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Home Genital Warts Genital Warts Genital Warts: Issues in Patient Management and Counseling

Genital Warts: Issues in Patient Management and Counseling

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An Interview with Gary Richwald, MD, MPH

External genital warts (EGW) are a common condition for which many patients seek care and counseling. Warts are often overlooked in HPV discussions, though, and patients often struggle to find the resources and information needed to cope with a diagnosis which can involve a significant emotional burden and cost of care.

For insight into the many issues faced by both patients and provider, we turned to Gary Richwald, MD, MPH, a communicable disease specialist and clinical virologist. For eleven years from 1989 to 2000, he served as the Chief Physician and Director of the Los Angeles County STD Program, the largest provider of sexual Gary Richwald, MD, MPHhealth and disease-related services in the United States. Dr. Richwald is a recognized expert in the management of EGW disease and has served as a CDC consultant in STDs, as co-chair of the AMA Consensus Development Group on External Genital Warts and HPV infection, and as a mentor for clinicians involved in treating patients with STDs.

HPV News: Talk about genital warts as a public health issue. Is there a perception that warts are a cosmetic issue, with few real health consequences?
Gary Richwald: I think it’s a vastly under appreciated problem. A prime responsibility of “public health” involves providing services to poor people who can’t afford health care, and whose numbers are swelling in the current economic decline and health insurance crisis. That’s a problem with conditions like EGW that usually involve multiple clinic visits and procedures; sometimes even multiple practitioners.

Warts do cause physical problems. They cause itching, small amounts of bleeding, and can become the focus of an individual’s life. Warts can be disfiguring and are obviously noticeable in the genital area. This can have a very strong impact on people’s sexual relationships and, in general, their sexual health. Stress related to warts can be intense, in some cases so severe it leads to other medical problems, such as headaches, insomnia, and lower back pain!  I recently saw a patient who hadn’t slept with his wife for six months because he’s afraid of giving her warts. He’s afraid to even discuss the problem with her. We’re talking about significant negative impact on relationships, so suddenly we go from a medical problem to an interpersonal problem, which often becomes a communication problem. In extreme cases, this leads to estrangement of partners. Now, I wouldn’t tell you this happens all the time but it is very real for some couples, and not to be taken lightly.

Our health care system doesn’t respond well to people with genital warts. Some practitioners are undereducated in the management of genital warts. Health care providers can be unprepared and fail to offer services for people with viral STIs other than HIV.  This is very concerning for patients because they become desperate for clear and accurate information, and for a thoughtful provider. I’ve seen patients get increasingly agitated when they don’t get answers or services. We see this all the time: The herpes support group in Los Angeles – for which I serve as medical advisor - is seeing more and more patients with HPV infection. While some of this is due to publicity around the HPV vaccine, a lot of it has to do with people wanting answers for critical issues like transmission, infectiousness, treatment, and post-treatment sexual activity and prevention.


How difficult are genital warts to diagnose? Are clinicians sufficiently trained in detection and treatment of these lesions?
I think clinicians are trained, but there’s an inherent problem that not every bump that looks like a wart in the genital area is in fact a wart. You can have skin tags, unpigmented moles, and the like. Visual diagnosis, however, is sufficient in more than 95% of cases. When seeing a genital wart, some clinicians have difficulty saying the words “You have a sexually transmitted infection.” What happens is sometimes patients are told “it looks like a wart,” or “I think it’s a wart” which can lead the patient to wonder if in fact they do have it. Doctors are sometimes concerned about delivering an STI diagnosis due to the time demands of subsequent counseling and continuing care. Some clinicians may not have the time to provide the services and answer questions about genital warts due to financial constraints. This can lead to a minimalization of the condition, and frustrated patients.

As I mentioned earlier, treatment for warts often requires multiple visits and can involve procedures, such as cryotherapy, which may not be available to the average family physician or internist. Clinicians are often not prepared to take on the full range of treatment warts entails, especially when “first-line” treatments fail or warts are recurrent (or widespread in the anogenital area).

Let’s talk about treatment. Most options are office-based, but there are also at home prescriptions creams and gels. Are patient-applied therapies sufficiently utilized?
The American Medical Association treatment guidelines for genital warts that were first published over a decade ago recommends that patients be offered both provider- and patient-administered treatment options.  I would say that often the counseling around treatment options is perfunctory and patients are not offered a choice of treatment regimens, along with discussion of the pros and cons of each. People are typically treated in the office and given Trichloracetic acid (TCA), which is applied to the warts by the clinician once or twice a week for a number of weeks, or the warts are frozen using liquid nitrogen (cryotherapy), also requiring a number of applications. Electrocautery, burning the lesions with an electric blade or needle, is also used. These procedures often have to be repeated several times, and the total cost of care can be very expensive. In some cases, doctors don’t have these modalities in their office and have to refer the patient to a dermatologist or Ob/Gyn, so now we’re talking about a second set of clinical encounters. The clinicians who are best prepared to do this may be in short supply and are subsequently least available in terms of cost and ease of access.

Are at home treatments utilized often enough?
These prescription creams aren’t recommended often enough. I think this has to do with doctors not being as familiar with these options, and possibly the cost. Also, there’s little on-going continuing medical education for genital warts management.

The standard patient-applied therapies are podofilox, sinecatchins, and Imiquimod (the latter of which stimulates the immune system in the area of the wart to both treat the wart and reduce subsequent recurrences). These products offer the convenience of being applied at home, as well as addressing privacy concerns. Patients are often anxious and when they come to the office will say, “I want these warts off now!” It may take a number of weeks or months for these patient-applied treatments to work, though, which can be tough on someone who’s understandably impatient. Of course, it also can take weeks to months for office-based treatments to remove warts, which is less commonly discussed with the patient.

In addition, some of these prescription creams are very expensive and a number of public health (STD) venues may not provide them due to cost.  

Do you agree that no one approach to treatment is universally regarded as best?
That’s true, but some options are what we call first line: These are TCA and cryotherapy among provider-administered options, and Imiquimod and sinecatchins among those that are patient-applied. One advantage to Imiquimod is it reduces the rate of subsequent recurrences. It is probably the best of the patient-administered options due to its advantages in reducing the rate of recurrence. Another approach is to simply monitor the warts to see if they resolve naturally. This works best with newly developed warts; lesions present for more than six months have a much smaller likelihood of going away without treatment.

Regarding lifestyle and diet, what should we say to someone with persistent warts, or warts that recur often.

Things to be aware of include smoking, alcohol use, and stress in general. Anything that impairs immunity reduces our natural control over warts. Reducing stress in those areas would be helpful in enhancing and strengthening a patient’s immune system, allowing it to play a stronger role in controlling the reactivation of warts.

What about partners?
The sex partner of someone with genital warts should have a visual examination of the genitals, as well as other appropriate STD tests. Since as many as half of unrecognized warts are in the perianal area, I recommend that a full genital exam (front and back of genital area with good lighting) of the partner be performed by a clinician.

I also recommend people use condoms during treatment for warts. There is research - done with women who are having treatment associated with abnormal Pap tests -that suggests using condoms post-treatment reduces the recurrence of HPV and related lesions following treatment. These studies weren’t done with couples diagnosed with warts, but I think it’s a very logical extension here.  Condoms should be used when having sex with new partners, and the number of sexual partners should be kept to a minimum. Condoms do offer some protection against acquiring HPV and developing genital warts, and this is often not emphasized by clinicians.