Indication	First Choice	Alternative	Comments/Special Issues
Primary Prophylaxis	HPV vaccine	N/A	See Figure 2 for detailed vaccine recommendations.
Secondary Prophylaxis	N/A	N/A	N/A
Treatment	Podofilox solution/gel (0.5%) applied topically BID for 3 consecutive days a week up to 4 weeks (patient applied). Withhold treatment for 4 days and repeat the cycle weekly up to 4 times (BIII) Imiquimod cream (5%) applied topically at night and washed off in the morning for 3 non-consecutive nights a week for up to 16 weeks (patient applied) (BII) TCA or BCA (80%–90%) applied topically weekly for up to 3 to 6 weeks (provider applied) (BIII) Podophyllin resin (10%–25% suspension in tincture of benzoin) applied topically and washed off several hours later, repeated weekly for 3 to 6 weeks (provider applied) (CIII) Cryotherapy with liquid nitrogen or cryoprobe applied every 1–2 weeks (BIII) Surgical removal either by tangential excision, tangential shave excision, curettage, or electrosurgery	Intralesional IFN-α is generally not recommended because of high cost, difficult administration, and potential for systemic side effects (CIII) Cidofovir topical gel (1%) is an experimental therapy studied in HIV-infected adults that is commercially available through compounding pharmacies and has very limited use in children; systemic absorption can occur (CIII). 5-FU/epinephrine gel implant should be offered in only severe recalcitrant cases because of inconvenient routes of administration, frequent office visits, and a high frequency of systemic adverse effects.	Adequate topical anesthetics to the genital area should be given before caustic modalities are applied. Sexual contact should be limited while solutions or creams are on the skin. Although sinecatechins (15% ointment) applied TID up to 16 weeks is recommended in immunocompetent individuals, data are insufficient on safety and efficacy in HIV-infected individuals. cART has not been consistently associated with reduced risk of HPV-related cervical abnormalities in HIV-infected women. Laryngeal papillomatosis generally requires referral to a pediatric otolaryngologist. Treatment is directed at maintaining the airway, rather than removing all disease. For women who have exophytic cervical warts, a biopsy to exclude HSIL must be performed before treatment. Liquid nitrogen or TCA/BCA is recommended for vaginal warts. Use of a cryoprobe in the vagina is not recommended. Cryotherapy with liquid nitrogen or podophyllin resin (10%–25%) is recommended for urethral meatal warts. Cryotherapy with liquid nitrogen or TCA/BCA or surgical removal is recommended for anal warts. Abnormal Pap smear cytology should be referred to colposcopy for diagnosis and management.

Key to Acronyms: 5-FU = 5-fluorouracil; BCA = bichloroacetic acid; BID = twice daily; cART = combination antiretroviral therapy; HPV = human papillomavirus; HSIL = high-grade squamous intraepithelial lesion; IFN-α = interferon alfa; TCA = trichloroacetic acid; TID = three times daily