Guideline sources The following summarized guidelines for the evaluation and management of anogenital warts are prepared by our editorial team based on guidelines from the International Union Against Sexually Transmitted Infections (IUSTI 2020). 1 Guidelines 1. Diagnostic investigations Physical examination: perform a physical examination using a good light source. B Show 4 more Screening for sexually transmitted infections: screen for sexually-transmitted infections as per local guidelines in patients with a first episode of genital warts. B https://web.pathway.md/diseases/recVOkmw42RORxf77 1/4 6/23/23, 2:36 AM Anogenital warts Pathway Screening for cervical cancer: inform female patients about cervical cytology screening as per local or national guidelines. B Assessment of sexual partners: offer clinical assessment for the presence of warts along with education and advise about HPV infection and screening for other STIs to current partners of patients with anogenital warts. B 2. Diagnostic procedures Colposcopy: consider magnification with a lens or colposcope for small lesions. C Proctoscopy: obtain proctoscopy if anal canal warts are suspected, such as external lesions extending into the anal canal, anal bleeding or discharge. B Biopsy: do not obtain biopsy for typical anogenital warts, unless there is diagnostic uncertainty or suspicion of precancer or cancer. D 3. Medical management First-line patient-applied therapy: Offer one of the following medications as first-line patient-applied therapy: podophyllotoxin 0.5% solution self-applied to lesions BID for 3 days, followed by 4 rest days, for up to 4 or 5 weeks A podophyllotoxin 0.15% cream self-applied to lesions BID for 3 days, followed by 4 rest days, for up to 4 or 5 weeks B imiquimod 5% cream self-applied directly to the warts thrice weekly before normal sleeping hours and washed off with soap and water between 6 and 10 hours later, until wart clearance, or for up to 16 weeks A sinecatechins 10% or 15% ointment self-applied TID until complete clearance, or for up to 16 weeks A Use podophyllotoxin cream in patients with vulval and perianal warts, as clinical experience suggests that for ease of application the cream formulation is preferable for warts at these sites. Trichloracetic acid: offer trichloracetic acid 80-90% solution as first-line clinician-applied therapy applied weekly directly onto the wart surface with either a wooden or cotton tipped applicator. Protect the surrounding skin with petroleum jelly, as excess application may cause scarring. Ensure readily available neutralizing agent (such as 5% sodium bicarbonate) in case of spills. A 5-fluorouracil: consider 5-fluorouracil when other treatments have failed. B Intralesional interferon injections: consider administering intralesional interferon injections for patients with refractory anogenital warts. B Podophyllin: do not use podophyllin preparations for the management of patients with anogenital warts because they contain a variety of compounds some of which may be mutagenic and severe https://web.pathway.md/diseases/recVOkmw42RORxf77 2/4 6/23/23, 2:36 AM Anogenital warts Pathway systemic toxicity after topical use has been described including death, intrauterine death, teratogenicity and neurological complications. 4. Nonpharmacologic interventions Smoking cessation: advise smoking cessation for general health benefit, acknowledging that there is no evidence that smoking cessation improves outcomes of wart treatment. B 5. Therapeutic procedures Photodynamic therapy: insufficient evidence to support photodynamic therapy for the management of patients with anogenital warts. I 6. Surgical interventions First-line clinician-applied therapy: Offer one of the following surgical methods as clinician- applied first-line therapy: surgical excision cryotherapy electrosurgery and electrocautery laser surgery (CO and neodymium:yttrium aluminium garnet laser). A Show 2 more Combination therapies: insufficient evidence to support any combination therapies for the management of patients with anogenital warts. I 7. Specific circumstances Management of internal involvement: treat patients with vaginal warts with either cryotherapy, trichloracetic acid or any surgical treatment modality. B Show 4 more Pregnant patients: avoid topical treatments in pregnant patients. Treat pregnant patients with ablation using cryotherapy, trichloracetic acid or any surgical treatment modality. Liaise with the obstetrician in all cases of pregnant patients. D Show 2 more 8. Patient education Patient education: provide patients with a detailed explanation of their condition, including advice about onward transmission. B https://web.pathway.md/diseases/recVOkmw42RORxf77 3/4 6/23/23, 2:36 AM Anogenital warts Pathway Show 2 more 9. Follow-up and surveillance Follow-up: follow-up patients at regular intervals, for example, every 4 weeks, until warts have resolved, and switch of treatments if an inadequate response is observed. B 10. Quality improvement Local treatment algorithms: develop local treatment algorithms that address the needs of the given patient population and are deliverable with the resources available to the service. B Surgical team safety: perform electrosurgery, electrocautery and laser surgery with the use of surgical masks by the treatment team, and use an extractor fan due to the potential presence of infectious HPV particles in the smoke plume generated by these techniques. B References 1. R Gilson, D Nugent, R N Werner et al. 2019 IUSTI Europe guideline for the management of anogenital warts. J Eur Acad Dermatol Venereol. 2020 Aug;34 8 1644 1653. Open https://web.pathway.md/diseases/recVOkmw42RORxf77 4/4