Table 4.

Guidance for daily practice situations and the subsequent action that can be taken

Daily practice situations	Actions
AGW remaining following ablation	Explain that residual or recurrent warts post‐ablation indicate that the immune system has not been activated, which can be more frequent in primary infections Initiate immunotherapy
Experience or fear of local side‐effects in genital area	Explain how immunotherapy works Advise patients that local side‐effects are a sign that the immune system has been activated and the therapy is working26, 30, 54, 66, 79 With imiquimod, explain that skin reactions are common and can sometimes be associated with adverse events (headache, fatigue, myalgia and nausea). Frequency of application may be reduced or treatment can be temporarily stopped if necessary79
Limited initial efficacy with imiquimod	Explain that some patients’ immune systems are slow to activate23, 56 Use an ablative method which can debulk and allow easier penetration Reassure and continue with imiquimod Inform the patient that some patients need the full 16‐week treatment course or even longer
Lack of adherence	Determine the extent to which the patient has adhered to the treatment regimen Understand the reasons for lack of adherence (e.g., complicated regimen/side‐effects) and ensure the patient is provided with sufficient information about AGW and the different treatments that is clear and simple, both verbally and in written form8, 75, 79 Try an alternative therapy that is associated with better adherence/improved patient satisfaction26
Lumps left may not be true warts	Explain (with the help of images; Fig. 2) that lumps left after treatment may not be genital warts and that they could be large, normal glands.
Heavy cigarette smoking	Explain that smoking depresses the immune system, particularly in relation to viruses74 and it is well recognized that smokers have more difficulty clearing warts and are more likely to get recurrences.16 Smoking cessation should be encouraged
Pregnancy	Explain that pregnancy is an immune suppressed state and therefore wart infections can become large during pregnancy but will usually disappear within weeks of delivery76 During pregnancy, the warts should not be treated if they do not represent an obstacle to delivery. If needed, only use ablative methods, e.g., cryotherapy or trichloroacetic acid3, 12, 50 Avoid extensive laser vaporization, electrocautery or surgery during the 6–8 weeks before delivery Be aware that in rare cases, HPV can be transmitted during child birth resulting in recurrent respiratory papillomatosis in the infant73, 78
Immune suppression	Establish the patient's HIV status Check to see whether they are on immunosuppressive drugs for inflammatory bowel disease, rheumatoid arthritis etc. Reassure the patient that clearance will still be achieved but it may take longer
Other conditions (i.e. diabetes, eczema, psoriasis)	Determine if the patient has other conditions, such as diabetes, which are associated with more extensive AGW and recurrences that may require prolonged treatment80 More ablation and prolonged imiquimod courses may be required It is recommended not to use imiquimod if there is eczema, psoriasis or other dermatoses in the genital area77
Concomitant local infections (e.g. bacterial, fungal etc.)	Should be treated promptly at any stage of AGW therapy