPV is the most common sexually transmitted disease in the world.
- At least 75% of sexually active adults in the United States have been infected with at least one genital HPV type at some point.
- The estimated chance that an unvaccinated person has HPV is about 10%-20%. An HPV vaccination significantly reduces the chances of getting the disease.
- Over 3 million sexually active people in United States, or 1% of the population, get genital warts each year.
How HPV transmission occurs
HPV is transmitted through direct skin-to-skin contact with infected skin or mucosa (mucosa is found inside the mouth, vagina, and rectum). The HPV virus invades skin cells through micro abrasions (tiny cuts).
Genital warts are almost always acquired through sexual contact. No visible warts are required for transmission, but visible warts are more contagious because the viral load is higher in visible warts.
Once acquired, HPV can cause a visible genital wart or can enter a latent state without visible sign and symptoms.
The usual incubation period for visible genital warts can be from three weeks to eight months. The median time is 2.9 months.
The chance of developing visual genital warts after contracting HPV-6 and HPV-11 infection appears to be high.
Genital warts' appearance and symptoms
- Genital warts are typically found on the vulva, penis, groin, perineum, anal skin, perianal skin, and/or suprapubic skin.
- A genital wart can be single or multiple, flat or dome-shaped, cauliflower-shaped or smooth (especially on the penile shaft).
- The color varies from white to brown.
- Warts are usually asymptomatic, but occasionally they cause itching. The itching is usually insignificant.
The disease course
- After their initial appearance, genital warts may increase in number and size, or they may go away spontaneously. It's estimated that approximately one-third (30%) of genital warts go away without treatment within four months. But 10% of HPV infections persist despite resolution of visible warts and may result in wart recurrence later. This stage when there are no symptoms is called the latent stage.
- Mechanical irritation, immunosuppression, and inflammation affect the number of viral copies in the latently infected skin cells and may predispose the infected person to a reappearance of visible genital warts.
Diagnosis
- In most cases, a doctor familiar with the condition can diagnose genital warts by physical examination. If there is uncertainty, a biopsy is performed.
- Testing to determine the HPV type is not routinely performed because it doesn't influence the papilloma treatment.
- Additional evaluation for internal involvement is necessary if genital warts are affecting the anus, urethra, vagina, or cervix. Specialist referral and evaluation is necessary if suspicion of internal involvement is high.
- Ideally, testing for other STDs is done, because a study from Australia between 2002 and 2007 showed that approximately 5% of people with genital warts also have chlamydia and gonorrhea.
- Application of acetic acid for diagnosis is not advised because of high false-positive rates and the pain associated with it.
Treatment of genital warts
Overview
Available genital warts treatment options are somewhat inadequate because the goal of such treatment is to remove the warts, decrease any symptoms, and help with cosmetic appearance rather than cure the underlying viral infection.
As yet, little evidence suggests that one type of treatment has emerged as a gold-standard treatment. Therefore, the choice of which treatment to have depends on the treatment goal and individual patient wishes.
Doctors have a few ways of treating genital warts:
- At-home treatment
- In-office treatment
- Combination treatment (in-office and at-home treatment)
Let's discuss each treatment option in more detail.
At-home genital warts treatment (removal) options
Two types of at-home treatment options are available:
- Over-the-counter treatment
- Doctor-prescribed medications
Over-the-counter treatment
- 17% salicylic acid, which can be obtained over the counter without a prescription.
- A great treatment option for the common wart on skin that's not in the genital area.
- However, genital skin is thinner, and salicylic acid can easily cause burning and scarring.
Doctor-prescribed medication
Most genital warts medication can be obtained only with a doctor's prescription.
The table below summarizes commonly prescribed medications.
Pay special attention to:
- The duration of treatment: some treatments are prolonged, and treatment compliance can become an issue
- Response rate: the percentage of people who respond to the medication with disappearance of all genital warts
- Recurrence rate: the percentage of people who get a recurrence of warts after the initial full response (that is, after visible warts have disappeared)
| Wart treat ment type |
Use | Side effects | Respo nse rate |
Recur rence rate |
Cost |
|---|---|---|---|---|---|
| Imiqui mod cream (brand name: Aldara) |
Applied once at a bedtime, 3 times a week for 16 weeks The area needs to be washed thorou ghly with soap and water 6–10 hours later. |
Redness, irritation, hypopig menta tion of the skin area treated |
56% | 13% | Covered by most health insurance plans If no health insurance is available, the cost at the pharmacy with a discount coupon is $17. |
| Sinecate chins ointment (brand name: Veregen) |
A thin layer of the oint ment should be applied three times a day for 16 weeks Advanta ges: no frequent follow-up needed; can be stored at room tempera ture. Special instruc tion: The area needs to be washed before sexual activity. |
5% of patients have applica tion site reaction: redness, soreness, ulceration |
58% | 6%–9% | Covered by most health insurance plans If no health insurance is available, the cost at the pharmacy with a coupon is $1,500 |
In-office (physician) genital warts treatment options
These treatment options are available in a STD doctor's office
- Acid application
- Freezing
- Electrosurgery
All of these are usually same-day, very minor, in-office procedures. Each procedure takes just a few minutes.
The table below summaries the procedures.
Pay special attention to:
- Response rate: the percentage of people who respond to the procedure with full disappearance of all genital warts
- Recurrence rate: the percentage of people who get the recurrence of warts after the initial full response (that is, after visible warts have disappeared)
| Treat ment type |
Proce dure |
Side effects | Respon se rate |
Recur rence rate |
Cost |
|---|---|---|---|---|---|
| Acid applica tion: trichloro acetic acid (TCA) |
Applied once at a bedtime, 3 times a week for 16 weeks The area needs to be washed thorou ghly with soap and water 6–10 hours later. |
Local pain and irritation | 70% | 18% | Covered by health insurance Cost without health insurance is $90 |
| Cryo therapy (freezing genital warts) |
Liquid nitrogen is applied to visible genital warts and the skin around them using a Q-tip or special gun. | Skin irritation and blister | 80%–90% Treat ments are done 2 weeks apart. |
16%–35% | Covered by health insurance The total cost without health insurance is $200 for two treat ments |
| Laser removal | Concen trated high energy is applied to destroy warts. |
Mild skin burning | 23%–52% | 77% | Very costly Done in special facilities |
| Electro surgery |
Warts are destroyed by a high-frequency electric current. | The proce dure is painful, so local pain killer is usually neces sary. |
94% | 22% | Covered by health insurance. Cost without health insurance is $500–$800. |
Comparing genital warts treatment types
Here we will compare the two major treatment (removal) types (in-office procedures and self-applied medication). This discussion will explain why some people choose one type of the treatment over the other.
Convenience
By convenience, we mean the duration of treatment. The longer the treatment, the less convenient it is.
The treatment time for home-applied medication is much longer, so treatment compliance becomes an issue (patients forget to apply the medication daily and at the right time).
- Self-applied at-home treatment: 1 month to 4 months
- In-office treatment: One-time, same-day procedure One or two follow-ups will be necessary, depending on wart size and the skin area affected.
Response rate
The response rate is the percentage of people who get better (complete disappearance of the warts) with treatment.
The response rate is much better with in-office procedures (70% to 94%) than with self-applied home treatment (42 to 58%).
Recurrence rate
The recurrence rate is the percentage of people whose warts return after their initial disappearance
The recurrence rate for both treatment types is more or less the same.
Privacy
Self-applied medication can be used privately and conveniently at home.
Cost
Both treatment types are covered by most health insurance plans. For uninsured patients, the cost of in-office procedure might be slightly higher.
How doctors choose the best treatment method for "your" genital warts
Since no single wart treatment is superior to others and good for everyone, doctors recommend treatment based on the following:
- Patient preference ("patient-preferred method")
- Genital warts morphology; that is, external appearance of the genital warts ("morphology method")
- Combination therapy when appropriate ("combination method")
Patient-preferred method of genital warts treatment
The patient-preferred method uses two lines of treatments:
- First-line treatment: the initial warts treatment
- Second-line treatment: treatment of resistant warts
First-line treatment for most genital warts
- Patient-applied treatment with podofilox (Condylox) or imiquimod (Aldara)
or
- Cryotherapy (a minor procedure in a doctor's office)
These first-line treatment options are comparably effective and the choice of which to use depends mainly on the patient's preference. That's why the treatment modality is called the "patient-preferred method."
Patient-preferred method of genital warts treatment
The patient-preferred method uses two lines of treatments:
- First-line treatment: the initial warts treatment
- Second-line treatment: treatment of resistant warts
The main differences between those two options are convenience and compliance:
- Doctors' office treatment options (cryotherapy and electrosurgery) are more aggressive and destroy warts with a one-time treatment. They are same-day, minor, in-office procedures.
- With self-applied prescription medication, the same results can be achieved, but it takes much longer (at least a month).
The patient should be compliant with a treatment for a longer time (it can take 4 to 16 weeks depending on the medication chosen).
The main advantage of this treatment option is that it can be done in the convenience and privacy of your own home.
Second-line treatment for most genital warts
If the warts do not respond to the initial treatment, second-line treatment can be tried:
- TCA (a minor procedure in a doctor's office)
- Surgical removal (also a minor procedure in a doctor's office)
Morphology method of genital warts treatment
Genital warts can be keratinized (that is, have a hard, thick surface) or non-keratinized. Keratinized warts have a thicker, drier surface (they feel like corn kernels on the skin) than non-keratinized warts, which are softer. Non-keratinized warts are more common in the genital area.
More aggressive (more destructive) treatment methods should be used for keratinized warts, since more dead skin layers must be penetrated with a treatment to get to the "root" of the wart.
Keratinized warts treatment
- Cryotherapy (a minor procedure in a doctor's office)
or
- Electrocautery
or
- Surgical excision
Non-keratinized warts treatment
Chemical treatment of warts is effective when skin is moist and soft:
- Patient-applied treatment with podofilox (Condylox) or imiquimod (Aldara)
or
- Cryotherapy (a minor procedure in a doctor's office)
Combination method of genital warts treatment
The combination-treatment approach of cryotherapy (or electrosurgery) plus imiquimod or podofilox is used by many clinicians, including our center, STDcenterNY
This approach has the best initial clearance rate of 96.3% and a recurrence rate of 7.4%.
The idea behind this approach is to destroy the initial warts with a powerful destructive method (cryotherapy) and follow that with self-applied podofilox (Condylox) to augment the initial treatment response and target latent (invisible) and residual HPV infection.
No treatment, or "watchful waiting"
No treatment, or "watchful waiting," is an option for any genital warts, especially in the vaginal and anal areas. It is an option because 30% of genital warts go away on their own within four months without treatment.
Here are the two major downsides of this method:
- The infection can spread to other parts of the skin initially (usually locally, but it can spread anywhere) and to the skin of sexual partners.
- The patient should have no sex for a few months until visible warts have disappeared.
What can be done for sex partners of HPV-positive people
This section is for sex partners of HPV-positive patients
Patients that have a history of HPV are presumed to have latent (dormant) HPV infection.
Anyone who has been identified as having genital warts should let their sexual partner(s) know about the wart's diagnosis.
For female partners
A female partner should be counseled about cervical cancer screening and getting an HPV vaccination if they haven't had one.
For male partners
A male partner's genital skin (including in the rectal area) should be visually examined. HPV vaccination should be considered for people who "receive" anal sex.
Future partners
Doctors make no recommendations about informing future sex partners of a past genital warts diagnosis (such disclosure is optional). The virus can be invisible but present on the skin and can be activated and be transmitted.
The good news is that most young people in the United States of both genders have been vaccinated with Gardasil (HPV vaccine) and are protected from the most common type of HPV.
