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  6. External Anogenital Warts
  7. Management
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Management

Warning

 

In General

  • No treatment may be an option, as about 30% of patients will experience spontaneous clearance of warts over a period of up to 6 months. However most patients seek treatment for the discomfort, anxiety, distress or the social unacceptability that warts cause.
  • The objective of treatment is removal of visible warts. Eradication of HPV is not an achievable goal with current therapies and treatment has no measurable effect on transmission rates between partners.
  • The evidence base to direct first and second line treatments is not strong
  • All treatments have significant failure and relapse rates see Results of randomized controlled trials of therapies 
  • Treatment may involve discomfort and local skin reactions
  • Treatment choice depends on the patient preference as well as morphology, number, and distribution of warts
  • Treatment decisions should be made after discussing the appropriate options with the patient
  • Provision of written information on management of treatment side effects is recommended
  • Very large wart lesions should be considered for surgical treatment
  • Topical anaesthetics (eg lidocaine cream, EMLA®) can be used prior to cryotherapy particularly when treating larger lesions.
  • Caution should be exercised using any modality of treatment because of the danger of oedema and necrosis of surrounding tissue.

Summary of the results of randomized controlled trials of therapies for anogenital warts among HIV negative patients (BASHH 2015)

 

Treatment  Range of clearance rates based on an `intention to treat analysis` Range of clearance
rates based on a `per protocol analysis` (determined at time in weeks; range)
Range of recurrence
rates (determined at time in weeks; range)
Podophyllotoxin solution
0.5%
45-83%  55-83% (3-6)  13-100% (8-21)
Podophyllotoxin cream
0.15%
43-70%  43-70% (4)  6-55% (8-12)
Imiquimod cream 5%  35-68%  55-81% (16)  6-26% (10-24)
Cryotherapy  44-75%  67-92% (6-10)  21-42% (4-12)

Note

  1. Clearance rates and recurrence rates are not directly comparable as clearance was measured at different times from the start of treatment and high loss to follow up was often experienced in the trials.
  2. The `intention to treat` analysis of clearance rates provides a conservative estimate of efficacy. The number enrolled into each group was taken as the denominator and the number known to have cleared as the numerator.
    For any missing data, participants were assumed not to be cleared. For the `per protocol analysis, only those for whom follow-up data were available were included in the denominator and numerator; this may overestimate the efficacy.

Guidance for the initial management of external genital and peri-anal warts in men and non pregnant women is set out in the  Initial Management of External Genital and Peri-anal Warts in Men and Non Pregnant Women algorithm.

Important Considerations

  • Latex condoms may be weakened by podophyllotoxin and imiquimod
  • Clinicians should avoid the inadvertent exposure of pregnant women to podophyllotoxin and imiquimod which potentially may arise though the use of these products in a sexual partner. The area which is under treatment in a partner should be thoroughly washed before sexual contact occurs.
  • GUM Consultants who are referred recalcitrant warts for review may consider additional therapeutic options such as trichloracetic acid
  • Surgical excision or hyfrecation should be considered for warts which have failed to respond
  • Biopsy may be necessary in some cases, eg, unusual appearance or failing to respond to treatment

Treatment Choice

In choosing between self-applied agents, podophyllotoxin and imiquimod appear broadly equivalent in safety
and efficacy. However its lower cost, shorter treatment duration and faster mode of action may make
podophyllotoxin preferred as a first choice. 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

Urethral meatus

  • If the base of the lesions is seen, treatment with cryotherapy
  • Lesions deeper in the urethra should be surgically ablated under direct vision, which may require referral to a urologist or the use of a meatoscope.

Refer to West of Scotland Pregnancy and STIs Guideline for the managment of Genital warts in pregnancy 

These may be refractory to treatment and should be discussed with a senior doctor from the outset.

Podophyllotoxin (WARTICON® and CONDYLINE® ) are purified extracts of podophyllin suitable for self administration

  • Warticon® and Condyline® are licensed for the treatment of warts of the penis or the external female genitalia.
  • Supervision by medical staff is recommended when the lesion area treated is greater than 4 cm2
  • Warticon® and Condyline® are not licensed for use of extragential warts, however Warticon® is commonly used on external lesions at all sites
  • Podophyllotoxin solution (0.5%) is preferred over the 0.15% cream formulation where it can be easily
    applied owing to slightly superior efficacy
  • Condyline® is only available as a 0.5% alcoholic solution
  • Treatment cycles consist of twice daily application for 3 days followed by 4 days rest for 4 cycles
  • Warticon® and Condyline® should not be used in pregnancy and lactation
  • It should not be used on broken skin
  • Treatment should be discontinued if significant side effects (eg soreness, ulceration)
  • Consider repeat cycles of treatment if the warts are responding although this is not licensed (see Initial Management of External Genital and Peri-anal Warts in Men and Non Pregnant Women)
  • Unprotected sexual contact should be avoided soon after application because of a possible irritant effect on the partner

  • Imiquimod (ALDARA®) is an immune response modifier
  • It is licensed for external genital and peri-anal warts
  • It should not be used in pregnancy and breast feeding
  • It should be applied three times per week (example: Monday, Wednesday and Friday) and washed off 6 to 10 hours later
  • It frequently causes local skin / mucous membrane irritation when applied for anogenital warts. This may be due to narrow therapeutic margin. Temporary halting of treatment may be required to manage side effects.
  • Unprotected sexual contact should be avoided soon after application because of a possible irritant effect on the partner
  • Use should continue until the clearance of visible genital or perianal warts or for a maximum of 16 weeks per episode of warts with 4 weekly reviews.
  • Response to treatment may be delayed for some weeks. Extending treatment to 20 weeks or beyond in those who are showing a response is common practice but there is no trial evidence concerning this.
  • Clinical trials of imiquimod versus placebo have shown response rates comparable with other topical agents.
  • A lower relapse rate has been suggested, but clinical trials comparing relapse after other topical therapies have not been conducted.
  • Normally used for refractory warts which have failed to respond to other treatments, or warts which have been assessed by a senior doctor/senior nurse and are thought likely to be refractory to treatment (eg extensive carpet warts). Some services may choose to use first line for keratinised lesions when cryotherapy is not an option.
  • Immune deficiency may not be a contraindication for the use of imiquimod topically for anogenital warts and it has been used in HIV positive subjects but use in patients who are immunosuppressed should be discussed with a senior clinician.
  • Has the potential to exacerbate inflammatory skin conditions; it should be used with caution in patients with autoimmune conditions although systemic absorption from topical treatment is likely to be negligible.

  • Cryotherapy is the name given to treatments which involve liquid nitrogen spray freezing the skin, causing cytolysis (cell breakdown) resulting in necrosis
  • Suitable for a small number of lesions
  • Success partly depends on ability to treat at regular (normally weekly) intervals. Services report high rates of non attendance for appointments. These factors should be taken into account when deciding whether home treatment with topical agents may be preferable.
  • Treatment of choice in pregnancy and intrameatal warts
  • Treatment should be applied until a halo of freezing has been established a few millimetres round the treated lesion. A freeze, thaw, freeze technique should be used.
  • Response rates depend on size and chronicity of the lesions
  • Usually repeated at weekly intervals; lack of response after four weeks should prompt consideration of an alternative treatment modality.
  • Liquid nitrogen is a hazardous substance which requires great care during handling. Only health professionals who have received appropriate training may administer cryotherapy.
  • Caution: The storage and handling of liquid nitrogen should be undertaken according to health and safety guidance (see British Oxygen British Oxygen, COSHH Essentials  and the Health & Safety Executive  

 

Editorial Information

Last reviewed: 31/05/2024

Next review date: 31/05/2028

Author(s): West of Scotland Managed Clinical Network in Sexual Health Clinical Guidelines Group .

Version: 8.1

Approved By: West of Scotland Managed Clinical Network in Sexual Health