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Infections and infestations Sexual health Skin and nail

Warts - anogenital

Last revised in May 2024

Anogenital warts (condylomata acuminata) are benign, proliferative growths occurring in the genital, perineal, anal, and perianal areas.

Warts - anogenital: Summary

  • Anogenital warts (condylomata acuminata) are benign, proliferative growths occurring in the genital, perineal, anal, and perianal areas.
  • Anogenital warts are caused by the human papillomavirus (HPV), most commonly low-risk genotypes 6 and 11.
  • In 2019, there were 50,691 newly diagnosed cases of genital warts in England, which accounts for approximately 10% of all cases of newly diagnosed sexually transmitted infections (STIs). 
    • There was a 14% decrease in the number of newly diagnosed cases of genital warts in England between 2017 and 2019.
    • The peak age of prevalence is 20–24 years. 
  • The most common mode of transmission is sexual contact, but anogenital warts may rarely be transmitted peri-natally or from hand warts.
  • Diagnosis is usually made on the basis of clinical examination:
    • Lesions may be single or multiple and tend to occur in areas of high friction. 
    • Warts on dry, hairy skin tend to be firm and keratinized (horny). Those on warm, moist, non–hair-bearing skin tend to be soft and non-keratinized.
    • Lesions may be broad-based or pedunculated (attached by a stalk), and some are pigmented.
  • Assessment of someone suspected of having anogenital warts should include:
    • Taking a brief sexual history to establish the risk of co-existing STIs.
    • Asking about the symptoms.
    • Examining the external genitalia and extra-genital sites.
  • Biopsy should not normally be performed unless the lesions are atypical. 
  • Other lesions which may be misdiagnosed as anogenital warts include:
    • Pearly penile papules.
    • Benign molluscum contagiosum, skin tags, and seborrhoeic keratoses.
    • Vulval, penile, or anal intraepithelial neoplasia, and frank malignancy.
    • Anogenital condylomata lata of secondary syphilis.
  • Referral to a sexual health specialist is recommended for all people with anogenital warts, especially: 
    • Women who are pregnant. 
    • Children (the possibility of sexual abuse should be considered).
    • People who are immunocompromised (for example HIV).
  • Referral is essential if:
    • The diagnosis is uncertain.
    • Malignancy or intraepithelial neoplasia is suspected.
    • The warts are cervical, intrameatal, or intra-anal.
  • Treatment for anogenital warts should only be offered in primary care if:
    • Referral to a sexual health specialist is declined or unavailable, and the diagnosis of external genital warts is certain.
    • The skills and resources to provide a comprehensive sexual health service are available.
  • Treatment options for anogenital warts include:
    • No treatment — one-third of visible warts disappear spontaneously within 6 months.
    • Self-applied treatments (podophyllotoxin 0.5% solution, or 0.15% cream, imiquimod 5% cream, sinecatechins 10% ointment). 
    • Ablative methods (such as cryotherapy, excision, and electrocautery) — these should be considered only if the practitioner is appropriately trained.
  • In addition:
    • An explanation of the condition and treatment should be given.
    • Women should be advised that no changes are recommended in the screening intervals of cervical cytology.
    • The use of condoms during sexual intercourse should be advised.
    • Smoking cessation should be advised, if relevant, to improve response to treatment.
  • The person's current sexual partner may benefit from assessment for undetected genital warts or other undetected STIs, or for explanation and advice about the disease process in their partner.

Have I got the right topic?

From age 13 years onwards.

This CKS topic is based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the US Centres for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines [CDC, 2021], and the 2019 European guideline for the management of anogenital warts [Gilson, 2020].

This CKS topic covers the assessment and management of anogenital warts in primary care.

This CKS topic does not cover verrucas, molluscum contagiosum, warts at sites other than in the anogenital region, cervical cytology, or human papillomavirus vaccination.

There are separate CKS topics on Molluscum contagiosum, and Warts and verrucae.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2024 — minor update. The sections on assessment, and management have been updated in line with the British Association for Sexual Health and HIV (BASHH) national guideline for the management of anogenital warts in adults (2024).

Previous changes

November 2022 — reviewed. A literature search was conducted in November 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Minor updates to structure and updated literature has been incorporated to provide supporting evidence for the guidance. No major changes to the clinical recommendations have been made.

April to May 2017 — reviewed. A literature search was conducted in April 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Some minor structural changes have been made to this topic, and information that sinecatechins ointment 10% is now a treatment option has been added.

May 2014 — minor update. The link to prescriptions has been removed.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

November 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

February 2012 — minor update. Typographical errors corrected. 

September 2010 — minor update. The figures for new diagnoses of anogenital warts in 2008/9 have been added, and secondary syphilis has been added as a possible differential diagnosis. 

January 2009 — minor update. Warticon FEM® has been discontinued; the manufacturer has advised that Warticon®should be used for both men and women. Prescriptions for Warticon FEM® have been deleted. 

December 2008 — minor update. Black triangle removed from imiquimod. 

July to October 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

  • BASHH (2024) Anogenital warts 2024. British Association for Sexual Health and HIV. [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2022.

Economic appraisals

No new economic appraisals since 1 November 2022.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 November 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 November 2022.

New policies

No new national policies or guidelines since 1 November 2022.

New safety alerts

No new safety alerts since 1 November 2022.

Changes in product availability

No changes in product availability since 1 November 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to: 

  • Recognize the signs and symptoms suggestive of anogenital warts.
  • Make an accurate diagnosis and exclude similar conditions.
  • Refer appropriately to secondary care or other specialist service, if possible.
  • Manage appropriately in primary care if specialist referral is not possible.
  • Provide advice to patients.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What are anogenital warts?

  • Anogenital warts (condylomata acuminata) are benign, proliferative growths occurring in the genital, perineal, anal, and perianal areas.
    • Lesions can also occur in the urethral meatus, vagina, cervix, and anal canal.
    • Anogenital warts are generally asymptomatic, but may be painful, friable or pruritic, or associated with bleeding, dyspareunia, local irritation, or discomfort.
    • They occur commonly at certain sites, including around the vaginal introitus, under the foreskin of the uncircumcised penis, and on the shaft of the circumcised penis.
    • Lesions may vary in size from a few milimeters to several centimetres, and can vary in colour from white or flesh-coloured to hyperpigmented or erythematous.

[RCGP, 2013; BASHH, 2015; Gilson, 2020; CDC, 2021; BMJ Best Practice, 2022]

What causes anogenital warts?

  • Anogenital warts are caused by the human papillomavirus (HPV), most commonly low-risk non-oncogenic genotypes 6 and 11 [BASHH, 2015].
  • Approximately 150 types of HPV have been identified, with at least 40 that are known to infect the genital region [CDC, 2021].
  • HPV primarily infects basal keratinocytes after viral penetration through microscopic abrasions or defects in the skin and mucosal surfaces. The virus subsequently undergoes a period of latency or pseudolatency before clinically apparent lesions present [BMJ Best Practice, 2022].
    • The incubation period between genital HPV infection and the appearance of warts is highly variable but has been found to be shorter in women (median 2.9 months) than men (median 11.0 months) [Gilson, 2020].

How are anogenital warts transmitted?

  • Infection with human papillomavirus (HPV) is through direct skin to skin contact, with a person who has clinical or subclinical HPV, or contact with genital secretions.
    • The most common mode of transmission is sexual contact, but anogenital warts may rarely be transmitted peri-natally or from hand warts.
    • Oro-genital transmission is also possible.
    • Transmission may occur in the absence of visible warts.
  • Infection can also occur from contact with contaminated surfaces or objects.
  • Auto-inoculation from one site to another is also common.
  • Perianal warts are not necessarily associated with anal intercourse.
  • Warts inside the anal canal are predominantly associated with penetrative receptive anal intercourse.
    • However, they can also occur in people who have not had anal sexual contact.

[RCGP, 2013; BASHH, 2015; Gilson, 2020; CDC, 2021; BMJ Best Practice, 2022]

How common are anogenital warts?

  • The estimated lifetime risk of genital warts in sexually active people is 10%.
  • Official statistics published by the UK Health Security Agency show that in 2019 there were 50,691 newly diagnosed cases of genital warts in England, which accounted for approximately 10% of all cases of newly diagnosed sexually transmitted infections [UKHSA, 2022].
    • There was an approximate 14% decrease in the number of newly diagnosed cases of genital warts in England between 2017 and 2019.
      • Previous decreases in the incidence of genital wart diagnoses have been attributed to the uptake of quadrivalent human papilloma virus (HPV) vaccine in young females, and herd protection offered to similarly-aged heterosexual males [UKHSA, 2019].
    • Figures for 2020 and 2021 are lower, but this may be reflective of a reduction in face-to-face consultations during the COVID-19 pandemic.
  • Heterosexual men and women accounted for 92% of diagnoses of genital warts.
  • Prevalence varies with age, sex, ethnicity, and sexual orientation. The peak age of prevalence is 20–24 years.
  • A younger age at onset of sexual activity; an increasing number of lifetime sexual partners/sexual contacts; and immunocompromise are associated risk factors for genital warts.

[RCGP, 2013; Karnes, 2014; UKHSA, 2022]

What are the possible complications of anogenital warts?

  • Although anogenital warts are caused by low-risk genotypes of human papillomavirus (HPV), HPV 6 and HPV11, there may be simultaneous infection with the high-risk oncogenic HPV genotypes that are associated with anogenital cancer.
  • Anogenital warts may be disfiguring, and cause anxiety or distress.
  • Possible complications associated with treatment include:
    • Persistent hypo- or hyper-pigmentation due to ablative therapy.
    • Hypertrophic scarring.
    • Bleeding, infection, or scarring due to surgical removal.

[BASHH, 2015; Gilson, 2020; BMJ Best Practice, 2022]

What is the prognosis for people with anogenital warts?

  • Anogenital warts are benign and usually asymptomatic.
  • Left untreated, anogenital warts will resolve spontaneously in 10–30% of people within 3 months.
    • Within 6 months, anogenital warts spontaneously resolve in 30% of people.
  • Most genital human papillomavirus (HPV) infections are transient.
    • HPV is not detectable in 95% of people within 2 years post infection.

[RCGP, 2013; BMJ Best Practice, 2022]

Diagnosis of anogenital warts

How should I assess someone with suspected anogenital warts?

  • Diagnosis of anogenital warts is based on clinical presentation. 
    • A biopsy is not usually performed unless the lesions are atypical (for example, pigmented, bleeding, ulcerated, or affixed to underlying tissue) or the diagnosis is uncertain.
  • Take a brief sexual history to establish the risk of co-existing sexually transmitted infection. Ask about:
    • A new sexual partner.
    • More than one sexual partner in the last year.
    • Current and previous sexual partners.
    • Use of barrier contraception.
  • Ask about symptoms.
    • In men, ask about the presence of urethral discharge and dysuria.
    • In women, ask about vaginal discharge and intermenstrual or post-coital bleeding.
    • Distortion of urine flow or bleeding from the urethra (suggesting an intra-meatal wart) and bleeding from the anus.
  • Examine the external genitalia, perianal area and adjacent areas (such as the mons pubis) to confirm the diagnosis and establish the extent of lesions.
    • Offer a speculum vaginal examination to people with warts at the introitus where the upper limit cannot be visualised or in those with external warts and other vulvovaginal symptoms such as irritation, bleeding or discharge.  
    • Routine proctoscopy is not required in patients presenting with genital warts — offer proctoscopy and digital anorectal examination to those with warts at the anal margin where the upper limit cannot be visualised or in those with external warts and other anal canal symptoms such as irritation, bleeding or discharge
    • Meatoscopy should be performed if there is difficulty in visualising the full extent of intra-meatal warts.
    • Occasionally urethroscopy is indicated for more proximal warts, or where there are urinary features (haematouria or distorted flow of urine).
  • Examine extra-genital sites (for example, oral cavity) if clinically indicated.
  • Consider the possibility of pregnancy, HIV, or immunosuppression.
  • Consider other alternative diagnoses. For more information, see the section on Differential diagnosis.

Basis for recommendation

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) national guideline for the management of anogenital warts in adults [Nugent, 2024], a joint guideline with the Royal College of General Practitioners Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the US Centers for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines [CDC, 2021], the 2019 European guideline for the management of anogenital warts [Gilson, 2020], and expert opinion in a narrative review Management of external genital warts [Karnes, 2014].

  • Expert opinion from UK primary care guidelines is that taking a detailed history, whilst ideal, may not be appropriate in primary care. They advise that a brief sexual history is sufficient during consultation, detailed history-taking and partner notification are best left to the sexual health clinics [RCGP, 2013].
  • A history of distortion of urine flow, or bleeding from the urethra or anus, may indicate internal lesions [BMJ Best Practice, 2022].

What are the signs and symptoms of anogenital warts?

  • Genital warts are usually asymptomatic. One or more may develop and tend to occur in areas of high friction.
    • Pain may occur if the lesions become friable or are irritated due to local trauma.
    • Urinary symptoms, such as terminal haematuria or abnormal stream of urine, can indicate lesions in the distal urethra and meatus.
    • Bleeding may occur due to local trauma (for example, by underwear).
    • Other symptoms may include local irritation and discomfort.
  • They may be broad-based or pedunculated. Some are pigmented.
    • Warts on non-hairy skin tend to be soft and non-keratinised.
    • Warts on dry, hairy skin are firm and keratinised.
  • Warts usually present as soft cauliflower-like growths of varying size.
    • Less commonly, they are flat, plaque-like, or pigmented.
    • The colour can vary, including being whitish, flesh-coloured, hyperpigmented, or erythematous.
    • They are usually less than 10 mm in diameter; however, they may coalesce into large plaques, especially in people who are immunosuppressed or have diabetes.
    • Rarely, large warts present with secondary infection and maceration.

Basis for recommendation

This information is based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], a joint guideline with the Royal College of General Practitioners Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], and the 2019 European guideline for the management of anogenital warts [Gilson, 2020].

What else might it be?

  • Pearly penile papules — 1–2 mm flesh-coloured papules distributed around the corona or sulcus of the glans penis. They are asymptomatic.
  • Molluscum contagiosum — flesh-coloured papules often with a central umbilication. They occur in children and sexually active adults, and are caused by a virus. They are self-limiting, with lesions persisting for up to 6 months. For more information, see the CKS topic on Molluscum contagiosum.
  • Condylomata lata — moist warty whiteish papules which may secrete fluid. Associated systemic signs and symptoms include: fever, malaise, adenopathy, and weight loss. They occur in secondary syphillis and are highly contagious.
  • Carcinoma in situ — multifocal erythematous macules, lichenoid, or pigmented papules, which may form plaques on the external anogenital region. The surface is usually smooth and velvety. For more information, see the CKS topic Gynaecological cancers - recognition and referral.
  • Other common, benign differential diagnoses include skin tags, seborrhoeic keratoses, epidermoid cysts, hidradenoma papilliferum, and sebaceous glands of the foreskin and vulva.

Basis for recommendation

This information is based on the Royal College of General Practitioners (RCGP) and the British Association for Sexual Health and HIV (BASHH) guideline Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], and a narrative review Management of external genital warts [Karnes, 2014].

Management

Scenario: Management

From age 13 years onwards.

How should I manage someone with anogenital warts?

  • If possible, refer all people with anogenital warts to a sexual health specialist. If this is not possible or acceptable, the person can be managed in primary care if the appropriate expertise is available.
  • Screening for co-existing sexually transmitted infections (STIs) is essential, particularly in people younger than 25 years of age and those with other genital symptoms.
    • Perform a vaginal speculum examination in women.
    • Perform proctoscopy (where available) if there is a history of anal receptive sex.
    • Tracing of previous sexual partner(s) is not recommended for people with anogenital warts in the absence of other STIs.
  • Only offer treatment for anogenital warts in primary care if:
    • Referral to a sexual health specialist is not possible (because it is declined or unavailable), and the diagnosis of external genital warts can be confidently made.
    • The skills and resources to provide comprehensive assessment and treatment, as well as screening and contact tracing for other sexually transmitted infections, are available.
    • For more information, see the section on treatment.
  • Provide information and advice about anogenital warts.
  • Refer where appropriate.
  • Follow up the person if required.

What treatments are available for anogenital warts?

  • The aim of treatment is to remove the warts.
  • Treatment options include:
    • No treatment — treatment is not always indicated as, in about 30% of people, warts disappear spontaneously within 6 months.
    • Self-applied treatments — these cannot be used in pregnancy (for more information see the section on Pregnancy), are not licensed for use in children, and have a high likelihood of adverse effects (e.g. application site pruritus, irritation, and pain). If a self-applied treatment is chosen, show the person the location of the warts and where to apply topical treatment (to reduce treatment failure owing to undertreatment).
      • Podophyllotoxin — available as 0.5% solution (Condyline® or Warticon®) or 0.15% cream (Warticon®) is purified extract of podophyllin. It is useful for soft, non-keratinized (non-horny) external lesions but is not licensed for anal warts. Cream may be easier to apply, but solution is preferred as it has slightly superior efficacy for initial wart clearance. Supervision by a healthcare professional is recommended when the lesion area to be treated is greater than 4 cm2. For more information, see the section on Advice. 
      • Imiquimod 5% cream (Aldara®) may be suitable for both keratinized (horny) and non-keratinized, external genital and perianal warts, but is not recommended for internal use — see Advice.
      • Sinecatechins 10% ointment (Catephen®) — this contains green tea plant (Camellia sinensis) extract, primarily the catechin, epigallocatechin gallate. It is licensed for the treatment of external genital warts in people aged 18 years or over who are not immunocompromised. For more information, see the section on Advice.
    • Other treatments
      • 5-fluorouracil 5% cream — this is not licensed for treatment of anogenital warts.  
      • Potassium hydroxide 5% solution — this is available over the counter as MolluDab® and is licensed for use in molluscum contagiosum, but not anogenital warts.
    • Specialist application 
      • Trichloroacetic acid (TCA) 80-90% solution.
      • Nitrizinc complex — this topical solution contains nitric acid, organic acids and zinc/copper salts.
    • Ablative methods (such as cryotherapy, excision, and electrocautery): consider if appropriately trained and resourced. These may be better for people with a small number of low-volume warts (regardless of type).
  • Treatments not recommended include:
    • Podophyllin — it is a herbal extract from the podophyllum plant in a 20–25% solution, and is a non-standardised preparation.
    • Interferon.

What treatment should I offer first-line for treating anogenital warts?

  • Podophyllotoxin, imiquimod, and sinecatechins are suitable for home treatment. The patient should be given a demonstration on lesion finding and treatment application.
  • There is no clear first-line treatment option, and no single treatment option is sufficient for all clinical presentations. 
  • All treatments have significant failure and relapse rates (see Table 1 for more information), so the choice of treatment is dependent upon the: 
    • Type of warts — soft, non-keratinised warts respond well to podophyllotoxin and trichloroacetic acid (TCA). Keratinised lesions may be better treated with physical ablative methods such as cryotherapy, excision, TCA or electrocautery.
      • Imiquimod is a suitable treatment for both keratinised and non-keratinised warts.
    • Number and volume of warts— a small number of low-volume warts, irrespective of type, can be treated with ablative therapy or topical treatment with podophyllotoxin.
    • Response to previous treatments.
    • Site of lesions — podophyllotoxin cream may be easier to apply than the solution, especially for less accessible lesions.
  • Other considerations include the availability, cost of treatment, clinician experience, the person's preference and any other co-existing medical conditions.

Table 1. Clearance and recurrence rates of genital wart treatments.

DrugClearance rate range*Recurrence rate range
Imiquimod cream 5%

35–68%

6–26%

Podophyllotoxin solution 0.5%

45–83% 

13–100%

Podophyllotoxin cream 0.15%43–70%6–55%
Sinecatechins ointment 10%

47–59%

57–11%

* Intent to treat
Source:[Lacey, 2013]

What treatments are available for people that are immunocompromised?

See the recommendations around referral of immunocompromised people with anogenital warts. The following is provided for general information purposes:

  • People with impaired immunity, such as those using immunosuppressant medications or those with HIV infection, are at increased risk of developing anogenital warts.
  • People who are immunocompromised may:
    • Have larger or more numerous lesions.
    • Be less likely to experience spontaneous resolution.
    • Be at increased risk of wart transformation into squamous cell carcinoma.
    • Be resistant to standard treatment approaches.
    • Have more frequent recurrences after treatment.
  • Although specific treatment guidelines do not exist, a longer duration of treatment or a combination of treatment options may be required.
  • Clinical assessment of the lesions over time should be used to guide treatment options.
    • In treatment-resistant cases, surgical excision followed by non-invasive therapies or other combination therapies may be needed.

How should anogenital warts be managed in pregnancy?

See the recommendations around referral of pregnant women with anogenital warts. The following is provided for general information purposes:

  • Anogenital warts may enlarge and multiply in pregnancy and may become more easily irritated.
  • Although wart removal during pregnancy may be considered, the presence of anogenital warts rarely impacts the pregnancy outcome, and resolution might be incomplete or poor until pregnancy is complete.
  • Spontaneous resolution of anogenital warts is frequently seen within the six-week postpartum period.
  • Delaying treatment until after delivery is common practice.
  • Where wart ablation in pregnancy is being considered:
    • Topical treatments are avoided.
      • This is due to either safety concerns (podophyllotoxin) or a lack of safety data (imiquimod and sinecatechins). 
    • Cryotherapy, trichloroacetic acid (TCA) or surgical treatment options are preferred.
  • If asked, pregnant women with anogenital warts can be counselled about the low risk of vertical transmission of human papillomavirus to their baby and the low risk of recurrent respiratory papillomatosis in the child.

Basis for recommendation

Management

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) national guideline for the management of anogenital warts in adults [Nugent, 2024], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the US Centres for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines [CDC, 2021], and the 2019 European guideline for the management of anogenital warts [Gilson, 2020].

Available treatments

These recommendations are based on the British Association for Sexual health and HIV (BASHH) national guideline for the management of anogenital warts in adults [Nugent, 2024], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the National Institute for Health and Care Excellence (NICE) evidence summary External genital and perianal warts: green tea (Camellia sinensis) leaf extract 10% ointment [NICE, 2015], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], and the 2019 European guideline for the management of anogenital warts [Gilson, 2020].

  • No treatment option
    • As warts may spontaneously regress, deferral of treatment is acceptable if this is the patient’s preferred option [Nugent, 2024]. 
  • Treatments that may be considered when recommended treatments are unavailable, unsuitable or have failed include 5-fluorouracil, potassium hydroxide, and nitrizinc complex [Nugent, 2024]. 
  • Ablative methods
    • A 2017 systematic review and meta-analysis found that the efficacy of cryotherapy did not differ from that of trichloroacetic acid (4 studies, pooled RR 1.09, 95% CI; 0.91 to 1.32), podophyllin (3 studies, pooled RR 1.41, 95% CI; 0.79 to 2.54), or imiquimod (2 studies, pooled RR 0.90, 95% CI; 0.73 to 1.12), was slightly less effective than electrosurgery (2 studies, pooled RR 0.80, 95% CI; 0.65 to 0.99), and was associated with more immediate low-level adverse events such as erythema, stinging, or irritation (2 studies, pooled RR 3.02, 95% CI; 1.38 to 6.61) and pain requiring oral analgesics than other treatment options (5 studies, pooled RR 2.11, 95% CI; 1.07 to 4.17) [Bertolotti, 2017].
Choice of treatment

These recommendations are based on the BASHH guideline [Nugent, 2024], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022] and Clinical evidence: Warts (genital) [Buck, 2014], a health technology assessment Clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic evaluation [Thurgar, 2016], and a systematic review [Werner, 2016].

  • BASHH recommends that local treatment algorithms should be developed as these have been shown to improve outcomes and that this should be based on local availability and adapted according to clinician experience and patient preference [Nugent, 2024]. 
  • BASHH advises that podophyllotoxin solution (0.5%) is preferred over the 0.15% cream formulation (where it can be easily applied) as it has a slightly superior efficacy, and that podophyllotoxin and imiquimod appear broadly equivalent in safety and efficacy. However, podophyllotoxin may be preferred as it has lower cost, shorter treatment duration and faster mode of action. Sinecatechins have similar clearance rates in trials, but no randomised head-to-head comparisons with other treatments have been performed and the frequency of dosing (three times daily) may be a barrier to adherence [Nugent, 2024]. 
  • A health technology assessment concluded that while podophyllotoxin 0.5% solution was likely to represent a cost­ effective first­line treatment option, the overall evidence base for anogenital wart treatments was limited [Thurgar, 2016].
  • A systematic review of evidence from 18 randomised controlled trials (RCTs) that looked at the efficacy of topical treatments for anogenital warts, found that [Werner, 2016]:
    • Imiquimod 3.75% and 5% cream, podophyllotoxin 0.5% solution and gel and polyphenon E (sinecatechins) 10% and 15% ointment were superior to placebo.
    • No significant differences were detected between imiquimod 5% cream and podophyllotoxin 0.5% solution and between polyphenon E 10% and 15% ointment.
    • In an active-controlled trial, podophyllotoxin 0.15% cream was inferior to podophyllotoxin 0.5% solution.
Management of immunocompromised people

This background information is based on the BASHH guideline [Nugent, 2024], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the US Centres for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines [CDC, 2021], and the 2019 European guideline for the management of anogenital warts [Gilson, 2020].

  • Although the response to treatment in HIV-positive people is impaired, and recurrences after treatment are more common, it is unclear whether those on effective HIV therapy with a normal CD4 count experience similar complications [Gilson, 2020].
  • Data regarding treatment options for immunocompromised people is highly limited.
    • A 2017 systematic review and meta-analysis identified a small number of controlled studies investigating interventions for the treatment of anogenital warts in immunocompromised patients. The authors concluded that evidence was available from a single trial which indicated imiquimod 5% cream was statistically significantly superior concerning partial clearance in participants who had external warts in comparison with placebo [Werner, 2017]. Adequate evidence investigating the efficacy of other interventions was not identified.
Management in pregnancy

This background information is based on the BASHH guideline [Nugent, 2024], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the US Centres for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines [CDC, 2021], and the 2019 European guideline for the management of anogenital warts [Gilson, 2020].

  • Juvenile onset recurrent respiratory papillomatosis is a very rare complication of vertically transmitted HPV, occurring in approximately 4 out of every 100,000 live births [Gilson, 2020]. However, the route of transmission (i.e., transplacental, perinatal, or postnatal) is not completely understood, and it is unknown whether cesarean delivery prevents vertical transmission [CDC, 2021]. Therefore, caesarean delivery is only indicated in rare cases where the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding [BMJ Best Practice, 2022; CDC, 2021; Gilson, 2020]. Pregnant women with anogenital warts should be counseled about the low risk of recurrent respiratory papillomatosis [CDC, 2021].

What advice should I give someone with anogenital warts?

  • Provide a written and verbal explanation of anogenital warts, their causes, complications, treatments and prognosis (for example, the NHS patient guide for genital warts found here).
  • Explain how to use the treatment, and that several treatment attempts are normally required before the warts subside. For more information see the sections on imiquimod, podophyllotoxin, and sinecatechins.
  • Inform the person that active treatments:
    • May take 1–6 months to work.
    • Have significant failure rates.
    • Have significant relapse rates (because they do not eliminate the human papillomavirus).
    • Often involve discomfort and skin reactions.
  • Advise women that no changes are recommended in the screening intervals of cervical cytology.
  • Recommend condom use and smoking cessation to improve response to treatment.
    • However, explain that latex condoms may be weakened if in contact with imiquimod.
  • If psychological distress is an issue, explain that psychological counselling is available.
  • If asked, reassure that the presence of anogenital warts does not always imply recent partner infidelity because human papillomavirus is thought to have a long latency period (3 weeks to 8 months).
  • Suggest that, with consent, the person's current sexual partner may benefit from assessment for undetected genital warts or other undetected sexually transmitted infections, or for explanation and advice about the disease process in their partner.

What advice should I give someone using imiquimod?

  • Advise anyone using imiquimod:
    • On how to apply the cream:
      • A thin layer of imiquimod cream should be applied 3 times a week (for example Monday, Wednesday, and Friday; or Tuesday, Thursday, and Saturday) at bedtime and should remain on the skin for 6 to 10 hours. After this period, imiquimod cream should be washed off with mild soap and water. Treatment should continue until the clearance of visible genital or perianal warts or for a maximum of 16 weeks per episode of warts.
    • To avoid getting the cream on normal or broken skin and open wounds.
    • That hands should be washed thoroughly before and after applying the cream.
    • To avoid unprotected sexual contact soon after application because of a possible irritant effect on the partner.
    • That latex condoms and vaginal diaphragms may be weakened if in contact with imiquimod.
    • That response to treatment and adverse effects may be delayed by some weeks.
    • That inflammation may occur within a few applications of imiquimod (because the immune system has been stimulated rapidly).
      • If this happens, they should stop applying the cream, allow the redness to subside, and then gradually reintroduce it once or twice a week.
    • That permanent hypopigmentation and hyperpigmentation may occur.
    • To avoid applying excessive amounts of the cream and to follow the instructions for application carefully. Excess cream or prolonged contact with the skin may result in a severe reaction at the application site.

What advice should I give someone using podophyllotoxin?

  • Advise anyone using podophyllotoxin:
    • On how to apply the cream:
      • Podophyllotoxin cream should be applied twice a day for 3 consecutive days, followed by 4 days of no application. This should be repeated weekly, if necessary, for a maximum of four 3–day courses (maximum of five 3–day courses for Condyline® 0.5% solution).
    • To avoid getting the cream onto normal skin and open wounds.
    • To avoid unprotected sexual contact soon after application because of a possible irritant effect on the partner.
    • That podophyllotoxin can cause local irritation of the treated area. This may occur on the second or third day of application and decreases after treatment is discontinued. In most cases the reactions are mild.
    • To discontinue treatment if there are significant adverse effects, such as soreness or ulceration.
    • To avoid applying excessive amounts of the cream, and to follow the instructions for application carefully.
      • Excessive application may cause severe systemic toxicity, including gastrointestinal, renal, haematological, and central nervous system effects.

What advice should I give someone using sinecatechins?

  • Advise anyone using sinecatechins
    • On how to apply the ointment:
      • A small amount of ointment (around a 0.5 cm strand) should be applied to each wart, three times a day, using the fingers. It should be dabbed on to ensure complete coverage, leaving a thin layer of ointment on the warts. A maximum of 250 mg in total should be used for all warts per single dose. It is not necessary to wash the ointment off prior to the next application.
      • Continue treatment until complete clearance of all warts; although, for no longer than 16 weeks in total, even if new warts develop during the treatment period.
    • To avoid unprotected sexual contact soon after application because of a possible irritant effect on the partner.
    • To wash off the ointment before using condoms and vaginal diaphragms, as it may weaken them. 
    • To avoid getting the ointment onto normal skin and open wounds.
    • That ointment can cause local irritation of the treated area, but this usually reduces after the first weeks of treatment.
    • To discontinue treatment if there are significant adverse effects, such as soreness or ulceration.
    • To avoid applying excessive amounts of the ointment, and to follow the instructions for application carefully. 

Basis for recommendation

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the 2019 European guideline for the management of anogenital warts [Gilson, 2020], and the British National Formulary [BNF, 2022].

Use of condoms
  • Consistent condom use has been shown to reduce the risk of acquisition of HPV infection and genital warts (a 30-60% reduction) [BASHH, 2015].
    • They may reduce recurrence when both partners are infected, but the extent to which recurrence is due to re-infection is unknown.
    • Latex condoms may be weakened if in contact with imiquimod.
How to use imiquimod

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], the 2019 European guideline for the management of anogenital warts [Gilson, 2020], and the British National Formulary [BNF, 2022].

  • Extending treatment with imiquimod to 20 weeks or beyond, in people who respond, is common practice, but there is no evidence to support this [BASHH, 2015].
How to use podophyllotoxin

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], the 2019 European guideline for the management of anogenital warts [Gilson, 2020], and the British National Formulary [BNF, 2022].

How to use sinecatechins

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], the 2019 European guideline for the management of anogenital warts [Gilson, 2020], and the Summary of Product Characteristics for Catephen 10% Ointment [ABPI, 2022].

When should I refer someone with anogenital warts?

  • If possible, refer all people with anogenital warts to a sexual health specialist.
  • Refer all people with anogenital warts if:
    • Diagnosis is uncertain.
    • There are recurrent perianal warts.
    • There are accompanying urinary symptoms (such as haematuria or abnormal urine stream).
    • There is suspected malignancy or intraepithelial neoplasia.
    • They are immunosuppressed (including HIV).
    • They have present or suspected cervical, intrameatal, or intra-anal warts.
    • They are pregnant.
    • They are a child.
    • They are elderly. 
  • Consider the possibility of sexual abuse in any child with anogenital warts, particularly if younger than 13 years of age.
  • Consider referral for counselling if the person has psychological distress.

Basis for recommendation

These recommendations are based on the British Association for Sexual Health (BASHH) and HIV UK national guidelines on the management of anogenital warts [BASHH, 2015], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the US Centres for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines [CDC, 2021], the National Institute of Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017], and the British National Formulary (BNF) [BNF for children, 2022].

What follow up is required for someone with anogenital warts?

  • Review the person after the completion of treatment to monitor its success and to assess for further therapy.
    • Change the treatment if the patient cannot tolerate the current treatment, or there is less than a 50% response to it by 4–5 weeks (8-12 weeks for imiquimod).
  • If the person is concerned about recurrences, consider arranging a follow up 3 months after successful treatment, as this is when they are most likely to occur.
  • Arrange more frequent follow up in people who are immunocompromised. 

Basis for recommendation

These recommendations are based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the 2019 European guideline for the management of anogenital warts [Gilson, 2020], and the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022].

When should I suspect sexual abuse of a young person?

  • Although rare, consider the possibility of sexual abuse in any child or young person with anogenital warts, particularly in the following circumstances:
    • The child is younger than 13 years of age, unless there is clear evidence of mother-to-child transmission during birth or non-sexual transmission from a member of the household.
    • The young person is aged 13–15 years, unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity with a peer.
    • The young person is aged 16–17 years and there is no clear evidence of non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity and there is a clear difference in power or mental capacity between the young person and their sexual partner (in particular when the relationship is incestuous or with a person in a position of trust, such as a teacher, sports coach, or minister of religion), or there is concern that the young person is being exploited.
  • Follow appropriate child protection procedures and refer to a paediatrician if necessary.

Basis for recommendation

These recommendations are based on the National Institute of Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017] and the British Association of Sexual Health and HIV (BASHH) national guideline on the Management of Sexually Transmitted Infections and Related Conditions in Children and Young People [BASHH, 2021]. These recommendations are also aligned with the recommendations in a clinical algorithm for clinicians which advises on How to manage children with anogenital warts [Kingston, 2017].

Key considerations 
  • Seven studies have collectively demonstrated that a significant proportion of children (31-51%) with anogenital warts were found to have been sexually abused [BASHH, 2021].
  • Two small studies have described cases of sexually transmitted anogenital warts in young children despite the presence of a maternal infection [BASHH, 2021].
  • Sexual abuse must be considered in any child, particuarly young children, presenting with anogenital warts [NICE, 2017; Kingston, 2017; BASHH, 2021].
  • Available evidence does not help to establish the age at which the possibility of vertical transmission can be excluded [Kingston, 2017; BASHH, 2021].
  • Available evidence does not help to clarify whether human papillomavirus (HPV) typing is of value in the diagnosis of sexual abuse [BASHH, 2021].
  • Any decision taken not to disclose concerns of sexual abuse shoud be discussed with a named or designated child protection doctor, with the final decision and reasons well-documented [BASHH, 2021].

Supporting evidence

This CKS topic is largely based on the British Association for Sexual Health and HIV (BASHH) UK national guidelines on the management of anogenital warts [BASHH, 2015], joint recommendations on Sexually transmitted infections in primary care [RCGP, 2013], the British Medical Journal (BMJ) best practice guide Genital warts [BMJ Best Practice, 2022], the US Centres for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines [CDC, 2021], and the 2019 European guideline for the management of anogenital warts [Gilson, 2020].

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of anogenital warts.

Search dates

August 2017 - November 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp condylomata acuminata/, genital wart$.tw, anogenital wart$.tw, vaginal wart$.tw, penile wart$.tw, venereal wart$.tw, condyloma acuminat$.tw

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ABPI (2022) SPC for Catephen 10% Ointment. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • BASHH (2015) UK national guidelines on the management of anogenital warts. British Association for Sexual Health and HIV. http://www.bashh.org [Free Full-text]
  • BASHH (2021) BASHH national guideline on the management of sexually transmitted infections and related conditions in children and young people (2021). British Association for Sexual Health and HIV. http://www.bashh.org [Free Full-text]
  • Bertolotti, A., Dupin, N., Bouscarat, F., et al. (2017) Cryotherapy to treat anogenital warts in nonimmunocompromised adults: Systematic review and meta-analysis. Journal of the American Academy of Dermatology 77(3), 518-526. [Abstract]
  • BMJ Best Practice (2022) Genital warts. BMJ Best Practice. https://bestpractice.bmj.com [Free Full-text]
  • British National Formulary for Children (2022) British National Formulary for Children. British Medical Association and Royal Pharmaceutical Society. https://bnfc.nice.org.uk
  • BNF (2022) British National Formulary. National Institute for Health and Care Excellence (NICE). https://bnf.nice.org.uk
  • Buck, H.W. (2014) Warts (genital). Clinical Evidence. BMJ Publishing Group. http://www.clinicalevidence.com [Free Full-text]
  • CDC (2021) Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for Disease Control and Prevention. https://www.cdc.gov [Free Full-text]
  • Gilson, R., Nugent, D., Werner, R.N., et al. (2020) 2019 IUSTI-Europe guideline for the management of anogenital warts. European Academy of Dermatology Venereology 34(8), 1644-1653. [Abstract] [Free Full-text]
  • Karnes, J. and Usatine, R. (2014) Management of external genital warts. American Family Physician 90(5), 312-318. [Abstract] [Free Full-text]
  • Kingston, M., Smurthwaite, D., Dixon, S. and White, C. (2017) How to manage children with anogenital warts. Sexually Transmitted Infections 93(4), 267-269. [Abstract] [Free Full-text]
  • Lacey, C.J.N., Woodhall, S.C., Wikstrom, A. and Ross, J. (2013) 2012 European guideline for the management of anogenital warts. Journal of the European Academy of Dermatology and Venereology 27(3), e263-e270. [Abstract]
  • NICE (2015) Evidence summary: External genital and perianal warts: green tea (Camellia sinensis) leaf extract 10% ointment.. [Free Full-text]
  • NICE (2017) Child maltreatment: when to suspect maltreatment in under 18s. CG89. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • Nugent, D., Apoola, A., Coleman, H. et al. (2024) British Association for Sexual Health and HIV national guideline for the management of anogenital warts in adults (2024). International Journal of STD and AIDS 0(0), 1-12. [Abstract]
  • RCGP (2013) Sexually transmitted infections in primary care. Royal College of General Practitioners. http://www.rcgp.org.uk [Free Full-text]
  • Thurgar, E., Barton, S., Karner, C. and Edwards, S.J. (2016) Clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic evaluation. Health Technology Assessment 20(24), 1-486. [Free Full-text]
  • UKHSA (2019) Health matters: preventing STIs. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • UKHSA (2022) Sexually transmitted infections (STIs): annual data tables. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • Werner, R.N., Westfechtel, L., Dressler, C. and Nast, A. (2016) Self-administered interventions for anogenital warts in immunocompetent patients: a systematic review and meta-analysis. Sexually Transmitted Infections, 1-7. [Free Full-text]
  • Werner, R.N., Westfechtel, L., Dressler, C. and Nast, A. (2017) Anogenital warts and other HPV-associated anogenital lesions in the HIV-positive patient: a systematic review and meta-analysis of the efficacy and safety of interventions assessed in controlled clinical trials. Sexually Transmitted Infections 93(8), 543-550. [Abstract] [Free Full-text]
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