Therapeutic efficacy of cryotherapy in genital warts: A case series with patient-reported outcomes

Abstract

Genital warts are common benign lesions caused predominantly by human papillomavirus types 6 and 11 and are associated with significant psychosocial morbidity. Cryotherapy remains a widely used ablative modality, yet data on patient-reported outcomes in real-world settings remain limited. To evaluate the therapeutic efficacy, safety profile, and patient-reported outcomes of cryotherapy in the management of genital warts. A case series of seven treatment-naive patients with clinically and dermoscopically confirmed genital warts was analyzed. All patients underwent cryotherapy with a cryoprobe using two freeze–thaw cycles per session at 2-week intervals. Pain was assessed using the Visual Analogue Scale (VAS), and quality-of-life changes were measured using the Dermatology Life Quality Index (DLQI) before treatment and two weeks after the final session. Complete or near-complete clearance was achieved in 71.4% of patients after 1–2 sessions. Adverse effects occurred in 57.1%, predominantly procedural pain and transient hypopigmentation. DLQI scores improved markedly among patients with complete clearance, indicating significant psychosocial recovery, whereas incomplete responders—particularly immunocompromised individuals—showed minimal improvement. Recurrence occurred in 14% of cases. Cryotherapy is a safe, cost-effective, and efficacious first-line treatment for genital warts, especially in immunocompetent patients. Incorporating patient-reported outcomes such as DLQI and VAS provides a holistic assessment of therapeutic success and should be adopted routinely.

Introduction

Genital warts, or condyloma acuminata, are benign proliferative lesions primarily caused by low-risk types of human papillomavirus, predominantly types 6 and 11. They are one of the most common sexually transmitted infections (STIs) globally, with an estimated lifetime risk of 10% in sexually active individuals.[1] Although not oncogenic, genital warts carry significant psychosocial morbidity, impacting self-esteem, sexual health, and interpersonal relationships.[2]

The treatment landscape for genital warts includes ablative, cytotoxic, and immunomodulatory modalities. Cryotherapy, using liquid nitrogen to induce tissue necrosis through freeze–thaw cycles, is one of the most commonly employed methods due to its ease of use, safety, and efficacy. It is also a viable option during pregnancy and in resource-limited settings.[3]

Despite its widespread use, most existing literature focuses on clinical outcomes, with limited attention to patient-reported outcome measures (PROMs). Understanding the subjective experience, including pain, cosmetic satisfaction, and psychological recovery, is crucial to holistic care, especially for stigmatizing conditions like genital warts.

We present a case series of seven treatment-naive patients treated with cryotherapy for genital warts, incorporating both clinical efficacy and PROMs to better evaluate its real-world effectiveness [Table 1 and Figures 1–7].

Table 1.

Clinico dermographic profile of the cases

Case	Age/sex	Site	Sessions	Clearance	VAS pain (average)	DLQI (pre → post)	Notes
1	28/male	Perimeatal	2	Complete	6	9 → 3	Regained sexual confidence
2	18/male	Penile shaft	2	Complete	7	8 → 2	Mild postinflammatory pigment change
3	32/male	Penile shaft	2	Complete	7	10 → 4	Moderate pretreatment distress
4	30/male	Perianal	2	Near-complete	8	11 → 5	Discomfort with defecation resolved
5	26/male	Penile root	2	Recurrence at 1 month	6	7 → 6	High-risk behavior; recurrence noted
6	38/female	Vulva	3	Incomplete	8	12 → 10	RVD positive; poor lesion regression
7	42/male	Prepuce	3	Incomplete	7	9 → 8	RVD positive; poor response

RVD=Retroviral disease; DLQI=Dermatology life quality index; VAS=Visual Analog Scale

Figure 1.

(a) Preprocedure. (b) Post-1^st session. (c) Post-2^nd session

Figure 7.

(a) Preprocedure. (b) Post-1^st session. (c) Post-3^rd session, lesions persist

Figure 2.

(a) Preprocedure. (b) Post-1^st session. (c) Post-2^nd session developed hypopigmentation

Figure 3.

(a) Preprocedure. (b) Post-1^st sitting. (c) Post-2^nd session developed hypopigmentation

Figure 4.

(a) Preprocedure. (b) Post-1^st session. (c) Post-2^nd session

Figure 5.

(a) Preprocedure. (b) Post-1^st session. (c) Recurrence after 1 month of the 2^nd sitting

Figure 6.

(a) Preprocedure. (b) Post-1^st session. (c) Post-3^rd session, lesions persist

All patients were treated with cryotherapy using a cryoprobe with two freeze–thaw cycles per session. Sessions were performed 2 weeks apart. PROMs were collected using Visual Analogue Scale (VAS, 0–10) for pain and Quality of Life (DLQI) (0–30 scale) pretreatment and at 2 weeks after the final session.[4,5]

In this series of seven patients with genital warts, the patients belonged to the age group of 20–40 years in accordance with existing literature. This represents the sexually active age demographic. Male predominance is noted; however, in certain studies, females outnumbered males. The gender disparity could be attributed to asymptomatic infections in females, socioeconomic factors.[6]

Duration of lesions ranged from 1 to 6 months. Sites involved were penile shaft (n = 2), prepuce (n = 1), perianal (n = 1), perimeatal (n = 1), penile root (n = 1), and vulva (n = 1). Morphology included verrucous papules and plaques. Diagnosis of genital warts was made primarily on clinical grounds. In doubtful cases, dermoscopy was used to visualize characteristic features (mosaic pattern and papillomatous surface), but biopsy was not required in this series as clinical and dermoscopic features were typical. Baseline investigations included complete hemogram, HIV, hepatitis B and C serology, and Venereal Disease Research Laboratory (VDRL) testing. Two patients were HIV positive (renovascular disease [RVD] positive) while the rest were seronegative for HIV and VDRL.

Cryotherapy provided complete or near-complete clearance in 71.4% of patients after 1–2 sessions. This aligns with previous studies that report efficacy rates between 70% and 80% using similar protocols.[3,7]

Adverse effects were observed in 57.1% (4/7) of patients. Pain during the procedure was universal. Hypopigmentation occurred in 28.6% (2/7) of cases, both at penile shaft sites. No blistering, ulceration, or scarring was seen. These findings reported correlate with existing literature.[3,7] Pain was a more consistent adverse event with VAS scores ranging from 6 to 8. Although transient, it was the most reported procedural discomfort, particularly in sensitive areas such as the perianal region. These pain levels are consistent with other reports of ablative genital wart therapies.[7]

No delayed side effects such as scarring, ulceration, or persistent pigmentary changes were noted at 1-month follow-up. Only transient postinflammatory hypopigmentation persisted in two patients.

Importantly, we evaluated DLQI scores, which reflect the psychosocial and functional burden of dermatologic disease. All patients with complete clearance showed marked improvement in DLQI scores, with post-treatment values falling into the “mild effect” range (0–5). This is consistent with studies that emphasize the negative psychological impact of genital warts, including embarrassment, sexual dysfunction, and social withdrawal.[8]

Conversely, patients with incomplete response or recurrence showed only minimal DLQI improvement, underscoring the ongoing emotional burden of unresolved disease. Two of these patients were RVD-positive, supporting prior literature suggesting immunosuppressed individuals have reduced response rates and higher recurrence risks.[9]

Recurrence rate noted in the present study is 14%, similar to those findings observed by Jahic.[3]

However, few studies documented higher recurrence rates.[10] Overall, the use of DLQI and VAS as PROMs adds depth to outcome assessment. These tools are easy to administer in outpatient STI clinics and reflect both the physical and psychological dimensions of therapeutic success.

Conclusion

This study highlights that cryotherapy is a simple, outpatient, cost-effective treatment with good efficacy in immunocompetent patients, making it practical for STI clinics and resource-limited settings. We recommend cryotherapy as first-line therapy for genital warts in immunocompetent individuals, with close monitoring of immunocompromised patients who may require adjunctive therapies. Incorporation of PROMs such as DLQI and VAS should be encouraged in routine practice to capture holistic treatment outcomes. Patients with complete clearance show significant psychosocial recovery, highlighting the need for early intervention. Poor responders, especially immunocompromised individuals, may benefit from adjunctive or alternative therapies and closer follow-up.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.