Position statement for the diagnosis and management of anogenital warts

Abstract

Background: Anogenital warts (AGW) can cause economic burden on healthcare systems and are associated with emotional, psychological and physical issues.

Objective: To provide guidance to physicians on the diagnosis and management of AGW.

Methods: Fourteen global experts on AGW developed guidance on the diagnosis and management of AGW in an effort to unify international recommendations. Guidance was developed based on published international and national AGW guidelines and an evaluation of relevant literature published up to August 2016. Authors provided expert opinion based on their clinical experiences.

Results: A checklist for a patient's initial consultation is provided to help physicians when diagnosing AGW to get the relevant information from the patient in order to manage and treat the AGW effectively. A number of frequently asked questions are also provided to aid physicians when communicating with patients about AGW. Treatment of AGW should be individualized and selected based on the number, size, morphology, location, and keratinization of warts, and whether they are new or recurrent. Different techniques can be used to treat AGW including ablation, immunotherapy and other topical therapies. Combinations of these techniques are thought to be more effective at reducing AGW recurrence than monotherapy. A simplified algorithm was created suggesting patients with 1-5 warts should be treated with ablation followed by immunotherapy. Patients with >5 warts should use immunotherapy for 2 months followed by ablation and a second 2-month course of immunotherapy. Guidance for daily practice situations and the subsequent action that can be taken, as well as an algorithm for treatment of large warts, were also created.

Conclusion: The guidance provided will help physicians with the diagnosis and management of AGW in order to improve the health and quality of life of patients with AGW.

Figure 1

Typical presentations of anogenital warts. (a) Acuminate genital warts: vulval warts, (b) Parafrenular papules with genital wart on frenulum: normal parafrenular papules together with warts on the frenulum, (c) Pigmented genital warts: widespread hyperkeratotic, confluent, pigmented papules of the anogenital region, (d) Leukoplakic genital warts: flat papules with a white surface over the foreskin; leucoplakia due to keratinization of mucosa, (e) Scattered penile genital warts: several lesions over foreskin and scrotum, (f) Multiple keratotic genital warts: multiple confluent papules of the vulva and perianal area, (g) Multiple non‐keratotic genital warts: typical localization of genital warts in men, (h) Multiple non‐keratotic genital warts: typical localization of anogenital warts in women.

Figure 2

Differential diagnoses (images on the left) of anogenital warts (images on the right). (a) (a1) Pearly penile papules: normal glands on the corona glandis, (a2) AGW: small cluster of warts on the coronal sulcus, (b) (b1) Parafrenular glands: normal glands on either side of frenulum, (b2) AGW: parafrenular glands with wart on the frenulum, (c) (c1) Fordyce spots: fordyce spots in a male, (c2) AGW: fordyce spots alongside a wart, (d) (d1) Papillomatoses of vulva: scattered raised glands can be confused with AGW, (d2) AGW: vulval warts – scattered, soft and fleshy, the vestibular area, (e) (e1) Syphilis on mucosal plates: painless plaque, which suddenly appears on one or more mucosal membranes, (e2) AGW: penile wart, (f) (f1) Lichen planus: whitish, fine reticulate papules on the glans and corpus, (f2) AGW: white wart patch, (g) (g1) Molluscum contagiosum and (g2) AGW (arrows on image show lesions): both pink dome‐shaped papules and warts, (h) (h1) Bowen's disease: whitish plaque on labia minora, (h2) AGW: extensive genital warts, (i) (i1) Pigmented intraepithelial neoplasia: pigmented popular strips that extend to the anogenital area, (i2) AGW: penile pigmented warts, (j) (j1) Vulvar intraepithelial neoplasia: pigmented popular strips that extend to the anogenital area, (j2) AGW: extensive soft warts and one large keratinized wart, (k) (k1) Invasive carcinoma of the penis: invasive cancer of the glans of the penis arising from penile intraepithelial neoplasia, (k2) AGW: condylomata acuminata on the urethral mucosa, (l) (l1) Buschke‐Löwenstein: rapid expansion of budding masses that coalesce to form tumours, (l2) AGW: vulval and anal warts.

Figure 3

Clearance of anogenital warts with Hydrozid^® cryotherapy: (a) wart on prepuce; (b) hole selected from template to shield surrounding tissue; (c) wart sprayed for a few seconds until frozen.

Figure 4

Clearance of anogenital warts with trichloroacetic acid: (a) application with a double‐ended cotton bud to allow any trickles to be instantly dried up; (b) rapid occurrence of frosting after application; (c) months later, no sign of warts and only slight scarring.

Figure 5

A new simplified algorithm for the treatment of anogenital warts. *If large warts (too large for local TCA or cryotherapy), see Fig. 6; **Even if some keratinized lesions are present, the goal is to treat the entire area so that non‐keratinized lesions are treated with immunotherapy followed by removal of keratinized lesions by ablative techniques. PCR, polymerase chain reaction; TCA, trichloroacetic acid

Figure 6

A new simplified algorithm for the treatment of large anogenital warts. *Large warts are defined as too large for local trichloroacetic acid or cryotherapy.

Figure 7

Example patient with large anogenital warts pre‐treated with imiquimod before surgery: (a) vulval and anal warts in a 19‐year old who was pre‐treated with imiquimod for 2 months while surgery was organized; (b) needle diathermy with smoke extractor at the start of surgery; (b) 3 weeks post‐operation, the patient remained clear of warts 9 months later.