Genital Warts. I’ll let you imagine where they might be located.

Aldo Torrente recently wrote, “Currently I have several patients with genital warts.  In my facility there are three alternatives: podophyline, verruca freeze, and trichloroacetic acid.
In all cases, the provider ONLY can apply the topical treatment.  What is the protocol to treat genital warts? What is the most effective method?”

Condylomata acuminata (genital warts) is,of course, a sexually transmitted disease caused by Human Papillomavirus (HPV).

There are three basic ways of getting rid of genital warts (or any warts, for that matter).  The first way is to destroy all of the tissue where the wart virus resides.  This is usually done surgically by excising all of the warts or burning them off with electrocautery. We probably will not be doing this much in correctional facilities.

Irritant Chemicals

The second approach is to apply an irritating chemical to the wart which works mainly by stimulating the patient’s immune system to recognize the diseased tissue and to destroy it.  There are various irritant chemicals that can be used for this purpose: Trichloroacetic acid and  podophyline mentioned by Aldo work, but podofilox, sinecatchins, and imiquinod are considered by dermatologists to be superior (and more expensive) agents.  These chemicals are all quite irritating so they need to be meticulously applied.  Many of them, like trichloracetic acid, should not be applied to the normal surrounding skin.  One way to do this is to create a moat-barrier of vaseline around the wart before you apply the irritant.  For a patient with a lot of warts, this can take quite a bit of time.  Also, these agents should be applied often.  Trichloroacetic acid is applied every 3 days.  Podofilox is applied 2 times a day for 3 days then not applied for 4-7 days and then the cycle is repeated.  Imiquod is applied 3 times a week for 8 weeks.  Clearly the chemical agents are labor intensive.

In the outside world of dermatology, these agents are typically only used on patients who are considered reliable and careful enough to apply these chemicals themselves.  This would not work in a correctional setting, of course.  There is too much risk of patients doing it wrong or using the irritating chemicals in mischievous ways.  However, to bring these patients into the prison clinic for each of these meticulous and time consuming applications takes too much of your time and effort.  This is true of outside dermatology clinics, as well.  Patients who are not good candidates for self-application of the chemicals are treated with the third treatment option, cryotherapy.

Cryotherapy

The last option for treating genital warts is cryotherapy.  Dermatologists use liquid nitrogen to freeze the warts but since liquid nitrogen evaporates, it is usually not feasible for use in our clinics. Much better for  our clinics are cans of freezing solution, like Histofreeze or Verrucafreeze mentioned by Aldo.  These do not get the tissue as cold as liquid nitrogen but they work just fine nevertheless.

Freezing the warts has several advantages over the chemicals, especially in correctional settings.   First, you only have to do the freezing once a month.  Regular warts on, say, the hand can be frozen more frequently but since genital warts are found on (How shall I put this?) delicate tissues, there is no advantage to freezing more often.  Second, you don’t have to be as meticulous as with the chemical agents.  Especially if you use the freezing guides that look like a big otoscope tip, these treatments can be done very quickly.  Third, cryotherapy is not as irritating or painful as the chemicals (though it still hurts).  There is no chance of the irritating chemicals accidentally rubbing off onto normal skin of the patient or others and causing problems.

So cryotherapy, in my opinion, is the best overall technique for getting rid of genital warts in correctional facilities.

The only problem with cryotherapy is the cost of the cans of commercial freezing agents.  Verrucafreeze and Histofreeze both cost well  over $400.00 for a canister with around 60 doses.  That is $7.00 per application!  No wonder correctional clinics have turned to chemical agents, despite their many disadvantages.

However, it turns out that there is a much cheaper alternative.

Using an air-duster can held upside down to freeze a wart.

You know those canisters of compressed air that are used to clean your computer keyboard?  I’m going to call them air-dusters.  If you hold air-dusters upside down, the spray they generate will freeze tissue  just like the  commercial sprays.  But air-duster canisters only cost around $6.00 a can rather than $400.00 a can.

The ingredients are almost identical.  Verrucafreeze contains tetrafluoroethane, pentafluoroethane and trifluoroethane, whereas a typical air-duster can contains tetrafluoroethane and difluoroethane.

At my prison facility where we do wart removal, we initially used the expensive commercial freezing canisters like Verrucafreeze, but about three years ago switched to using air-duster cans held upside down.  I can tell you from experience that they are identical in efficacy to the commercial products.

So there is your answer, Aldo.  The most cost-effective technique for treating genital warts is cryotherapy done with an air-duster can held upside down.

Is anyone else using this technique?  Please comment.

Would your facility be interested in doing and publishing a formal study comparing commercial freezing sprays to air-duster cans?

Especial thanks to Neelie Berlin, PA Extraordinaire, who helped me extensively with this post!