Introduction

Genital warts are one of the most prevalent sexually transmitted diseases. It is a viral infection caused by human papillomavirus (HPV) and is marked by the appearance of tiny and rough bumps around the genitals and anus.¹ Even though they are usually not dangerous, they can cause physical discomfort such as itching, swelling, and pain. Moreover, untreated warts can spread to other parts of the body or to sexual partners.¹ Genital warts can also have a serious psychological impact due to the stigma associated with sexually transmitted diseases.² Therefore, it is crucial to treat them promptly to ensure your overall well-being.

Identifying genital warts

You can get genital warts by having sex with someone with this condition. However, it could take weeks or even months for the symptoms to appear, even if you get infected.¹ These usually appear as rough bumps alone or in clusters (with an appearance like cauliflowers) around the penis, vagina, anus, or perineum. They can be white, red, or skin-toned to darker than the surrounding skin.¹

Symptoms include:

• Pain, itching, or bleeding.
• Discomfort during sex.
• Difficulty peeing, with occasional blood in the urine, 
• Change in the normal flow of urine¹

Treatment options

The causative agent of genital warts, HPV, has no known treatment, and removing noticeable warts does not always stop your underlying HPV infection from spreading. Sometimes, treatment for genital warts is not necessary because they might disappear on their own. Around 80% of HPV-positive people will naturally recover from their infection in around 24 months.³ However, getting treatment for genital warts is better as it:

• Reduces the possibility of the infection spreading
• Removes warts that are challenging to maintain clean
• Able to ease any discomfort or irritation⁴

The appearance, location, and size of the warts and your overall health (like pregnancy or immunity) will determine the kind of treatment suitable for you.^1,3,4

Topical medications

Genital warts can be removed more successfully with physically ablative treatments. However, topical medications like creams, solutions, or ointments are frequently chosen by patients as a first line of treatment, particularly for smaller lesions.³

Podofilox

• It is a solution that is applied to external warts (outside the genital skin)
• It works by preventing the growth of the wart cells and causing the wart to fall off^1,3
• The medication inhibits an enzyme, which prevents DNA from unwinding and replicating, thereby inhibiting cell division⁵
• It is usually recommended twice daily for three days with a 4-day break. However, it can result in side effects like mild skin irritations, insomnia, headaches, and vomiting⁷
• Using podofilox during pregnancy and for warts close to the rectal region is not advised⁶

Imiquimod

• This cream acts as an immune response modifier
• It strengthens the immune system to combat HPV and cure genital warts
• It's applied three times a week and generally leads to non-scarring healing^1,3

Sinecatechins

• It is an ointment derived from green tea extract and is used for external warts and warts surrounding the anus
• It helps by reducing the viral proteins of HPV that are responsible for wart growth
• This ointment has a success rate in clearing warts with fewer side effects compared to other treatments
• However, it takes longer to work and may cause redness and inflammation^1,3,4

Isotretinoin

• This drug is commonly used to treat acne, but it is also occasionally used to treat genital warts that are difficult to cure, especially in individuals with weakened immune systems
• Due to its serious side effects, which include severe birth defects, women who are of reproductive age must utilise tight birth control
• Moreover, it causes dry skin and sun sensitivity^1,3

Trichloroacetic acid and Bichloracetic acid 

• Both of these acids can destroy wart tissue
• However, trichloroacetic acid is more commonly used
• It needs to be applied by a healthcare provider once a week for 4-6 weeks
• It can cause pain and burning but is safe during pregnancy^{3, 7}

Interferons

• These are proteins that stop the virus from replicating in affected cells
• They increase cytokines that lower the viral load and size of the wart⁸
• It is available as both a topical gel and an injection⁶

Some tips to ensure effective treatment include

• Always apply these medications following careful attention to instructions, e.g., some need washing off after a certain amount of time
• Avoid smoking, as it helps treatments work better
• Wait till the warts have disappeared before having any intercourse
• Avoid using over-the-counter wart treatments, as these medications may not be specific to the genital warts you have. Always take medications only with a prescription after consultation with a doctor
• Do not apply any creams to open wounds or healthy skin¹

Procedural treatments

There are several procedural treatments to treat genital warts when topical medicines are insufficient. While selecting a technique, doctors usually consider the type of warts and the patient's preferences.¹  

Cryotherapy (freezing)

Using a very cold substance such as liquid nitrogen or a mixture of dimethyl ether and propane to freeze out warts is known as cryotherapy. This approach targets the wart tissue, causing a blister to form and eventually fall off as the wart thaws and heals. They are used for localised warts and not for widespread ones. Since the warts may regrow, this approach often requires multiple sessions. It often takes one to three weeks to recover, depending on how many and where the warts were removed.^{4, 9, 10}

Following therapy, you may notice:

• Blisters or sores
• Exfoliating dead tissue
• Swelling
• Mild pain, irritation and burning
• Change in skin colour¹⁰

Electrocautery (burning)

• This technique uses an electrical current and a low-voltage electrified probe to burn off the warts
• Similar to cryotherapy, it is used for small areas of warts. Usually, healing takes two to four weeks, and scars from treatment are possible¹¹

Electrocautery risks include:

• Slight bleeding. 
• Swelling and redness
• Pain, sometimes requiring medication 
• Infection–To lower the chance of infection, antibiotics may be administered at the time of the procedure¹¹

Laser treatment

A high-intensity laser beam is used in laser therapy to target and destroy wart tissue.

The recovery period is generally two to four weeks, depending on where and how many warts are removed. This treatment is appropriate for warts that are widespread and have not been successfully removed by medication. However, if you are pregnant, it's important to speak with your doctor to decide when the procedure is best timed.

After the procedure, you may experience:

• Itching, swelling, or pain
• Sores in the treated region
• Tissue that sticks to one another
• Scarring^11,12

Surgical removal by excision

Surgical removal involves cutting out the warts using a scalpel or other surgical instruments. When a wart is large, widespread, or has not responded to previous treatments, this method is often chosen. Usually, a single procedure may be sufficient. Similar to other procedures, how long it takes to recover depends on where and how many warts are removed. Typically, it takes a week or two, and usually, people may resume their regular activities in one to three days.¹³

Surgical risks include:

• Scarring
• Bleeding
• Infection– antibiotics could be given to lower your risk 
• Pain for a few days following the surgery is usually managed with medication¹³

Warts during pregnancy?

During pregnancy, genital warts may grow and multiply faster and become irritated easily. Rarely can they be passed to the baby during birth. Since most treatments are not recommended during pregnancy and because warts can often disappear within 6 weeks after delivery, treatments are usually delayed until the baby is born. However, if you are pregnant, it is crucial to inform your doctor so that they can choose an appropriate treatment for you.¹

Home remedies

Many people explore natural home remedies for genital warts. The following are a few of the best home remedies:

• Apple cider vinegar removes warts by turning them into dry and scaly tissue
• Tea tree oil has antiseptic and antiviral properties; it may help reduce warts and itching
• Castor oil darkens and causes warts to fall off in about 2-3 weeks
• Garlic has antiviral properties that may inhibit wart growth and help with removal
• Banana peels contain enzymes that may help dissolve warts when applied regularly
• Witch hazel has astringent properties that might help shrink warts
• Thuja occidentalis is often used in homoeopathy to treat warts
• Onion juice, with its antimicrobial properties, may assist in wart removal
• Olive leaf extract was historically used to inhibit viral growth and may help with warts
• Pineapple juice contains bromelain, which may help with inflammation and scar reduction
• Willow tree bark contains salicylic acid, which may help reduce warts due to its anti-inflammatory properties¹⁴

Preventing occurrence

HPV vaccination

The HPV vaccination lowers your chance of contracting the virus that causes genital warts. Recent CDC and FDA guidelines advise that individuals up to 45 years old receive an HPV vaccination.^1,6

Safe sexual practices

The most effective way to reduce your chance of developing genital warts is to engage in safer sexual practices. This includes using a condom during oral, anal, and vaginal intercourse and while sharing sex toys. However, because a condom does not completely protect the genital region, it does not eliminate risk. Even if you use a condom, avoid having intercourse if you have visible warts.^{1, 15}

Summary

Genital warts are a sexually transmitted disease caused by the human papillomavirus. It results in rough bumps on the genital region and anus. Treatment of genital warts includes topical medications like podofilox, imiquimod, and sinecatechins. Cryotherapy, electrocautery, laser therapy, and surgical excision are examples of procedural therapies. It is crucial to follow safe sexual practices and to get vaccinated to prevent disease.