Venereal warts

Venereal warts are benign tumours of the skin or mucous membranes due to certain papilloma viruses (HPV).

Clinical features

• Venereal warts are soft, raised, painless growths, sometimes clustered (cauliflower- like appearance) or macules (flat warts), which are more difficult to discern. Warts can be external (vulva, penis, scrotum, perineum, anus) and/or internal (vagina, cervix, urethra, rectum; oral cavity in HIV infected patients).
• In women, the presence of external warts is an indication for a speculum examination to exclude vaginal or cervical warts. Speculum exam may reveal a friable, fungating tumour on the cervix, suggestive of cancer associated with papilloma virus a Citation a. Certain types of HPV may cause cancer. Presence of genital warts in women is an indication to screen for precancerous lesions of the cervix, if feasible in the context (visual inspection with acetic acid, or cervical smear, or other available techniques), and to treat any lesions identified (cryotherapy, conisation, etc., according to diagnosis). .

Treatment

Choice of treatment depends on the size and location of the warts. Treatment may be less effective, and relapses more frequent, in HIV infected patients.

External warts < 3 cm and vaginal warts

podophyllotoxin 0.5% b Citation b. Podophyllum 10%, 15% or 25% resin is another preparation which is much more caustic, and should be applied only by medical staff. Protect the surrounding skin (vaseline or zinc oxide ointment) before applying the resin. Wash off with soap and water after 1 to 4 hours. Apply once weekly for 4 weeks.  solution may be self-applied by the patient, but in the event of vaginal warts, the treatment must be applied by medical staff.

Explain the procedure to the patient: apply the solution to the warts using an applicator or cotton bud, sparing the surrounding healthy skin, allow to air dry. On vaginal warts, the solution should be allowed to dry before the speculum is withdrawn.
Apply the solution 2 times daily, 3 consecutive days per week, for up to 4 weeks.

Podophyllum preparations are contra-indicated in pregnant c Citation c. Treatment of warts is not an emergency and may be deferred if alternatives to podophyllum preparations are not available. Genital warts are not an indication for caesarean section: it is uncommon for warts to interfere with delivery, and the risk of mother-to-child transmission is very low.  or breastfeeding women. They should not be applied on cervical, intra-urethral, rectal, oral or extensive warts. Improper use may result in painful ulceration.

External warts > 3 cm; cervical, intra-urethral, rectal and oral warts; warts in pregnant or breastfeeding women

Surgical excision or cryotherapy or electrocoagulation.