Warts - Anogenital (1 of 8)

1 Patient presents w/ signs & symptoms of anogenital warts

2 DIAGNOSIS ALTERNATIVE Do history & clinical features No DIAGNOSIS conﬁrm diagnosis of Treat patient anogenital appropriately warts?

Yes

LOCALIZE THE WARTS

EXTERNAL CERVICAL INTRA INTRAVAGINAL URETHRAL GENITAL WARTS ANAL WARTS MEATUS WARTS WARTS WARTS

A Patient education A Patient education Perform colposcopy & biopsy before Any of the following treatments: treatment. If no cervical Physician-applied intraepithelial neoplasia (CIN): B Non-pharmacological therapy Physician-applied B • Cryotherapy Non-pharmacological therapy • Electrosurgery • Cryotherapy C Pharmacological therapy • Electrosurgery • TCA C Pharmacological therapy • TCA Refer to specialist if CIN is present A Patient education Any of the following treatments A A if bases of lesions can be seen: Patient education Patient education Patient-applied Any of the following treatments: Any of the following C treatments: Pharmacological therapy Patient-applied • Imiquimod C Pharmacological therapy Physician-applied • Podophyllotoxin • B Imiquimod Non-pharmacological Physician-applied • Podophyllotoxin therapy B • Sinecatechins • Cryotherapy Non-pharmacological • Electrosurgery therapy Physician-applied • B • Laser treatment Cryotherapy Non-pharmacological therapy • Electrosurgery • C Cryotherapy Pharmacological • Laser treatment • therapy Surgical removal/destruction C Pharmacological therapy • TCA C Pharmacological therapy Lesions deeper than urethra Management should also • Trichloroacetic© acid (TCA) MIMSshould be referred to a include a specialist referral urologist

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

B1 © MIMS 2019 WARTS - ANOGENITAL • • • ofLesions Assessment • • • • Diagnosis • • • • Transmission • • WartsAnogenital • • • • • • Meatoscopy is indicated if w/ history of distorted urine fl urine ofdistorted ifw/history isindicated Meatoscopy urethra from orbleeding ow anus from orbleeding warts clearance ofperianal sex, ofanalreceptive ifthere isindicated ishistory Proctoscopy - the skin &surrounding anogenital external region Examine purposes fordiagnostic Notroutinely used - chain amplifi polymerase eg detection, isthrough DNA viral Virological ofHPV diagnosis cation (PCR) multiple warts occurring presenting w/newly forpatients <35 years, isusuallyunnecessary Histology - warts &pigmented Atypical - for: isnecessary Histology isusuallysuffi exam eye Naked glass - amagnifying by aided may exam be visual cient; presentation clinical isusuallymadeby Diagnosis handwarts from eg perinatally transmitted be May also ofwarts signs visible without oneven passed be can Infection skin infected shaving ortraumatizing previously Autoinoculation scratching, occur by can fl bodily via isnottransmitted evirus - discharge)uids (eg semen, orblood vaginal contact effi most the skin-to-skin spreads infection Direct - ciently w/multiple partners sexual increases ofacquiring Risk infection - contact sexual by often Most years latent several after &reactivate transient 12 months within are subclinical, &spontaneously clear infections but may remain Manyalso HPV - 6 &11 HPVs low-risk by w/>90%ofthe genotypes caused lesions (condylomas) HPV by areAnogenital caused warts - Perianal may common men butare lesions sexes most occur inboth inhomosexual - urethral meatus &analcanal Vagina, cervix, - any site thatPatient intercourse sexual inareas are by w/lesions traumatized usuallypresents butmay occur at also - Lesions unresponsive tostandard therapy unresponsive Lesions - Presence ofulceration orinduration - - Pruritus - Pain - w/: associated May be distressing may disfi may little some cause be physical discomfort, asymptomatic, are often Lesions &psychologically guring ormulticentric Multifocal - ormultiple that lesions lesions discrete may be May coalesce also into confluent plaques - 5to≥15lesions ormore &usuallyoccur as singular may be Lesion(s) &fiKeratinized skin non-hairy moist, onwarm, &soft skinwhilenonkeratinized hairy ondry rm orpinkgiant condyloma Red w/caulifl genital skin ondry surface ower - Smooth, fl warts) ormoistskin(carpet orblack oneither brown, red, dry at-topped papules that are pink, - vulgaris) genital on drier surface skin(verruca papules w/rough warty Skin-colored raised - Skin-colored fi onmoistmucosal skin(condyloma warts liform acuminata) - ofgenital warts: ere are 4types onthe oralcavity, seen may Extragenital lesions be cavity, orconjunctivae nasal larynx -

examination, standard or high-resolution anoscopy may be beneﬁ may anoscopy examination, standard be orhigh-resolution cial digital ofthe by analcanal evaluation have also intra-anal warts, analwarts w/external individuals most As tendencies ﬁLesions tounderlying tissueorw/bleeding xed cancer &anogenital cancercervical intraepithelial squamous w/high-grade lesions, that lesions are associated subclinical cause which can HPVs w/ high-risk 16, 18, 31, 33 & infected 35) may be (eg also Patients types warts who present w/ visible w/human papillomavirus (HPV) infected tocollection inthis ofgenital area secretions secondary though may lesions Warts have developed analsex, foundinpenetrative inthe are typically analcanal © MIMS around the (especially anus) &soreness Irritation Warts -Anogenital(2of8) 1 2 GENITAL WARTS DIAGNOSIS B2 Patients >35 years - - - treatment during worsens Condition - -

trauma &irritation at siteprone to iflocated &infection Bleeding lial neoplasia Uncertain that diagnosis may suggest intraepithe- may indicate internal lesions orcervix urethra, fl ofurine Distortion anus, from orbleeding ow © MIMS 2019 WARTS - ANOGENITAL • Diff Diagnoses erential • Transmitted Sexually (STIs) forOther Infections Screen • • • • • • • (Cont’d) ofLesions Assessment • • • • Referral Specialist • • • • • • • papules, vulval papillae vulval papules, contagiosum, molluscum dermatofi malignant lesions, outcondylomaConsider torule lata, penile broma, recommended Many may patients have whopresent w/anogenital other warts STIs &anappropriate forSTIs is screening toexclude CIN high-grade exophytic warts forcervical w/biopsy Colposcopy - - the patientsEmphasize importance ofscreening forSTIs (eg reactions adverse pain,discomfort) It help decrease will - that coitalPatients informed throughout rest shouldbe therapy isrecommended - onthe ofcondoms use Patients advised shouldbe implications the totheir Emphasize long-term health &their partners - recurrence may Clearance takeupto1-6months, can occur, &complete eradication occurs later - spontaneously remain innumber Untreated orsize, orresolve unchanged may lesions increase - explanation oftheir adetailed conditionPatients given shouldbe patients forhigh-risk cytology Cervical - &cervix ofthe exam vagina Speculum - forfemales Additional tests useful &recording ongenital be lesions maps will morphology wart Classifying formore proximal warts Urethroscopy isperformed prevent newborn HPV infection infection HPV prevent newborn solely to counseled that isnotperformed shouldbe cesarean delivery Pregnant women w/anogenital warts isapparent, distress counselingWhen appropriate may psychological be contacts treat sexual If required, &other STDs benefi may forwarts be Screening cial tothe patient &the partner sexual - Immunocompromised patients - Intractable lesions - disease disseminated Large-volume - patients: referral inthe following Consider specialist in treatment, orreferral to a specialist Absence ofsignifi change consideration warrants foranalternative diagnosis, 4-6weeks within cant response ofthe Experience physician - Available resources - Adverse effects - &convenience Cost of treatment - Morphology, ofwarts number &distribution - Treatment choice on: depends &other STIs benefi may ofpresence ofwarts be Assessment tothecial both patient &thepartner sexual - infected the are subclinically ofpartners already majority isofnoproven benefi evaluation partner Sex orcomplicationt inpreventing transmission/reinfection since therapy totopical best Warts respond ormoistsurfaces areas foundinintertriginous No defi that suggests anynitive evidence ofthe treatment than optionsare better the others All treatments have signifi treatment itself cant &recurrence noteradicate failure rates the as virus does symptoms goal oftreatment that orpsychological physiological istoeliminate cause Primary warts

should be recommended recommended should be Many may patients have whopresent w/anogenital other warts STIs &anappropriate forSTIs screening continued tothe virus re-exposure & preventing the infection by acquisition genital ofHPV against protection warts haveCondoms shown - Not necessary for women <25 years & in patients w/ normal-smear intervals &inpatients forwomen <25 years w/normal-smear Notnecessary - © MIMS PRINCIPLES OF THERAPY 2 A Warts -Anogenital(3of8) PATIENT EDUCATION DIAGNOSIS (CONT’D) B3 Patient preference - Children - Pregnant patients - ofthe Condition patient, pregnant or eg - Age ofthe patient -

immunocompromised © MIMS 2019 WARTS - ANOGENITAL • • • Removal Surgical • • • • • • • • • Cryotherapy • Physician-Applied • No Treatment • TreatmentLaser • • • Photodynamic erapy - Excision/Curettage - Electrosurgery treatment Warts 1 offi are after usually removed however, afterce lesions visit; new 30% of patients develop will iscommon blistering &sometimes necrosis by Pain followed in patientsContraindicated w/cryoglobulinemia treat w/Imiquimod 4 weeks, after isnotachieved If 50%resolution 1st-line therapy forpregnant patients treated are tobe oralarge ofwarts area painifmultiple warts may anesthetic ease Use oflocal &fi perforation tothe ofvaginal risk Due isnotrecommended cryoprobe stula ofvaginal formation, use - Perform at intervals weekly - size onits depending the for10-30seconds lesion freezing isused, technique Afreeze-thaw-freeze - white turned until skinhas nitrogen 2mmofsurrounding Liquid wart toeach isapplied applications are usuallyneeded Repeated - Studies effi show 65-85% rates between cacy - Damages the aff cell &organelles membranes freezing by cells ected &moistwarts dry &both Suitable &internal forexternal warts, tophysical ablative better tend methods torespond warts Keratinized eff oftreatmentect transmission &future &the uncertainty resolution ofspontaneous tothe w/regards ofthe possibility An optionat any sitebecause - Dioxide Lasers Carbon - inpregnant women used be Can - contraindications Noknown - inpregnant women used be Can - anogenital forexternal &oralwarts Used - proteins tissues Coagulates oftreated - Studies show that results are equal or better thanStudies that orbetter other are show equal ornoscarring treatment results w/less modalities agentphotosensitizing accumulation tostimulate porphyrin inthe a tissuewhich acid(ALA) then as acts 5-aminolevulinic Uses mucosal &intraepithelial insensitive Used tissueincluding neoplasia venereal warts smokeplume may contain as DNA HPV observed workers ofhealthcare Adequate protection shouldbe - Notconsidered 1st-line ofcost treatment because - Treatment &may leave painful scars be can - Vaporization ofwarts - -

pedunculated orexophyticwartsataccessiblesites Useful if there is a small number of keratinized, tery, &hyfrecator surgery monopolar electrosurgeries are electrocau- 3 commonly used into the extracellular butisreleased which area may isnotdestroyed produce animmunologic response HPV meatus) at diffi &warts forlarge-volume/extensiveUseful anogenital warts (egcult anatomical sites intra-anal, urethral issuggested anesthetic oflocal injection before cream Use ofEMLA © MIMScurettage w/ fiMay remove warts or scalpel ne scissors, Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B NON-PHARMACOLOGICAL THERAPY Warts -Anogenital(4of8) B4 - - isrequired Noadditionalhemostasis - Avoid abnormalities inpatients w/bleeding - - - -

be observed as smokeplumemay contain as DNA HPV observed be workers ofhealthcare Adequate protection should scarring tocontrol topreventNeed depth ofcautery during procedure during pain is recommendedanesthetic to ease Local because warts are exophytic warts because Wound usuallyonlyextends into dermis upper chemical styptic orhemostatic solution chemical styptic unit, donew/ electrosurgical may be Hemostasis © MIMS 2019 WARTS - ANOGENITAL • • • • • • • (Topical)TCA Physician-Applied • • • • (Topical)Sinecatechins • • • • • • • Podophyllotoxin (Topical) • • • • • • • • • (Topical)Imiquimod Patient-Applied • (1%Preparation) Cream Sulfadiazine Silver • Preparation Imidazole Local • Anesthetic • • Bath Saltwater Symptomatic erapy Can be used inpregnant women used be Can application after An intense sensation experienced may burning be available be orsoap, shouldalways Na bicarbonate eg agents, Neutralizing - jelly isrecommended application ofthe skin w/ petroleum &protection surrounding Careful - Extremely corrosive tothe skin butare notwell tolerated Multiple applications necessary may be 70-81%butrelapse may upto36% may be be Initial response agentCaustic that incellular results necrosis ulceration into because the may dermis forlarge-volume occur Notrecommended warts - Tends eff less tobe orlarge forkeratinized buteff lesions ective - &moistwarts fordry ective suitable butismost at forsmallacuminate anatomical sites most orpapular warts used May be contact off diaphragms weaken &condoms washed Can &shouldbe orsexual tampon avaginal toinserting prior women infected immunocompromised, inthe orby pregnantoractive-herpes anus orvagina used Should notbe Have antioxidant &immune-enhancing ofactionisunknown actionsthough mechanism exact forupto16weeks Applied wart onexternal inpregnancy,Contraindicated lactation &children <0.5mL/day shouldbe totalvolumeused tolesions, applying Exercise caution whenever not visualized wart areas >10 cm areas wart in extragenital anal warts, for use Not recommended eg lesions days afew within &heal are shallow necrotize that Erosions the warts occur as - well totreatment respond warts nonkeratinized Soft - than better Podophyllin tobe seems Clearance ofwarts ofcondylomas tocellularBinds causing necrosis mitoticdivision microtubules &inhibits &incertain urethral meatus genital warts nonkeratinized external, warts forvisible, used May be Podophyllotoxin isthe purifi extractofPodophyllined 4 weeks erapy every continued may assessment w/clinical be upto16 weeks continue treatment upin4 weeks, donotclear If warts totreatment weeks delayed mayResponse forseveral be orforinternal lesions inpregnancy Not recommended low Recurrence rate issaidtobe - Wart clearance iscomparable inonset isslow though w/other response chemical agents, at the immune siteofapplication response localized Topical modifi immune response er that which produces stimulates theofinterferons production &cytokines female introitus eg area &perianal warts forcarpet useful Particularly warts Suitable men forwomen w/foreskin-associated &some ornonkeratinized keratinized anogenital forallexternal warts, used May be forlarge ablation after raw used May areas be ifthere isconcomitant used May be infection thrush that &defecation tomicturition anesthetic prior onraw applied may areas be Local - Xylocaine gel (2%preparation) bath ofplainsaltper twice daily or2tbsp doneat2 handfuls inlarge least bowl the &heal genital treatment during Helps area soothe

© MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing C PHARMACOLOGICAL THERAPY Warts -Anogenital(5of8) B5 2 , in ternal warts, or warts or warts warts, ternal © MIMS 2019 WARTS - ANOGENITAL • • • • • • Vaccine HPV Quadrivalent • • • • Vaccines • • • • Vaccine HPV 9-valent - Relapses should be treated according treated shouldbe Relapses tothe types lesion - 3monthsPatients successful treatment after concerned recurrence about evaluated may be forother modalities tocurrent & 6 weeks forImiquimod treatmentresponse 16 weeks after Change intherapy ifthe patient isindicated isnottolerating current therapy, sideeff w/severe or<50% ects continue w/current regimen can well are totreatment developing lesions have lesions responded butinwhomnew Patients original whose referral forspecialist need Assess - Evaluate recurrence - forchanges intreatment need modalities Assess - totherapy, Monitorresponse 3months within ietreatment ismostly noted oftherapy response - in order to: Patients for treatment weekly toreturn are undergoing removed until therapy allthe advised warts shouldbe Studies effi show inpreventing type-specificacy infection c HPV 16,18,6&11 oftype capsids Contains HPV pregnancy during foruse Not recommended for5 years observed been Stable has protection tothe virus orexposure activity tosexual prior given Ideally Safe &highlyeff inpreventing HPV ective cancer produce cervical infection since notall HPV oncytology at shouldstart appropriateFrequent screening based age &be cervical III &CIN II CIN genital against protection warts, limited provide Condoms For noeff prophylactic only&has use disease orestablished infections onactiveHPV ect 31,33,45,52&58 types: fi has vaccine butalso 6,11,16&18similartothe quadrivalent HPV types Contains HPV ve additional © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Warts -Anogenital(6of8) PREVENTION FOLLOW-UP B6 © MIMS 2019 WARTS - ANOGENITAL acedoben) acedoben) dimepranol Inosine (Inosiplex, pranobex Inosine vaccine recombinant 31, 33,45,52,58) 6,11,16,18, (types papillomavirus human9-valent vaccine recombinant 16, 18) 6,11, (types virus human papilloma- Quadrivalent All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © MIMS 14-28 days 8 hrly x 1 gPO treatment: surgical or topical tostandard Adjunct 0, 2&6mth at 0.5 mLIMx3doses Females ≥15yr: 0, 2&6mth at 0.5 mLIMx3doses or dose 5-13 mth 1st after date & elected 1st dose at 0.5 mLIMx2doses Females 9-14yr: 0, 2&6mth at 0.5 mLIMx3doses Females ≥14yr: 0, 2&6mth at 0.5 mLIMx3doses or 0 &6mth at 0.5 mLIMx2doses Females 9-13yr: Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not VACCINES, ANTISERA&IMMUNOLOGICALS Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage Warts -Anogenital(7of8) Dosage Guidelines ANTIVIRAL • • Instructions Special • • Reactions Adverse • • • Instructions Special • • Reactions Adverse coagulation disorder orany Use w/caution inpatients w/thrombocytopenia higher anterolateral ofthe area thigh Inj IMinto orinthe the ofthe arm deltoid upper region fever, nausea dizziness, Headache, Systemic reactions: pruritus erythema, Pain,swelling, Inj sitereactions: thrombocytopenia orany disorder coagulation thrombocytopenia Use immune w/caution inpatients w/impaired response, administered should be always dose than earlier 6mths a3rdadministered the 1stdose, after is For dose ifthe 2ndvaccine schedule, the 2-dose higher anterolateral of the area thigh Inj IMinto orinthe the ofthe arm deltoid upper region Fever, nausea Systemic headache, reactions: dizziness, hematoma pruritus, erythema, Mild-moderate pain,swelling, Inj sitereactions: B7 • Instructions Special • Reactions Adverse function, gout orhyperuricemia function, Use w/caution inpatients w/impaired renal &urine serum Transient N/V, acidconc uric in increased Remarks Remarks © MIMS 2019 WARTS - ANOGENITAL acid (TCA) Trichloroacetic resin Podophyllum (Podofi lox) Podophyllotoxin Apply 3x/wk 5%cream Imiquimod All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed soln 80-90% Apply <1-2 mL 25% soln 0.5% soln cream 0.15% Available

© MIMS Strength Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please WARTS &CALLUSES PREPARATIONS required wkly if May repeat warts ontosoln offi ce: Apply physician’s Apply in treatment per onto warts cycles treatment Max: necessary as cycle Repeat treatment 4 daysby ofno 3 days followed Apply 12 hrly x 16 wk of or amax clearance wart treatment until Continue offwash 6-10 hr then onfor Leave at bedtime Warts -Anogenital(8of8) Dosage Dosage Guidelines 4 B8 • • • Instructions Special • Reactions Adverse • Instructions Special • • Reactions Adverse • Instructions Special • • Reactions Adverse • Reactions Adverse jelly Avoid contactw/normalskin;protectpetroleum spills orifexcess acidisapplied Talc available totreat shouldbe orNabicarbonate thatso awhite layer develops todry &allow Apply asmallamount onlytowarts carefully applied ifnot ulceration. May scarring cause Pain, burning, treatment hrafter several circulation; ifw/alcoholblood consumption for infl orpatients w/poor diabetics orirritated; amed tissueis orsurrounding ifgrowth hair; growing w/ orunusual marks birth warts moles, hemorrhagic, that are eitherwarts fl w/largeorid or area surface Avoid orany ontongue mucosal use tissue,genital coma &death thrombocytopenia, leukopenia, ileus, paralytic polyneuritis, Systemic eff transient fever, Urticaria, paresthesia, ects: hyperplasia pseudoepitheliomatous circumcision, paraphimosis requiring area, effLocal ofanogenital &scarring necrosis Severe ects: forapplication needed &tactilesensationwhere self exam are digital totreat w/cream easier may be &analwarts vulvar convenient maySoln while be warts forpenile s t c ff e e Topical systemic serious overdosage cause can headache pain,inflBurning, ammation, erosion &pruritus, headache edema, excoriation, fl skinerosion, erythema, Local aking, Remarks © MIMS 2019