A systematic review and network meta-analysis 3 assessing comparative clinical effectiveness for interventions used in the treatment of anogenital warts (AGWs) included 37 RCTs. Carbon dioxide laser therapy is the most effective treatment for achieving complete clearance of AGWs at the end of treatment. Of patient-applied topical treatments, podophyllotoxin 0.5% solution was found to be the most effective at achieving complete clearance, and was associated with a statistically significant difference compared with imiquimod 5% cream and polyphenon E 10% ointment (p<0.05). Few data were available on recurrence of AGWs after complete clearance. In terms of recurrence, no statistically significant difference in risk of recurrence at a maximum follow-up of 6 months was found between podophyllotoxin 0.5% solution and any of cryotherapy, imiquimod 5% cream and surgical excision, with surgical excision identified as the most effective treatment for reducing risk of recurrence after complete clearance.
Another network meta-analysis 4 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 T1.
| 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 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.
In a randomized, open label trial 1 the effectiveness and safety of self-applied imiquimod 5% cream and podophyllotoxin 0.5% solution for anogenital warts were compared (n=45). The rates of clearance of baseline warts among treatment groups were 72% (95% CI 52%-86%) in the podophyllotoxin group and 75% (95% CI 53%-98%) in the imiquimod group. Statistically, clearance rates were identical (P=1). The differences in side effects between treatment groups were statistically not significant (P=0.24).
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