A systematic review 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 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.
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