## Treatment of Genital Warts (Condyloma Acuminata) **Key Point:** Podophyllotoxin (or podophyllin resin) is the first-line topical agent for external genital warts caused by HPV, particularly HPV-6 and HPV-11 (low-risk types). [cite:Harrison 21e Ch 226] ### Mechanism of Action Podophyllotoxin is a plant-derived cytotoxic agent that arrests mitosis in metaphase by inhibiting microtubule formation, leading to necrosis of wart tissue. ### Topical Agents for Genital Warts | Agent | Type | Mechanism | Contraindication | Notes | |-------|------|-----------|------------------|-------| | **Podophyllotoxin** | Plant alkaloid | Mitotic arrest | Pregnancy | First-line; applied 3 days/week | | Imiquimod | Immune modifier | TLR7 agonist | Pregnancy | Alternative; slower but durable | | Sinecatechins | Polyphenol | Apoptosis | Pregnancy | Green tea extract; alternative | | Cryotherapy | Physical | Ice-induced necrosis | — | Effective but painful | | Laser therapy | Physical | Thermal ablation | — | For extensive lesions | **High-Yield:** Podophyllotoxin is contraindicated in pregnancy due to teratogenicity. In pregnant women, cryotherapy or imiquimod are safer alternatives. ### Clinical Pearl Genital warts caused by low-risk HPV types (6, 11) are benign and do not progress to malignancy. Treatment is for symptomatic relief and cosmetic reasons, not cancer prevention. High-risk types (16, 18) are associated with cervical and anogenital cancers and are prevented by HPV vaccination. ### Why Antivirals Are Not First-Line Acyclovir and valacyclovir are nucleoside analogues effective against herpesviruses (HSV, VZV) but have no activity against HPV. HPV is a DNA virus but does not encode viral DNA polymerase in the same manner as herpesviruses, making nucleoside analogues ineffective.
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