STD Toolkit

Human Papillomavirus (HPV)


  • Asymptomatic
  • Genital warts
  • Cervical abnormalities

Definitive Diagnosis:

  • Genital Warts: visual inspection, biopsy
  • Other forms of HPV: detection of viral DNA
Biopsy should be performed on genital warts when:
  • There is an uncertain diagnosis
  • A patient is immunocompromised
  • Warts are pigmented, indurated, or fixed
  • They don't respond to, or get worse with, treatment
  • There is persistent ulceration and bleeding
HPV DNA Testing should be performed:
  • For women over age 30 and due for cervical cancer screening
  • For women over age 21 with ASC-US cytology
Recommended, with reservations:
  • Biopsy - specimen is genital wart or cervical tissue. Not for routine testing, should only be done for genital warts in the circumstances listed above, or for cervical tissue when abnormalities have been found.
  • HPV DNA Testing - specimen is cervical cells (brush or broom, may be Thin Prep pap) in females or anal swab or brush in males. Not for routine testing, see above for indications.

Provider-Applied Therapies

Cryotherapy with liquid nitrogen or cryoprobe - Treat only visible warts; freeze each lesion 10-15 seconds or until white, allow the lesion to thaw, then repeat; repeat applications every 1-2 weeks; safe in pregnancy.

Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90% repeated weekly if necessary; small amount should be applied to only the warts and allowed to dry before the patient sits or stands; safe in pregnancy.

Patient-Applied Therapies

Imiquimod 3.75% or 5% cream once daily. For persons prescribed Imiquimod 3.75%, apply once every night for up to 8 weeks. For persons prescribed Imiquimod 5%, apply once daily (usually at bedtime) 3 times a week for up to 16 weeks; the treated area should be cleansed 6-10 hours after each application; safety in pregnancy has not been determined.

Podofilox 0.5% solution or gel twice a day for 3 days, followed by 4 days without treatment; repeat this weekly cycle as needed for up to 4 weeks; avoid in pregnant women.

Sinecatechins 15% ointment should be applied 3 times daily for no longer than 16 weeks. The medication should NOT be washed off after use; sexual contact should be avoided while the ointment is on the skin; safety in pregnancy is unknown.

Consider referral of selected patients to an appropriate specialist for possible surgical excision, laser therapy, or other treatment: Widespread anogentital warts, cervical warts, giant condylomata, mucosal warts (other than small, easily accessible vaginal or meatal lesions), and warts not responding to the above measures over 3-4 weeks of repeated therapy.

HIV patients usually require a longer course of therapy. These patients should be referred to their personal physician.

Treatment is only recommended for cervical squamous intraepithelial lesions; subclinical infection or cervical intraepithelial neoplasia 1 do not require treatment. Treatment for cervical squamous intraepithelial lesions is based on histopathologic findings, and the patient may need to be referred to a specialist.

There are several vaccines currently available to help prevent HPV infection: Cervarix, protective against types 16 and 18; quadrivalent Gardasil, protective against types 6, 11, 16, and 18; and Gardasil 9, a 9-valent vaccine protective against types 6, 11, 16, 18, 31, 33, 45, 52, and 58. Cervarix is only approved for females; Gardasil may be given to males or females. All three vaccine types follow the same schedule: three doses over six months, where the second dose is given two months after the first, and the third dose is given four months after the second. Any of these three vaccines fulfills the recommendations for routine vaccination at age 11-12 years. These vaccines may, however, be given at anytime between the ages of 9 and 26 years dependent on insurance coverage, though administration before onset of sexual activity is preferable.

See MDHHS's Immunization website for more information.

Michigan Vaccine Information Statements: Gardasil

Have a patient without insurance who can't afford the vaccine? See GSK Vaccines Access Program.

Recommendation for increased HPV vaccinations

Penile Genital Warts
Penile Genital Warts
Anal Genital Warts
Anal Genital Warts
Labial/Vulvar Genital Warts
Labial/Vulvar Genital Warts