A network meta-analysis «Bertolotti A, Ferdynus C, Milpied B, et al. Local Management of Anogenital Warts in Non-Immunocompromised Adults: A Network Meta-Analysis of Randomized Controlled Trials. Dermatol Ther (Heidelb) 2020;»3 evaluating the efficacy of topical treatments and ablative procedures for the management of AGWs included 70 RCTs involving 9 931 patients. Surgery achieved the best complete lesion response compared to placebo, see table «Intervention for anogenital warts»1.
| Intervention | Complete lesion response compared with placebo | |
|---|---|---|
| RR | 95% CI | |
| Podophyllin solution | 5.65 | 3.12–10.25 |
| Imiquimod | 4.75 | 2.86–7.89 |
| Surgery | 10.54 | 4.53–24.52 |
| Cryotherapy | 4.34 | 2.50–7.53 |
| Electrosurgery | 7.10 | 3.47–14.53 |
| CO2 laser | 5.62 | 3.00–10.54 |
A systematic review «Thurgar E, Barton S, Karner C et al. Clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic evaluation. Health Technol Ass»2 evaluated the clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts. 60 randomised controlled trials (RCTs) evaluating 19 interventions were included. Analysis by mixed-treatment comparison (MTC) indicated that ablative techniques were typically more effective than topical interventions at completely clearing warts at the end of treatment. Podophyllotoxin 0.5% solution was found to be the most effective topical treatment evaluated. Networks for other outcomes included fewer treatments, which restrict conclusions on the comparative effectiveness of interventions. Podophyllotoxin 0.5% solution first line followed by carbon dioxide (CO2) laser therapy second line if warts did not clear was most likely to be considered a cost-effective use of resources at a willingness to pay of £20,000-30,000 per additional quality-adjusted life-year gained. Probability (percentage) of complete clearance at another time point by treatment (sensitivity analysis): Placebo/no treatment 7.9, imiquimod 5% cream 44.7, cryotherapy 52.4, cryotherapy plus podophyllotoxin 0.15% cream 57.5, electrotherapy 65.5.
A topic in Clinical Evidence «Buck H. What are the effects of treatments for external genital warts.? Genital warts. Clinical Evidence 2005;13:2005-2015.»1 summarizes the results of RCTs on electrosurgery. One RCT (n=230) found that electrosurgery diatermy increased clearance of warts at 6 months (82% vs 8% with no treatment, p<0.001). One RCT (n=450) found that electrosurgery increased wart clearance compared with podophyllin (94% vs 41%, p<0.05). Cryotherapy was less effective at 6 weeks (clearing warts 79% with cryotherapy vs 94% with electrosurgery, p=0.003) than electrosurgery. Electrosurgery may cause pain (17%) and dyspareunia (4%) for a median of 2 weeks.
Comment: The quality of evidence was downgraded by limited study size for each comparison.