Understanding Medications for Genital Warts
Genital warts, caused by the human papillomavirus, are spread through sexual contact. They affect the genitals, cervix, and the area around the anus. Genital warts are the most commonly sexually transmitted disease and it is estimated that there are 1 million new cases each year. Anyone who is sexually active is a candidate for the virus. HPV infection is more than 50% more common than other STDs studied. This is because the peak incidence of infection is in the late teens and early 20s, and individuals in this age group are more likely to have several partners. Overall prevalence of genital warts in the US is 1% and appears to be increasing. This is likely due to better recognition of warts, improved diagnostic techniques, and a true increase in incidence. In developing countries the prevalence can be as high as 4%. Genital warts affect both males and females and are responsible for significant cost in both time and resources to the health care system. Although genital warts are not life threatening, they are a cause of significant psychological distress and can be very difficult to treat.
What are Genital Warts?
Genital warts are growths on the surface of the skin and mucous membranes of the anogenital area. There are two types of warts, distinguished by their appearance and site. Condylomata acuminata are visible warts that appear as small, cauliflower-like bumps, sometimes clustered together. They can be found on the anogenital skin, i.e. the penis, vulva, urethra, perineum, scrotum, and anus. Less common types of visible warts, which are usually flat, less conspicuous, and more difficult to see, occur on the cervix and in the urine passage. The other type of genital wart is less visible; these subclinical warts are flat and only seen with acetic acid application and colposcopy. Warts of both types come in a variety of sizes and may appear singly or in multiples. They can also be spread into large masses in the anogenital area. Subclinical warts on the cervix can cause abnormal cervical cell changes that are detectable on Papanicolaou (Pap) tests. Genital warts are the most common sexually transmitted disease, with a prevalence running into the double digits. In most cases, visible warts are caused by the human papillomavirus (HPV). Over 100 types of HPV have been identified; about 40 of these types are tropic for the anogenital area and can infect it. Low-risk types of HPV cause visible warts without a potential for cancer. High-risk types of HPV can cause precancerous changes and cancer of the cervix, vulva, vagina, anus, penis, and oropharynx. Whether a HPV infection regresses, persists, or progresses to a precancerous lesion is not fully understood. Reassuringly, most HPV infections and even some changes in the cervical cells will regress on their own without treatment.
Causes and Risk Factors
Genital warts are a common sexually transmitted infection caused by the human papillomavirus (HPV) with 50-65% of people who have had any form of sexual contact contracting the disease at some point in their lives. There are over 100 known types of human papillomavirus. HPV types 6 and 11 are the typical cause of genital warts. HPV is spread through direct skin-to-skin contact, typically during vaginal, anal, or oral sex with an infected individual. It is possible to be infected with HPV and show no signs or symptoms. Furthermore, it is possible to spread the virus to others unknowingly. Because of this, it is not always possible to determine when the virus was first contracted or who it was contracted from. People with low immune function are more vulnerable to HPV. This is especially significant when considering HPV's link to cervical and anal cancer in addition to its link to recurrent respiratory papillomatosis in children. Recurrent respiratory papillomatosis can be especially detrimental, and potentially fatal, in patients who have had the virus since birth.
Symptoms and Signs
Symptoms include itching and discomfort around the genitals and rectal areas. Then, within a matter of days, small, soft, flesh-colored swellings appear, which can be less than half an inch across. The warts may appear on their own or in small groups. In women, genital warts can grow on the vulva, the perineal area, inside the vagina or the anus, on the cervix, or in the groin. It is unusual for warts to cause any significant discomfort, although in some cases, the increased moisture and warmth of the area can cause itching. The warts can be so slight they are not visible to the human eye; the sufferer is then often unaware of them, although they may still be transmitted to others. This is difficult to diagnose, but more sophisticated tests are being developed. After a few weeks, months, or even years, the warts may go away on their own. This is unusual, and it is common for warts to persist and increase in number. Any resolution of warts on the skin needs monitoring, as the virus may still be alive but changes in the cells are not taking place. This is more common in patients where the warts were invisible. In general, changes are limited, but treatment can often lead to psychological relief for sufferers, who may be greatly distressed by warts regardless of their severity. This also stems from the comparison of a patient's own virus warts with someone else's unaffected skin.
Diagnosis and Testing
Another way to diagnose genital warts is the application of acetic acid, which is essentially swabbing the area with vinegar. This can be done in a physician's office or given to the patient to do at home. The area is then inspected for any white areas which display as a positive reaction. This has been said to enhance the ability to detect warts compared to non-acetic acid or visual inspection. An important thing to remember about acetic acid is that it can result in a false positive because there are many different conditions and irritations that can result in the skin appearing white following the application of acetic acid. This procedure is not recommended for diagnosing subclinical symptoms.
Commonly, genital warts are diagnosed by visual inspection. The problem that is associated with it is that many times, a biopsy may be needed especially if the warts are not the typical cauliflower shape that the doctor or patient are uncertain of. This may then lead to a false negative due to the fact that a biopsy can miss the location of an HPV infection and cut into healthy skin. Alternatively, if the result is positive and the physician is incorrect, this can lead to unnecessary treatments that can have large damaging effects on the patient.
Treatment Options
The application of liquid nitrogen to the wart is the most common form of treatment, and is usually carried out in a physician's office. The liquid nitrogen is applied to the wart, effectively freezing the tissue and creating a blister around the wart. The dead tissue will fall off within 1-3 weeks. This treatment can cause some discomfort and may require several return visits to fully rid the patient of the warts. It is relatively inexpensive but can cause mild scarring in the genital area. Topical medications. Various prescription ointments are available to treat genital warts. They are usually applied at home several times a week. These will commonly irritate the skin, and if used improperly, can cause chemical burns. Dicloac and Aldara are two commonly prescribed medications. Dicloac is a 10-25% solution of Podophyllin and 10-25% solution of Podophyllin resin, which must be applied by a physician. Both are highly effective in eliminating warts but can cause burning and stinging. Contraindicated during pregnancy, they can cause birth defects or fetal death. Try to avoid using these medications for extensive periods of time, certainly until better long-term studies have been done, as the carcinogenic properties of these medications are not yet well known.
Topical Medications
An estimated correct for imiquimod was significantly greater than vehicle, and the complete response rate was 50% and 53%, compared to 1% and 3% for the vehicle groups. This means that imiquimod-treated patients had a much better chance of successfully eradicating their warts than those treated with placebo. This illustrates that the medication is more beneficial to the patient than any other therapy using vehicle. Step "%" means any size of lesion can be treated without preference, and in "?" means that the medication should be applied for all lesions at the same time.
Topical medications are self-applied to the affected area. These medications come from several drug classes. Podofilox is a patient-applied, self-administered, topically active antimitotic agent. Imiquimod is an immune-response modifier that is self-administered. Both treatments are designed for external application and can be used for several weeks. The exact mechanism by which these medications work is unknown, but they are capable of eradicating visible lesions.
Cryotherapy
Patient-applied therapies have had success rates of up to 50% when used as a single treatment, but are more effective when repeated over an extended period of time. This is due to the non-adequate administration of the therapy, either through improper solution storage, poor technique, or too infrequent application. If done correctly, the solution is an effective form of self-treatment, as it is easy to obtain, causes minimal discomfort, and can be used on internal genital warts. Unfortunately, the first three of the four studies were talking about the treatment of hand warts and did not specify the location of genital warts on the male or female genitalia. A study done by the "Administration of Podophyllotoxin / Imiquimold Self-Applied Treatment for Genital Werruca" or APIT trial compared cryotherapy with the self-application of podophyllotoxin and found that podophyllotoxin was a much more effective treatment.
Cryotherapy destroys warts by freezing them with a liquid nitrogen solution. The method relies on the physical destruction of infected tissue by the freezing of intracellular fluid and ischemic necrosis that occurs within 24-48 hours of freezing due to blockage of the microcirculation to the wart.
Surgical Procedures
Patients should be aware that the recurrence rates for all treatments are high, with one quarter to one third of patients requiring a repeat treatment and some studies have found that up to half of patients require further treatment. Patient-applied treatments are a useful alternative for some motivated patients. However, the most important aspect of treating genital warts is the prevention of further transmission of the HPV to others, and to the same or other sites in the patient. This may require multiple interventions over time and close follow-up for an extended period.
Surgery is indicated for genital warts that are large, when warts are in hard-to-treat areas, in patients who are immunocompromised and unable to use or tolerate conventional treatments. In general, it is better to use the least painful and most cost-effective approach first. All surgical treatments require training and may cause complications, including urinary retention and meatal stenosis. The choice of therapy should reflect the size and anatomic site of the lesions, available resources, and the patient's preference for the type of treatment, as well as their tolerance for adverse effects, pain, and cost.
Alternative Remedies
Another form of alternative remedy is a digital eBook that provides a step-by-step procedure on how to get rid of genital warts. It provides the solution to different types of warts and where they are located on the body. This eBook was researched and written within two years and the author claims that it can help people get rid of the virus within a few weeks. Always be cautious about buying digital eBooks such as this, because the results may vary and the buyer cannot get a refund if money is spent.
For those of you who like essential oils, there are antiviral essential oils that you can use which can help fight viruses, increase the immune system's health and stamina, and aid in emotional recovery from the virus. The oils are bergamot, eucalyptus, tea tree, geranium, and rose. One type of alternative therapy is called Hypericum Mysorense. An Indian scientist by the name of Dr. K.S. Srinivasan has formulated it. Hypericum Mysorense is believed by Dr. Srinivasan to enhance the immune system to reactivate itself, and the cost of this is about a month's supply for $60.00. It claims that it can cure a person within 3 months to 1-2 years, depending on how severe the person's condition is.
One of the reasons people turn to alternative remedies is that it is natural, has fewer side effects, and is less expensive than conventional medical treatments. There are numerous alternative remedies for genital warts. Results on these treatments have varied with each person.
Emotional and Psychological Impact
Coping strategies are behaviors and thoughts that one uses to deal with stress from the condition. Problem-focused coping involves coming to terms with the condition and trying to eradicate the warts, for example, seeking treatment. Emotion-focused coping is aimed at reducing the emotional impact of the condition and often involves avoiding others or denial. A study by Breitkopf et al. found that although people who use emotion-focused coping strategies have been found to have warts with less severity, they reported to have a greater negative impact from the warts. This suggests that approaching the emotional impact of the condition is the most effective way to reduce the overall detrimental effect.
While genital warts may not elicit the same emotional response that other chronic conditions or life-threatening illnesses do, it is still a stressor that affects many aspects of a person's life. It often brings unwarranted guilt and shame to the affected person, changes the way they view themselves as a sexual being, and often affects personal relationships. These emotional impacts may seem trivial to those not affected with the condition, but it is important to recognize and address them in order to seek a satisfactory treatment outcome. A study by Weydt et al. showed that genital warts have a significant impact on a patient's quality of life, which was also demonstrated to be correlated with the number, size, and duration of warts.
Support Groups and Counseling
Support groups and counseling can be very valuable to people coping with genital warts. Psychological distress is common, and evidence has shown that the distress and worry experienced by people with genital warts is often disproportionate to the medical implications of the virus. This can have a profound impact on the individual's relationships, social life, and day-to-day living. It can also hinder the body's ability to fight the virus. Women with a diagnosis of HPV will also experience worry and concern about the potential link between HPV and abnormal smears or cervical cancer. Unfortunately, whether this is the truth or not is often irrelevant as the anxiety about the possible consequences is enough to cause a large amount of psychological distress. One study reported that approximately 46% of women with an abnormal pap smear experienced high levels of psychological distress 2 months after being told of their results. While many healthcare providers involved in the care of people with genital warts may not appreciate the seriousness of the distress caused by the virus, the fact that management of the virus is essentially cosmetic and the warts themselves are not medically harmful does not lessen the impact on the individual. Visiting a psychologist or psychiatrist can be beneficial. Various therapy techniques can be used such as supportive therapy, cognitive-behavioral therapy, and mindfulness. These therapy techniques are known to be effective for depression and anxiety, two very common consequences of having genital warts. A recent randomized controlled trial found that group psychological therapy was effective in reducing psychological distress and anxiety in women with genital warts. The structured nature of the intervention allows the content to be tailored to the needs of the individuals involved. Given that all these therapy techniques can be performed without recourse to medication, it has to be considered a safe and viable option for anyone suffering psychological difficulties as a result of the virus.
Disclosure and Communication
What to say and when to say it will depend on the individual, your significant emotional attachment to the person, and their personality. As a general rule, it is better to get to know the person and allow them to see who you are before dropping the bombshell; this may help to lessen the blow. Some may feel that they are "tricking" the other person, but it is really just a way to get a fair chance before their partner makes his/her judgment. It is probably not a good idea to wait until you are sexually intimate to disclose this information. If the individual decides to reject you, you may feel more rejected and hurt than if they had been informed upfront. It can also be seen as a betrayal of trust. Be prepared for various questions from the other person and have your facts ready. If he/she decides to accept the situation, show your appreciation but also still be prepared for any possible negative outcomes in the future.
One of the hardest aspects of having a sexually transmitted disease is informing the person who you wish to become intimate with. It can be very difficult to disclose this type of information to another person. It is important to realize that many people will react with some initial discomfort and rejection; it is a natural response. In a study conducted in Seattle by the Westover Heights Clinic, it was found that a person's past experience with a partner who had a sexually transmitted disease greatly affected their response to information. If the individual's experience was negative, they were much more likely to reject the infected person; likewise, if it was positive, they were more likely to accept the infected person. This may be at least one reason why the CDC reports that over 50% of sexually active adults will contract HPV and other STDs in their lifetime. It may also be of interest that the same study found that after St. John's Wort supplementation and standard treatment for a 6-month period, only 3 out of the 100 participants were still HPV positive and HPV DNA negative by polymerase chain reaction test at the end of the trial period.
Garza, Kristian, et al. “Framing the Community Data System Interface.” Proceedings of the 2015 British HCI Conference, ACM, 13 July 2015. Crossref.