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Also known as condylomata acuminata or
venereal warts, is one of the most common
types of sexually transmitted infection and
primarily affect younger people.
The disease usually is caused by HPV genotypes
6 or 11, which normally are not involved with
cancers but can cause abnormal pap smear.
In 8 to 14%, the person has been infected with
more than one type of HPV
50 to 80 percent of sexually active women
are infected at least once in their lifetime.
Transient or undetectable
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Women under 25 to 30 years have higher
rates of infection although a second peak has
been described in postmenopausal women.
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Association with HPV genotypes 16 and 18
can give rise to subclinical lesions associated
with CIN and squamous cancer.
Approximately 1 million cases of genital
warts occur each year in the United States
and an estimated 32 million cases occur
worldwide.
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In women, genital warts can appear on the
vulva, the walls of the vagina, the perianal
area, and the cervix. May increase in size
during pregnancy.
In men, they may be found on the tip or shaft
of the penis, the scrotum, or the anus.
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In neonates, respiratory & laryngeal
papillomatosis follows NVD but can occur
after C/S. Typically presents between 2 & 3
years of age and extends into adolescence.
About 37% of laryngeal papillomatosis
become malignant.
Occurs more commonly in first-born children
and in the children of young mothers who
had genital warts.
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100 types of HPV ( double stranded DNA virus)
Viral replication takes place only in fully
differentiated epithelium.
Cutaneous and mucosal types,
High, intermediate and low risk types
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Papule or plaque
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can also remain dormant within epithelial cells
without visible disease
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HPV type 2 on hands and feet
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Benign lesion: the viral genome replicates
separately to the host cell’s DNA.
Malignant lesion: the HPV DNA is integrated
into the host cell’s chromosomes.
After integration a series of events leads to
deregulation of the E6 and E7 genes of HPV.
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5 - Fluoruracil (5-Fu)
Bichloroacetic or
Trichloroacetic Acid
Cryotherapy
Surgical Excision or
Curettage
Cautery
Imiquimod
Interferon
CO2 Laser
Podophyllin
Podophyllotoxin
Vacinne
Antimetabolic
Tissue Chemical Destruction
Physical Freezing
Surgical Removal
Tissue Physical Destruction
Immunomodulator
Antiviral(immunomodulator)
Tissue Vaporization
Antimitotic
Antimitotic
Antiviral(immunomodulator)
Claudio S Batista, Álvaro N Atallah,
HumbertoSaconato, Edina MK da Silva
2010 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
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Types of studies, Only randomized controlled
trials (RCTs) were included in this review
Types of participants, Women and men aged
18 years or more, nonimmunocompromised,
with clinical or subclinical genital warts.
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5-FU Vs placebo
5-FU 5% Vs Meta-cresol-sulfonic Acid (MCSA)
5-FU 5% Vs Podophyllin
5-Fu 5% Vs CO2 Laser
5-FU 5% Vs 5-FU 5% + INF -2a (Low dose)
5-FU 5% Vs 5-Fu 5% + INF -2a (High dose)
5- FU 5% Vs 5-FU 5% + CO2 Laser + INF -2a
(High dose)
5-FU 5% + CO2 Laser Vs CO2 Laser plus
Primary Outcomes
 • Patient or warts response: cure or partial
improvement
 • Recurrence rate
Secondary Outcomes
 • Local reactions
 • Other related adverse events (alteration in
lab data)
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Botacini et al, 1993,5% vag. gel 5 gr Qod x15
Females with HPV infection
64 Vs 16
The outcomes after 12 wks Rx were:
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Cure(-ve colpo, pap & Bx): 52/64 vs 5/16
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*
Partial response (only+ve cyto): 7/64 vs 1/16
No response: 5/64 vs 10/16 *
0.02
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Syed at al, 2000, 1% vag. gel 4 gr Qod x4 wks
30 females in each group with intravaginal warts
312 genital warts: 162 Vs 150
The results were:
Cure (Nl colpo & -ve HPV): 25/30 Vs 4/30 * 0.02
side effects : 2/30 Vs 1/30
Lesion recurrence : 2/30 Vs 1/30
Warts cure:141/162 lesions Vs 21/150 * 0.0001
Low index of side effects ( local Rxn, dysuria &
local hypersensitivity )
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Weissmann et al, 1982, 0.5% gel. Anogenital warts
59 patients: 30 male (14 Vs 16) & 29 female (16 Vs
13 )
The results were:
Cure: 18/30 patients (10/14 male & 8/16 female) Vs
8/29 patients (4/16 male & 4/13 female) * 0.031
Improvement: 6/30 patients (2/14 male & 4/16
female) Vs 4/29 patients, (1/16 male & 3/13 female),
No response: 6/30 patients (4/14 male & 2/16
female) Vs 17/29 patients (8/16 male &
9/13 female).
* 0.0068
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Data from these 3 studies Botacini 1993;
Syed 2000; Weismann 1982 could be pooled
but demonstrated heterogeneity (I 2= 62%).
[RR 0.39 (95% CI, 0.23 -0.67)]. NNT = 2
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Botacini et al, 1993, all females
74 patients Vs 9 (MCSA Qod x30 days)
Results after 12 weeks were:
Cure: 52/74 Vs 3/9 *
Partial response: 7/74 patients Vs 1/9
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No response: 15/74 patients Vs 5/9
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* 0.0075
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Botacini et al, 1993, all females
74 pts 5-FU 5% gel (2/wk x8 wks),
40 pts Podophyllin 2% (vag.gel 5gr Qod x15)
5 pts Podophyllin 4%. (vag. gel 5gr Qodx15)
The results after 12 weeks:
Cure: 52 patients /19/ 3 *
Partial response: 7 patients/5/1
No response: 15 patients/16/1 * 0.039
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Wallin et al, 1977, All males
42 male patients:20 patients(cream qhs x2w) Vs 22
( solution by doctor weekly x 4)
Withdrawals: 2 Vs 3
The results after 4 and 9 weeks.
Cure after 4 weeks : 10/18 patients Vs 11/19 0.89
Cure after 9 weeks: 6/18 patients Vs 10/19
Recurrence of lesions p less than 0.00001
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Data from two studies (Botacini 1993; Wallin
1977) could be pooled and did not
demonstrate heterogeneity (I2 = 32%).
[RR 1.26 (95% CI, 0.86 - 1.82)]. NNT = 6
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Relakis, 1996, performed 3 study groups
all males
Condyloma Acuminatum (CA): cream qhsx5, if no
response other 3 courses,
Condyloma Plain (CP): single dose
Condyloma acuminatum & plain (CA+CP): single dose
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The only studied outcome was Treatment Failure.
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Lesion Recurrence observed in the first year after
treatment was considered as Treatment Failure
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Side Effects were observed in 11% of the patients
treated with 5-FU
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In CA group, 33 males Vs 12
Treatment Failure was: 8/33 Vs 4/12 0.53
In CP Group, 156 males Vs 39
Results were: 29/156 Vs 12/39 0.085
In CA + CP Group, 29 males Vs 20
Results were: 14/29 Vs 14/20 0.12
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Relakis et al, 1996, all male patients
5FU 2 courses x 5 days + INF 1.5 SC x 6 days
In CA group: 33 Vs 27
Results were 8/33 Vs 7/27 0.88
In CP group: 156 Vs 18
Results: 29/156 Vs 2/18 0.34
In CA + CP Group: 29 patients Vs 0
Results 14 patients
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Relakis et al, 1996, all males
5FU 5% cream 2 courses x 5days + INF 3 IU
SC x 6 days
In CA Group: 33 Vs 0
Treatment Failure in 8/33
In CP Group: 156 patients Vs 58
Result: 29/156 Vs 1/58
In Ca + CP Group : 29 Vs 0
Result: 14/29 patients
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Relakis et al., 1996, All males
CO2 laser after 2 courses of 5FU cream
In CA group: 33 Vs 30.
Results: 8/33 patients Vs 0/30 0.056
In CP group: 156 Vs 20
Results: 29/156 Vs 1/20 0.18
In CA + CP group: 29 Vs 16
Results: 14/29 patients Vs 3/16
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failure * 0.00001
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Carpinello et al., 1988, all males
5FU 5% one wk after Laser x 30 days
68 patients, 41 Vs 27
The outcome studied was Lesion Recurrence
Even one lesion after treatment
Results: 28/41 Vs 19/27 0.86
Considering cure alone, 5-FU was superior
to placebo, to MCSA and the Podophylin
 considering only treatment failure/ no
response, 5-FU was superior to placebo, to
MCSA, Podophylin 2% and equal to CO2 Laser
and 5FU + INF-2a (low dose) and inferior to
5-FU + INF - 2a ( high dose) and 5FU + Co2
Laser +INF- 2a (high dose).
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There was no statistical significance between
the treatments of 5-FU + INF - 2a (high dose)
and 5-FU + Laser of Co2 + INF- 2a (high
dose).
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is a good treatment
option in view of the costs of
INF- 2a and the CO2 Laser.
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Six trials involving 988 pts (645 women and
343 men) and reporting 8 comparisons were
evaluated.
Two studies reported withdrawals and
dropouts.
5-FU presented better results for cure than
placebo or no treatment (relative risk RR
0.39), meta-cresol-sulfonic acid (MCSA) (RR
2.11, 95% ), Podophyllin 2%, 4% or 25% (RR
1.26, 95% CI 0.86 to 1.82).
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There were no statistical differences for
treatment failure for 5-FU Vs CO2 Laser (RR
0.69, 95% CI 0.43 to 1.11) Vs 5-FU + INF-2a
(low dose) (RR 1.02, 95% CI 0.87 to 1.119).
Worse results were found for 5-FU Vs 5-FU +
INF-2a (high dose) (RR 10.78, 95% CI 1.50 to
77.36), and 5-FU + CO2 Laser + INF-2a (high
dose) (RR 7.97, 95% CI 2.87 to 22.13).
Thank You