Consensus guidelines from the ECHPV guide GPs in the choice of therapy for patients with anogenital warts, and identify which patients to refer, as Dr Charles Lacey reports

Anogenital warts are common and present in a variety of clinical settings. The recent availability of self-applied therapies prompted the European Course on HPV Associated Pathology (ECHPV) to develop guidelines applicable to a wide range of practitioners in the European setting.1 The consensus guidelines recognise the role of GPs in the management of anogenital warts.

Anogenital warts are the most common, clinically recognised, sexually transmitted disease (STD). These benign lesions, usually caused by the human papillomavirus (HPV) genotypes 6 or 11, are disfiguring and may impact on quality of life, since they are associated with unpleasant physical and psychosexual symptoms.

Patients with visible warts may be infected simultaneously with the high-risk genotypes 16 and 18, which are associated with the development of carcinoma of the cervix and anogenital cancer.

The past 25 years have seen a substantial rise in the prevalence of anogenital warts in the UK, with 110 840 cases reported in 1998.2

GPs can reliably diagnose newly occurring acuminate warts without routine histology in patients younger than 35 years, and can institute effective home-based treatments such as podophyllotoxin, provided that they also undertake any necessary STD screening and contact tracing.

However, routine biopsy is encouraged for papular and macular lesions (those which are not condylomatous in appearance) as well as for warty lesions in people aged over 35-40 years.

This will usually be performed by a specialist. In general, HPV typing of routine external anogenital warts is thought not to add information of clinical use.

Treatment recommendations are based on recent national guidelines from the UK3 and US4. The evidence supporting the recommendations was evaluated using grades developed by the Agency for Health Care Policy and Research5 (see tables 1 & 2, below).

Table 1: Levels of evidence5 *

Level Type of evidence (based on AHCPR 1992)
Ia Evidence obtained from meta-analysis of randomised controlled trials
Ib Evidence obtained from at least one randomised controlled trial
IIa Evidence obtained from at least one well designed controlled study without randomisation
IIb Evidence obtained from at least one other type of well designed quasiexperimental study
III Evidence obtained from well designed, non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Table 2: Grading of recommendations5 *

Grade Recommendation (based on AHCPR 1994)
A (evidence levels Ia, Ib) Requires at least one randomised, controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation
B (evidence levels IIa, IIb, III) Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation
C (evidence level IV) Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality
* Tables 1 & 2 are reproduced from von Krogh G, Lacey CJN, Gross G et al. European course on HPV associated pathology: guidelines for primary care physiscians for the diagnosis and management of anogenital warts. Sex Transm Inf 2000; 76: 162-8, by kind permission of the BMJ Publishing Group

When seeing a new patient, it is important that the GP builds on the doctor-patient relationship to get a clear picture of the patient's sexual history and relationships, as well as his/her occupation and place of work. Such factors may affect the treatments which practically can be offered, in terms of the patient's availability to attend the healthcare facility, and should be discussed with the patient.

Home- or clinic-based treatment may be offered, depending on the extent and severity of the warts, and the patient's preference. Given the intimate nature of the condition, most patients prefer self-applied treatments.

Provided that the GP is satisfied that the patient is able to undertake self-treatment, the guidelines recommend the use of podophyllotoxin 0.5% solution or 0.15% cream (Ib,A) or imiquimod cream, 5% (Ib,A). Routine use of podophyllin is not recommended in primary care.

However, podophyllotoxin cream may be the more appropriate first-line agent in primary care, since it acts quickly. Imiquimod cream takes longer to act and is probably better reserved for more resistant cases treated by genitourinary specialists.

First-line treatment usually achieves clearance in most patients within 1–3 months, although disease persists in up to one-third of patients. Lesions occurring at new sites during treatment or after clearance do not necessitate a change of treatment, but persistence or reappearance of the treated lesion is usually an indication to switch to an alternative treatment.

For patients who do not opt for self-treatment, physicians should discuss single-session surgical treatments vs multiple treatments, bearing in mind that multiple sessions are generally not well tolerated by patients.

However, where there are only a few small lesions, these can be effectively removed under local anaesthesia by scissors excision (Ib,A), diathermy (Ib,A), cryotherapy (Ib,A) or trichloroacetic acid (TCA) 80-90% solution (Ib,A) as a single-session treatment.

The key points of treatment are shown in Table 3 (below).

Table 3: Treatment – key points*
  • First-line treatment will achieve clearance in most patients within 1–6 months, although disease persists in up to one-third of patients
  • Home therapy can be proposed in most cases as first-line therapy for a first attack of acuminate warts. Acuminate warts respond in up to 90%, but papular and macular lesions in only 50% of cases
  • Few, small lesions can be easily treated under local anaesthesia by scissors excision, diathermy, cryotherapy, or trichloroacetic acid (TCA)
  • TCA should not be used on large lesions and multiple sessions are not well tolerated by patients
  • Lesions occurring at new sites during treatment or after clearance do not necessitate a change of treatment modality
  • Persistence or reappearance of the treated lesion is usually an indication to switch to another treatment modality
  • Patients should be evaluated regularly until the warts are cleared
  • Patients should be informed that periods of coital rest throughout the course of the therapy might reduce therapy-related symptoms such as pain or discomfort
* Table 3 is reproduced from von Krogh G, Lacey CJN, Gross G et al. European course on HPV associated pathology: guidelines for primary care physiscians for the diagnosis and management of anogenital warts. Sex Transm Inf 2000; 76: 162-8, by kind permission of the BMJ Publishing Group

Although some anogenital warts can be managed by GPs, specialist referral will still be required for certain groups. Most GUM clinics have open access and offer advice to primary care teams.

  • Children with genital warts require highly specialised management and should always be referred to paediatricians working with multidisciplinary teams.
  • Intraepithelial neoplasia or vaginal warts should be managed by gynaecologists, urologists or proctologists trained in colposcopy.
  • Pregnant women, particularly later in pregnancy, should be managed in conjunction with an obstetrician.
  • Difficult warts (i.e. widespread or with a protracted course, or where the differential diagnosis is not clear), intraurethral warts, anal warts, and warts in immunosuppressed patients should be dealt with by appropriate specialists.

Discussions with the patient should describe the probable time course of treatment at the outset, and patients should be evaluated regularly until the warts are cleared.

Patients should be informed that periods of coital rest throughout the course of the therapy might reduce therapy-related symptoms such as pain or discomfort. Where this advice is not accepted, it may be appropriate to encourage patients to use barrier methods of contraception with new sexual partners until successful treatment has been completed.

Female patients should be advised to participate in regular cervical cytology screening, although they should be reassured that there is no direct link between HPV 6 and 11 and cervical cancer.

GPs should recommend that current partners are screened for STDs and given appropriate advice.

The key points of patient counselling are shown in Table 4 (below).

Table 4: Patient counselling – key points*

  • Patients should receive clear information, preferably written, as to the cause, treatment, outcomes, and possible complications of anogenital warts
  • Reassure patients that although wart clearance may take 1–6 months, and recurrences may occur, complete clearance will occur sooner or later
  • Smokers with recalcitrant lesions should stop smoking, as a correlation exists with wart development6
  • Advise female patients about regular participation in cervical cytology screening programmes. Reassure that risk of cervical cancer is low and ample time exists for detection and removal of any cervical intraepithelial neoplasia
  • Encourage patients to use barrier protection with new sexual contacts until successful treatment has been completed. The use of condoms within a stable relationship may not be needed as the partner will already have been exposed to the infection by the time of consultation. Condom use does not influence the outcome of HPV-associated morbidity once infection has become established in the individual
  • Owing to long latency periods after transmission, the development of condylomas in only one partner in a steady relationship does not inevitably signify sexual contact outside that relationship
  • Current partners and, if advisable, other partners within the past 6 months should be assessed for the presence of lesions and for education and counselling about STDs and their prevention
* Table 4 is reproduced from von Krogh G, Lacey CJN, Gross G et al. European course on HPV associated pathology: guidelines for primary care physiscians for the diagnosis and management of anogenital warts. Sex Transm Inf 2000; 76: 162-8, by kind permission of the BMJ Publishing Group

The Government's public health White Paper Saving Lives: Our Healthier Nation contained a commitment to a national sexual health strategy, which is currently being developed by the DoH. It will propose an integrated approach to sexual and reproductive healthcare that includes:

  • Identifying the range of services that needs to be available
  • Improving links between them
  • Improving access to services and ensuring equity
  • Identifying the needs of high-risk target groups such as young people
  • Spreading best practice in service delivery.

This is likely to result in the development of local shared-care protocols. It is hoped that the recommendations contained within these evidence-based guidelines will inform the development of these protocols.

Figure 1: Algorithm for the management of external anogenital warts in the primary care setting*
* Reproduced from von Krogh G, Lacey CJN, Gross G et al. European course on HPV associated pathology: guidelines for primary care physiscians for the diagnosis and management of anogenital warts. Sex Transm Inf 2000; 76: 162-8, by kind permission of the BMJ Publishing Group

  1. von Krogh G, Lacey CJN, Gross G et al. European course on HPV associated pathology: guidelines for primary care physicians for the diagnosis and management of anogenital warts. Sex Transm Inf 2000; 76: 162-8.
  2. Lamagmi TL, Hughes G, Rogers PA et al. New cases seen at genitourinary medicine clinics: England 1998. Communicable Diseases Report 9: 1-12.
  3. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). National guideline for the management of anogenital warts. Sex Transm Inf 1999; 75 (Suppl 1): S71-5.
  4. Centers for Disease Control and Prevention. Guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47 (RR-1): 1-111.
  5. US Department of Health and Human Services, Agency for Health Care Policy and Research. Acute pain management: operative or medical procedures and trauma. Clinical Practice Guidelines No. 1. Rockville, MD: AHCPR. Publication No. 92-0023, 1993: 107.
  6. Feldman JG, Chirgwin K, Dehovitz JA et al. The association of smoking and risk of condyloma acuminatum in women. Obstet Gynecol 1997: 89: 346-50.

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Guidelines in Practice, November 2000, Volume 3
© 2000 MGP Ltd
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