Jill Zelin. May 2014 FINAL. Barts Health NHS Trust c/o Barts Sexual Health Centre Address

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1 DOCUMENT NAME DOCUMENT AUTHOR(S) and REVIEWER DIVISION CAU DOCUMENT ISSUE DATE and REVIEW STATUS (Draft, Final) Guidelines for the treatment of Genital Warts for people who are attending sexual health services at Barts Health NHS Trust (formerly Barts and The London NHS Trust) Dr Jill Zelin ECAM Infection & Immunity May 2014 FINAL REVIEW DATE May 2016 The principal editors of this document are: Editors: Jill Zelin Trust Barts Health NHS Trust Address c/o Barts Sexual Health Centre Address to whom all requests for updates, corrections, or amendments should be sent.

2 Anogenital wart virus infection Codes: first presentation C11A, recurrence C11D Introduction These local guidelines are based on the 2007 UK National Guidelines on the Management of Ano-genital Warts (BASHH 2007) Aetiology Caused by Human papilloma virus (HPV). Over 90 genotypes have been identified of which >30 are genital types. Most commonly anogenital warts are caused by HPV types 6 & 11. HPV types 16 & 18 are associated with cervical intraepithelial neoplasia (CIN) and anogenital cancers. Subclinical disease and latent infection is common. Symptoms Presence of warts; Patients may be asymptomatic (especially perianal and intrameatal) Signs Single or multiple, may be keratinised, pedunculated, broad based, or pigmented. Perianal warts found in 25% of patients with warts regardless of sexual practices NB Anal intraepithelial neoplasia can occur in HIV positive patients in the absence of anal intercourse. Warts can also be found in mouth, larynx, nasal cavities and conjunctivae. Diagnosis Clinical: Initial assessment should include vaginal/cervical examination and proctoscopy if relevant. Differential diagnosis includes condylomata lata (2 o syphilis) and normal coronal and vulval papillae. If in doubt, refer to specialist clinic for biopsy under local anaesthetic. Genital mapping of lesions at each visit to assess response to therapy. Management See treatment algorithm Offer full STI screen All treatments have significant failure and relapse rates which should be explained to the patient. Treatment choice may depend on size and number of warts involved, extent of lesions and whether treatment is home or clinic based Treatment of external warts may cause spontaneous regression of internal lesions Patients may opt for no treatment as some warts may regress spontaneously Caution: risk of scarring or pigment changes with cryotherapy Treatment

3 First line Second line Alternatives Pregnancy risk Recalcitrant Warts Warticon (podophyllotoxin 0.15%) cream Apply twice daily for 3 days; treatment may be repeated at weekly intervals if necessary for a total of four weeks Imiquimod 5% cream (Aldara) Apply thinly 3x per week at night. Wash off after 6-10 hours for up to 16 weeks (See BNF) Cryotherapy (alone or in conjunction with 1 st and 2 nd line therapy) Cryospray (liquid nitrogen) x2 at weekly intervals for up to two months Cryoprobe (nitrous oxide) x2 at weekly intervals for up to two months Cryotherapy Refer to problem clinic for cautery (see flow chart) Clearance rate (%) Recurrence rate (%) BNF Price ) Warticon (podophyllotoxin 0.15%) cream Indication: external anogenital warts Contraindications: intrameatal, anal and intraanal warts, genital ulceration, hypersensitivity to podophyllotoxin, pregnancy & breast feeding 2) Cryotherapy Indication: Single or few warts (use STAT in conjunction with home treatment). Meatal, intra-anal. cervical, intra-vaginal and perianal warts and as per flow chart; Safe in pregnancy/risk of pregnancy and breast-feeding Contraindication: genital ulceration 3) Imiquimod 5% cream (Aldara) Stimulates host immunity to HPV; may cause local reactions including: itching, pain, erythema, erosion oedema and excoriation. Indication: 2 nd line after warticon for 1 st episode warts. First line for persistent/recurrent external genital and perianal warts e.g. if Warticon/cryotherapy ineffective. Contraindications: pregnancy/risk of pregnancy and breast-feeding Caution: Patients with genital dermatosis 4) Excision / Cautery under LA

4 Suitable for recalcitrant or pedunculated warts. May be used if biopsy is also required Local anaesthetic creams +/- intradermal anaesthetic e.g. lignocaine 2% (Emla) can be used before ablative therapy Combination adrenaline/anaesthetic should not be used for lesions on penis or near clitoris. Follow-up See treatment algorithm Review is recommended at end of course if lesions are still present Patients whose original lesions have responded well to treatment but in whom new lesions are developing can continue with current regimen. Change is indicated if: 1. patient is not tolerating current treatment, 2. under 50% response to current treatment by six weeks (8-12 weeks for 3. imiquimod). Relapses should be treated as appropriate Other Management Issues Advise use of condoms/femidoms, Issue contact slip(s). Refer to specialist clinic if poor/no response to therapy Cervical cytology should be as per National Screening Programme. No increased screening required. Sexual Partner(s) Current sexual partner(s) may benefit from assessment as they may have undetected genital warts, undetected other STI, or need an explanation and advice about disease process in partner Tracing of previous sexual partner(s) is not recommended Special Considerations by anatomical site: Meatal/urethral warts Cryoprobe is preferred or cautery/ hyfrecation. Intra-anal warts If external warts also present, treat 1 st as may cause internal warts to resolve Treat is symptomatic-benefits of treatment if asymptomatic unknown. Treatment options include cryotherapy, electrosurgery, laser Consider referral for anoscopy especially HIV positive patients (Imiquimod may be used under senior doctor supervision) Perianal warts Massive perianal warts: consider referral for scissor excision Intra-oral warts Cryotherapy or cautery if easily accessible.

5 Refer to Oral surgery if not. Vaginal warts Refer to Cervico-Vaginal clinic (CV) at Barts Exophytic cervical Any woman with macroscopic warts on the cervix should be referred to CV clinic Pregnancy: See separate guidelines

6 WARTS Consider stat cryotherapy Podophyllotoxin or Imiquimod Offer to review at 4 weeks only if warts persist. If any response Continue on present treatment If no response Check Compliance, then consider: 1. Imiquimod or Podophyllotoxin whichever not already used 2. Cryotherapy 3. Cautery Offer to Review at 4 weeks only if warts persist Non-Clearance after 3 months Refer problem clinic or CV clinic SPECIAL CONSIDERATIONS 1. Pregnancy 2. 1 or few warts 1. Cryotherapy 2. Cautery Intrameatal warts use Cryoprobe Cervico-vaginal warts-refer to CV Clinic