Table 2.

Preferred and alternative treatment options: Ranges in rates of clearance and recurrence reflect the variation of results across studies.

TREATMENT, LEVEL OF EVIDENCE, AND GRADE OF RECOMMENDATION	CLEARANCE, %	RECURRENCE, %	APPLICATION REGIMEN	ADVERSE EFFECTS	SAFE FOR INTRAVAGINAL OR INTRA-ANAL USE	SAFE FOR USE IN PREGNANCY OR LACTATION
Patient-applied treatments
Imiquimod 5% cream5–7 (grade B, level I)* Imiquimod 3.75% has not been evaluated for the treatment of genital warts	51	22–63	Apply with finger 3 nights/wk for 16 wk Wash off in the morning	Localized erythema, burning, inflammation; rarely, hypopigmentation Might weaken latex condoms and diaphragms	No	No; safety unknown
Podophyllotoxin 0.5% solution or gel7 (grade B, level I)* More efficacious and less toxic than podophyllin	56	2–90	Apply with swab or finger 2 times/d for 3 d, then 4 d off, for up to 4 cycles. Limit of 10 cm2/d of skin surface or 0.5 mL/d	Localized burning, pain, itching, erosion, inflammation	No	No; it is an extract of podophyllin, which is teratogenic
Provider-applied treatments
Cryotherapy8–12 (grade B, level I)*	27–88	25–55	Once per wk with cotton swab, spray, or cryoprobe (not in the vagina)	Localized pain, inflammation, scarring Risk of vaginal perforation if using cryoprobe	Yes	Yes
TCA10,11,13 (grade B, level I)*	63–70	35	Once per wk with cotton swab or toothpick	Localized pain and ulceration Can neutralize with sodium bicarbonate solution	Yes	Yes
Excision14 (grade B, level I)†	35–72	19–79	Local anesthesia then excision of lesions	Pain, bleeding, infection	Yes	Yes
Electrocautery14 (grade B, level II)†	61–94	22	Local anesthesia then destruction of lesions with cautery tools	Pain, bleeding, infection Operator should wear a virus-filtering mask	Yes	Yes
Alternative treatments
Podophyllin 25% in tincture of benzoin14–16 (grade C, level I)‡	23–72	23–65	Once per wk with cotton swab or toothpick Limit 10 cm2 of skin surface or 0.5 mL per treatment	Localized burning, pain, itching, erosion, inflammation	Limit < 2 cm2 of skin surface	No; is teratogenic
Sinecatechins (green tea extract) 15% ointment17,18 (grade B, level II; 2 trials)‡	57	6.5	Apply 3 times/d for up to 16 wk	Localized erythema, burning, pain, rash, ulceration	No; not studied	No; not studied
Fluorouracil 1% gel or 5% cream19,20 (grade C, level II)‡ Useful for large numbers of vaginal or urethral-meatal warts in which cryotherapy or TCA are not tolerated	80–90	No data	Insert applicatorful into vagina 3 nights/wk	Erythema, erosion, edema	Yes	No; is teratogenic
Interferon21 (grade C, level II)‡	44.4	21.1	One applicatorful in vagina twice daily for 5 d/wk for 4 wk	Headache, tenderness, transient fever	Yes	No; not studied
Observation*14	40–60	No data	No data	No data	No data	No data

TCA—trichloroacetic acid.

^*First-choice therapy.

^†Second-choice therapy.

^‡Not-generally-recommended therapy.