Do genital warts come back after treatment?

Two things make this question hard to get a straight answer to. The first is that clinics answer it, and a clinic quoting a cure rate for the procedure it sells is not a neutral source. The second is that the honest answer is unsatisfying, and it is unsatisfying for a reason worth knowing.

What treatment actually does#

Laser, cryotherapy, electrocautery, excision and the topical creams all do the same thing in different ways: they destroy or remove the visible lesion. None of them removes human papillomavirus from the surrounding skin. Whether warts return depends on whether the immune system clears the infection, which is not something any of these treatments does.

The evidence on which treatment is best, and how often warts return#

A systematic review searched four databases from inception to 2018 and found 37 randomised trials, then combined them in a network meta-analysis. Clearance and recurrence were both prespecified outcomes.

• Of the options compared, carbon dioxide laser was most effective for complete clearance at the end of treatment.
• Among patient-applied treatments, podophyllotoxin 0.5 percent solution was most effective, significantly more so than imiquimod 5 percent cream and polyphenon E 10 percent ointment.
• Twenty of the 37 trials were at unclear risk of bias and the rest at high risk of bias.

The authors' conclusion is the part that answers the question asked here: taken as a collective, the quality of the evidence is low, and few studies evaluate treatment options against each other at all.

That is why no honest source will give a single recurrence percentage. The number would have to come from trials that either were not done, were not compared, or were not done well enough to rely on. A clinic that quotes one precisely is quoting something the literature does not contain.

The explanation that does not hold up#

A common account of recurrence is that it depends on which HPV type someone has, and typing is sometimes offered on that basis. A meta-analysis of eight studies covering 1,070 patients tested it.

The authors conclude that HPV subtype is not significantly associated with persistence or recurrence. The interval is wide and does not exclude a real effect, so this is a finding of no evidence rather than evidence of no effect — but it does not support typing as a way of predicting whether warts will return.

What is happening in Korea#

National claims data from the Health Insurance Review and Assessment Service shows how much of this is being treated.

Prevalence was highest between the ages of 25 and 29, at 1,492 per 100,000 in 2018 — roughly one in 67 men in that age band treated in a single year. A separate analysis of treatment methods from 2010 to 2019 found that surgical treatment predominated in men and drug treatment in women, that surgery for anorectal warts rose by more than 250 percent over the decade, that men had it four times as often as women, and that the mean number of sessions was higher in men. Most treatment took place in primary care clinics.

What this does not say#

1. It does not say treatment is pointless. Clearing visible warts is a real outcome, and the trials do show treatments differ in how well they achieve it.
2. It does not say warts always come back. It says the recurrence rate is not reliably known, which is a different claim and the one the evidence supports.
3. The network meta-analysis searched to 2018. Newer trials exist, but nothing since has replaced low-quality evidence with high-quality evidence on this question.
4. The Korean prevalence figures count people who sought treatment and were coded for it. They are a measure of diagnosis and treatment, not of how many people have warts.
5. The 59.1 percent HPV positivity figure comes from men who underwent testing, a group already more likely to be infected than the general population.
6. This covers warts, which are caused mostly by low-risk HPV types. It does not address high-risk types and cancer risk, which is a separate subject.

The defensible summary is that treatment removes warts and not the virus, that warts can return afterwards and nobody can honestly tell you how likely that is, that the HPV type does not usefully predict it, and that a precise recurrence figure quoted by whoever is selling the treatment is not coming from the published evidence.