Why it is Important to Evaluate Your Warts
By Dr. Kate Dudek
Warts are common, non-cancerous growths that appear on the surface of the skin. Caused by infection of the outer layer of the skin with human papillomavirus (HPV), they vary in size and location, but are most frequently seen on the hands, the face and the soles of the feet. Warts are normally hard, small and rough to the touch; they can occur in isolation, or in clusters and can spread from one location to another, for example, those who bite their fingernails, will often see new wart growth around their mouth. Warts are completely benign and most will spontaneously resolve within two years.
Warts that are found around the urinary and genital tracts are known as urogenital warts. They are frequently found around the vagina and within the urogenital tract, which includes the cervix, the vagina, the urethra, the perineum, the perianal skin and the anus. 90% of these warts are caused by HPV type 6 or type 11, which are both non-cancerous variants of the virus. Urogenital warts are very common, affecting up to 15% of sexually active women. One of the reasons why so many people contract urogenital warts is that they may only be identified months, or even years, after the initial HPV infection; meaning that they lie dormant for a significant period of time.
Urogenital warts are often asymptomatic. However, depending on their location, can cause pain or discomfort. They are usually diagnosed following visual inspection and treatment will depend on their size, location, quantity and patient preference. Many will resolve over time without the need for treatment; however, if they are causing pain or having a psychosocial impact on a person's emotional wellbeing, there are removal options.
Treating Urogenital Warts
It is important to remember that treating the warts, will not be curing the underlying virus, so recurrence rates are high, particularly in the three months following treatment. The HPV vaccine, which is growing in popularity and should, over the coming decades, drastically reduce the number of women diagnosed with cervical cancer, will prevent HPV infection, but will not cure the virus once it has been transmitted. The vaccines in use today both protect against HPV-6 and HPV-11 as well as the most carcinogenic forms of the virus.
The main treatment options are:
- Patient-applied topical creams. Imiquimod is an immune enhancer, stimulating the production of cytokines. Podofilow prevents cell division and leads to wart necrosis. The efficacy of these treatments depends, in part, on how well they are applied by the patient. They are only suitable for use on external genital warts.
- Cryotherapy. Liquid nitrogen is used as a means of thermally-induced cytolysis. Requires a trained specialist and sometimes leads to blistering of the surrounding skin. Not recommended for vaginal warts, due to the risk of vaginal perforation.
- Surgical excision. Warts removed with scissors, lasers, electrocautery (burning), scalpels or carbon dioxide. Multiple warts can be targeted in a single procedure. Suitable for external warts, as well as cervical, vaginal and intra-anal warts.
- Trichloroacetic acid (TCA)/Bichloroacetic acid (BCA). These are caustic agents that destroy warts by chemically coagulating proteins. Should be applied with care as an excess of TCA/BCA can cause damage to the surrounding tissue. There is some evidence that TCA treatment can be as effective as cryotherapy, but the lack of comparison with a placebo, means that this is a widely used treatment option that is poorly investigated. Used for external genital warts, as well as cervical, vaginal and intra-anal warts.
When to Evaluate Your Warts More Closely
The HPV variants that cause genitourinary warts are different to those that cause cancer and, as such, 'normal' genital warts will not progress to cancer. However, warts that are atypical in appearance should be evaluated by a specialist. This includes warts that are pigmented, bleeding or ulcerated. In these instances, a doctor will usually take a biopsy to look for abnormal cells. High-grade squamous intraepithelial lesion (H-SILs) are abnormal cells caused by chronic infection with HPV that, if left untreated, may progress to cancer.
Any warts that are identified within the cervix, should be evaluated by a specialist first to rule out the presence of precancerous lesions.
Warts and Pregnancy
The topical creams recommended for the treatment of external genital warts, should not be used in pregnancy, due to limited available safety data. Women with anogenital warts may find that their warts start to proliferate, or crumble (become friable) during pregnancy. Attempts to remove warts during pregnancy are often ineffectual and thus many doctors recommend waiting until after delivery.
The concept of virus transmission from mother to unborn baby is not well understood; in very rare cases the baby may develop warts on their larynx (respiratory papillomatosis), but Caesarean sections (C sections) should not be recommended as standard. In some cases, the warts will block the pelvis, meaning that a C-section does become necessary.