Venereal warts — MSF Clinical guidelines — Médecins Sans Frontières 2026

Q: How is podophyllotoxin 0.5% applied for external warts <3 cm?

Apply the solution to the warts using an applicator or cotton bud, sparing healthy skin, and allow to air dry. Apply twice daily, 3 consecutive days per week, for up to 4 weeks. Patients may self-apply for external warts; medical staff must apply for vaginal warts.

Q: Which warts should not be treated with podophyllum preparations?

Podophyllum should not be used on cervical, intra-urethral, rectal, oral or extensive warts, nor in pregnant or breastfeeding women. These require surgical excision, cryotherapy or electrocoagulation.

Q: What should be done if a woman has external genital warts?

Perform a speculum examination to exclude vaginal or cervical warts. If feasible, screen for precancerous cervical lesions using visual inspection with acetic acid, cervical smear or other available techniques, and treat any lesions identified.

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 9: Genito-urinary diseases · Médecins Sans Frontières, Current online edition, 2026

MSF guidance on diagnosis and treatment of genital warts (HPV) for clinicians in resource-limited settings.

In one sentenceTreat external warts <3 cm with podophyllotoxin 0.5% twice daily, 3 consecutive days/week for 4 weeks; use excision/cryotherapy for larger/internal warts and in pregnancy.

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Clinicians in resource-limited settings
Evidence: Expert consensus
Reviewed: 21 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 21 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline section addresses venereal warts, benign tumours caused by human papillomavirus (HPV) presenting as soft, painless growths on external or internal genital sites. The guideline emphasises recognition of flat and cauliflower-like lesions, the importance of speculum examination in women to exclude vaginal/cervical involvement, and screening for precancerous cervical lesions when feasible.

Treatment is stratified by size and location: external warts 3 cm), cervical, intra-urethral, rectal and oral warts, and warts in pregnant or breastfeeding women require surgical excision, cryotherapy or electrocoagulation. The guideline cautions that podophyllum preparations are contraindicated in pregnancy and breastfeeding, and that treatment may be less effective in HIV-infected patients.

The central message is practical case management in resource-limited settings with clear thresholds for topical versus procedural treatment, alongside cervical cancer screening where possible.

Key points

For clinicians — doses and thresholds as stated in the guideline

External warts <3 cm and vaginal warts: podophyllotoxin 0.5% solution applied twice daily, 3 consecutive days per week, for up to 4 weeks
Alternative podophyllum resin (10%, 15% or 25%) applied by medical staff only, washed off after 1–4 hours, once weekly for 4 weeks
External warts >3 cm require surgical excision, cryotherapy or electrocoagulation
Cervical, intra-urethral, rectal and oral warts require surgical excision, cryotherapy or electrocoagulation (not podophyllum)
Podophyllum preparations are contraindicated in pregnant or breastfeeding women
All women with external warts should undergo speculum examination to exclude vaginal or cervical warts
Presence of genital warts in women is an indication to screen for precancerous cervical lesions (visual inspection with acetic acid, cervical smear or other available techniques) and treat any lesions identified
Treatment may be less effective and relapses more frequent in HIV-infected patients

Treatment of venereal warts by size and location

Table extracted from the guideline

Wart characteristics	Treatment options	Key details
External warts <3 cm and vaginal warts	Podophyllotoxin 0.5% solution	Apply twice daily, 3 consecutive days/week, up to 4 weeks. May be self-applied (except vaginal warts). Contraindicated in pregnancy/breastfeeding
External warts <3 cm (alternative)	Podophyllum resin 10%, 15% or 25%	Applied by medical staff only. Wash off after 1–4 hours. Once weekly for 4 weeks
External warts >3 cm	Surgical excision or cryotherapy or electrocoagulation	—
Cervical, intra-urethral, rectal, oral warts	Surgical excision or cryotherapy or electrocoagulation	Podophyllum preparations should not be used
Warts in pregnant or breastfeeding women	Surgical excision or cryotherapy or electrocoagulation	Podophyllum contraindicated. Treatment may be deferred (not an emergency)

Source: Médecins Sans Frontières, Venereal warts — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“Presence of genital warts in women is an indication to screen for precancerous lesions of the cervix, if feasible in the context (visual inspection with acetic acid, or cervical smear, or other available techniques), and to treat any lesions identified.”

— Médecins Sans Frontières, Venereal warts — MSF Clinical guidelines, Clinical features (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise that this MSF guideline offers practical, resource-stratified management of genital warts that aligns well with Georgia's primary care capacity. The clear 3 cm size threshold for topical versus procedural treatment and the twice-daily, 3-consecutive-days-per-week podophyllotoxin regimen can be readily incorporated into national STI protocols. I would stress to Georgian clinicians the recommendation to use every presentation of genital warts in women as an opportunity for cervical screening, supporting our national cancer prevention objectives. The main implementation challenge will be ensuring consistent availability of podophyllotoxin 0.5% solution in rural health centres and establishing accessible cryotherapy services for cases where topical treatment is contraindicated or fails.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026

Applicability

Georgia and the South Caucasus

This guideline is directly applicable to Georgia and the South Caucasus, where HPV-related disease remains a public health concern and cervical cancer screening coverage is incomplete. Georgian national programmes should consider integrating opportunistic cervical screening into genital wart management, ensuring access to podophyllotoxin 0.5% solution in primary care settings, and establishing referral pathways for cryotherapy or surgical excision where topical treatment is contraindicated or insufficient. The guidance on deferring treatment in pregnancy and avoiding unnecessary caesarean section is particularly relevant in settings where caesarean rates are high.

Questions this guideline answers

Quick answers

Can pregnant women with genital warts be treated?

Podophyllum preparations are contraindicated in pregnancy and breastfeeding. Surgical excision, cryotherapy or electrocoagulation may be used, but treatment is not an emergency and may be deferred. Genital warts are not an indication for caesarean section.

How is podophyllotoxin 0.5% applied for external warts <3 cm?

Apply the solution to the warts using an applicator or cotton bud, sparing healthy skin, and allow to air dry. Apply twice daily, 3 consecutive days per week, for up to 4 weeks. Patients may self-apply for external warts; medical staff must apply for vaginal warts.

Which warts should not be treated with podophyllum preparations?

Podophyllum should not be used on cervical, intra-urethral, rectal, oral or extensive warts, nor in pregnant or breastfeeding women. These require surgical excision, cryotherapy or electrocoagulation.

What should be done if a woman has external genital warts?

Perform a speculum examination to exclude vaginal or cervical warts. If feasible, screen for precancerous cervical lesions using visual inspection with acetic acid, cervical smear or other available techniques, and treat any lesions identified.

Related on GMJ

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Upper genital tract infections (UGTI) — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Genital ulcers — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Abnormal vaginal discharge — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Urethral discharge — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Genital infections — Clinical guidelines — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Acute prostatitis — MSF Clinical guidelinesChapter 9: Genito-urinary diseases

Venereal warts — MSF Clinical guidelines

What this guideline says

Key points

Treatment of venereal warts by size and location

From the guideline