Genital Warts

Question 1

Usual incubation for warts

Answer 1

3weeks to 8/12 but up to 18/12

Question 2

Name of rapidly growing ward which can infiltrate local tissue and erode

Answer 2

Buscheke - lowenstein lesion

Question 3

Features concerning of neoplasia on genitals

Answer 3

Pigmentation
Depigmentation
Pruritis
Immune deficiency 
Previous VIN etc

Question 4

Examination for women first presentation warts

Answer 4

Include speculum to check for internal warts

Question 5

General advice re warts

Answer 5

Give a leaflet
Use condoms
Counselling if needed
Smokers respond less well to Rx
Several Rx usually needed before subside
Full sti screen

Question 6

Better options for soft non keratinised warts

Answer 6

Podoph

Trichloroacetic acid

Question 7

Better option for hard keratinised warts

Answer 7

Cryo/ excision
TCA
Electrocautery

Question 8

Podophyllotoxin

Answer 8

0.5% solution
0.15% cream
Licensed up to 5 weeks
Medical supervision if over 4cm
Penis or external genitalia
BD for 3/7 then 4/7 rest. Up to 5 weeks
Stop if irritation
Avoid sex afterwards
Avoid in pregnancy
Can repeat Rx if not gone at 5/52

Question 9

Imiquimod

Answer 9

Immune modulator
Acts as a toll like receptor 7 agonist (TLR7). Stimulate immune response
5% cream
Three times weekly and wash off after 6-10 hours
Use up to 16 weeks
Avoid sex afterwards
Weakens latex
Don’t use in pregnancy

Question 10

Cataphen 10% ointment

Answer 10

Extract of green tea plant
Tds for up to 16 weeks
External warts

Question 11

Trichloroacetic acid (TCA)

Answer 11

80-90% solution 
Weekly application in specialist clinic
V corrosive
Cellular necrosis
Intense burning 10min post
Surrounding skin use Vaseline or topical neutraliser e.g sodium bicarbonate solution

Question 12

Weird topical wart RX

Answer 12

5-flurouracil - dna anti metabolite 
5%cream
Adverse effects - vulval burning
Inferior cure rates
Not routine Mx

Interferons - can inject also. Expensive, not great response rate

Question 13

Wart ablation options

Answer 13

Excision under LA - can use monsels if needed or electrocautery
Cryo - necrosis at dermal/epidermal junction. Weekly and usually if not better after 4 weeks - change
Electrosurgery - burning
Laser - good for large warts, co2 lasers. Expensive

Question 14

Wart follow up

Answer 14

At end of Rx course

If less than 50% response by 5 weeks for podoph or 8-12 weeks by imiquimod - change therapy

Question 15

Warts in pregnancy Mx flow chart

Answer 15

Cryo x 1 weekly
Review at 4 weeks
If >50% resolved continue cryo
If not - excision or wait until delivered

Question 16

Wart flow chart if one or few warts in women

Answer 16

Cryo weekly for 4 weeks and if no better then switch to imiquimod or podoph.
Or
Podoph twice daily 3 days a week. Review at 4-5 weeks and either swap to imiquimod or if >50% resolved continue podoph

Question 17

Management of multiple external genital warts women flow chart

Answer 17

Podoph twice daily for 3 days a week
Review at 4-5 weeks
If <50% resolved - imiquimod three times weekly for up to 16 weeks

Question 18

Multiple warts in men flow chart

Answer 18

Podoph twice daily for 3 days a week
After 4-5 weeks if less than 50% better - imiquimod for up to 16 weeks
If still not cleared - excision or repeat Rx

Question 19

One or few warts Mx in men flow chart

Answer 19

Cryo weekly and after 4 weeks podop or imiquimod if not improving
Or
Podoph then imiquimod

Question 20

Management of urethral meatal warts in men flow chart

Answer 20

See wart base then cryo weekly then podoph or imiquimod if no better
If can’t see wart base - cryo weekly and if after 3 session still can’t see base of wart then refer to urology