Genital Warts

How to identify them

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Dr. Christopher Tzermias

Dermatologist – Venereologist

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Methods of Treatment

Final elimination of warts with CO2 Laser treatment.


REALITY: Warts go away if thorough treatment is performed and followed by frequent re-examination.

As it is generally true for all viral infections, so is the case for an infection from HPV strains that cause warts

  • Immune system is called upon to fight it. Whether the immune system wins out or not depends on its contemporary status and the viral load it has to fight.
  • In case the viral load has reached high levels due to repeated contacts and infections from the virus and no treatment follows, then the immune system, no matter how strong it may be, cannot cope with it and warts arise.
  • But if the viral load is minimised through thorough treatment and frequent re-examination for a considerable amount of time, then even an immune system of moderate competence can prevail over the virus and clear it from the body.
  • Relapses are probably attributed to either inadequate treatment or inadequate re-examination combined with a weak immune system or re-infection. The latter is a possibility often concealed for reasons of social discomfort. The hypothesis that the virus remains within the body at a latent state and is reactivated from this state because of a causation is not scientifically proven.
  • Thorough examination of all skin areas is necessary to detect potential subclinical lesions (i.e. those not visible to the naked eye) so as to treat them. These, not easily detectable lesions, are the most common cause of frequent relapses and expansion of lesions.
  • Guidance and counselling are also essential in the prevention of relapses: partner’s treatment, avoidance of shaving, avoidance of rubbing the skin with towels or sponges, balanced diet, sleeping and avoidance of alcohol abuse are all common advice.

Why is it crucial to treat warts?

Although warts are attributed to low-risk HPV strains (i.e. non oncogenic), high-risk HPV strains (i.e. oncogenic) may coexist in the same lesion. If thorough detection and treatment are not performed, continuous reinfection between sexual partners is inevitable. Therefore, chances are high that viral transmission from the external to the internal genitals occurs, which poses a threat for malformation and cancer.

Oncogenic HPV strains are highly responsible for cervical cancer (almost 100%), anal (95%), vaginal (65%), vulvar (50%) and penile (35%) cancer.

How to react when warts appear on the skin

As soon as lesions are manifested on the skin, complete and thorough examination, using bright focused light, high-resolution magnifying lenses and other equipment used in dermatology, such as a dermatoscope, should be performed by a dermatologist-venereologist.

Thorough detection and treatment is the key.

This is the only way to detect and treat thoroughly all lesions at a given moment, even the subclinical lesions (those that are not visible to the naked eye). It is of vital importance to eliminate the subclinical lesions too, so that they won’t become a cause of relapses and a source of transmission to the surrounding areas or to a sexual partner in the future.

Thorough treatment with Laser

Thorough treatment can be performed with laser, which has two additional advantages:

  • recovery demands less time
  • no scars are left at lesion areas

Thorough treatment should be followed by frequent medical supervision for 8-9 months, so that any possible new lesions are treated in a timely manner, before producing new daughter lesions.

If thorough detection and treatment is not performed and followed by frequent re-examination, then lesions that carry significant viral load remain in the area and the virus is able to prevail over the immune system.

If a complete and thorough treatment is not performed, then lesions that carry significant viral load remain in the area, and the virus eventually manages to prevail over the immune system when the latter is weakened. Weakening of the immune system may be a result of another disease, stress, smoking or alcohol abuse, lack of sleep, poor nutrition habits, etc. If such is the case, it is only a matter of time for new lesions to occur.

Reappearance of lesions after thorough treatment, close supervision and a period of at least 8 months free of lesions, including subclinical lesions, is extremely rare, except for reinfection from a sexual partner.
Therefore, in case of a permanent monogamous relationship, it is of utmost importance that both partners receive treatment; otherwise, reinfection will perpetuate between partners.

Treatment application

Given the setting of a fully equipped and organised dermatology practice and the appropriate expertise in the treatment of genital warts, the effective and safe handling to follow is thorough detection and elimination of all lesions.

In our dermatology practice, ultrapulse CO2 laser is used along with special magnifying lenses with enhanced light beam. In certain cases, identification of HPV strains by HPV genotyping is recommended.

Following the vaporisation of the lesions using ultrapulse CO2 laser, abrasion is applied to achieve complete elimination of the skin lesion. Shortly afterwards, the immediate repeat application of ultrapulse CO2 laser, even in the broader area within a few millimetres around the lesion, ensures complete and effective elimination of genital warts.

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CO2 Laser therapy

  • As soon as detection even of the most microscopic, incipient lesions, subclinical lesions (these lesions not visible to the naked eye) is ensured, these are selectively eliminated to avoid turning into foci of transmission, expansion and development of new lesions and thus foci of consecutive relapses.
  • This way, this method effectively handles the ground responsible for genital warts’ relapse, since it eliminates all foci of lesions and inhibits further propagation of the virus.
  • Selective and effective elimination of lesions using CO2 laser, which is usually performed after applying a potent local anaesthetic cream, allows for the complete elimination of all lesions in short time, with no scarring, hypopigmentation and pain during recovery.
  • In certain, and not only of interest to forensics, cases, application of CO2 laser with the technique of tangential excision, allows sampling, which is then sent for molecular analysis and DNA isolation.

Recurrent warts

  • In the case of durable warts in the vulvar area that relapse, colposcopy is recommended upon removal of external warts.
  • In the case of durable warts in the anal area that relapse, proctoscopy is recommended upon removal of external warts.
  • In the case of durable warts in the urethral area that relapse, urethroscopy is recommended upon removal of external warts.
Self-examination is vital

In any case, patients should examine themselves frequently, so that possible new lesions are identified and eliminated promptly. These might be residual lesions or lesions previously incubated. Since incubation time ranges from 1 to 8 months, the absence of lesions for 8 months serves as the criterion for cure.

However, a monthly dermatologic examination is important, as well as a more frequent patient self-examination for the following 8 months, so as to identify potential daughter lesions, which may have been “implanted” before the elimination. For this reason, each new lesion should be immediately removed, before producing daughter lesions.