Genital warts

In females they are found on the vulva, perineum and vagina. In males they are found on the penis. The perianal area can be affected in those who have anal sex. They may be small but can grow into large cauliflower-like lesions (Gawkrodger, 2003).

Management

1. No treatment is a valid option but pain, interference with function, cosmetic embarrassment and risk of malignancy are indications for treatment (Sterling et al., 2001). An immune response is needed for clearance, so immunocompromised patients may never show clearance.
2. The majority can be treated in primary care. There is no treatment which is 100% effective and different types of treatment may need to be combined. Gibbs and Harvey (2006) found a considerable lack of evidence on which to base the rationale of topical treatments for warts, although they found evidence to support the use of simple topical treatments containing salicylic acid. There was less evidence for the efficacy of liquid nitrogen.
3. In hand and foot warts, the hyperkeratotic areas can be pared down with a pumice stone and allows for topical treatment. There are many wart paints now available, most of which contain salicylic acid. This is a keratolytic which slowly destroys the virus-infected epidermis. They should be applied after bathing which will help to moisten the warts. Treatment needs to be continued for at least 3 months. Wart paints are not suitable for the management of facial and anogenital warts or warts on or near areas of atopic eczema.
4. Topical treatments should always be tried before cryotherapy. Cryotherapy with liquid nitrogen is painful and should not be carried out on small children. It should be applied every 2–3 weeks and can be carried out on hand, foot and genital warts. It can cause blistering, scarring and damage to nail growth. Hypo- and hyperpigmentation can occur in skin types 5 and 6.
5. Surgical removal by curettage or blunt dissection followed by cautery may be useful for filiform warts on the face and limbs but can result in scarring.
6. Patients with anogenital warts should be managed by genito-urinary physicians to exclude the possibility of other sexually transmitted infections (Sterling et al., 2001).
7. While many children under 3 years of age have vertical transmission of anogenital warts, sexual transmission (and therefore sexual abuse) should always be considered, especially in older children with no warts elsewhere. This emphasises the need for careful physical examination and historytaking as well as thorough assessment of the social and family dynamics (Wyatt, 2008).