Management of STIs/RTIs
Chapter 8. Management of symptomatic STIs/RTIs

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Key points

• Women with vaginal discharge should be treated for the common vaginal infections (bacterial vaginosis, trichomoniasis). Treatment for yeast infection should be added if relevant clinical signs are present.
• Women with lower abdominal pain should be treated for gonorrhoea, chlamydia and anaerobic infection. Hospitalization or referral should be considered if infection is severe or if there are other danger signs.
• Women and men with genital ulcers should be treated for syphilis and chancroid. Management of genital herpes, including antiviral treatment where available, should be added in regions where HSV-2 is common.
• Men with urethral discharge should be treated for gonorrhoea and chlamydia. Women whose partners have urethral discharge should receive the same treatment.
• All symptomatic patients should receive counselling on compliance with treatment, risk reduction, and condom use.
• Treatment should be given to partners of patients with genital ulcer or urethral discharge. Partners of women who are treated for PID or cervicitis should be counselled and offered treatment.

• Routine follow-up visits are not necessary for most syndromes, provided the patient finishes the treatment and feels better. Women treated for PID should be re-examined 2�3 days after starting treatment, or sooner if they have fever.

 

This chapter covers the management of STIs/RTIs in people who seek care because they have symptoms, or when a health care provider detects signs of possible infection while addressing other health care issues. A symptom is something that the patient notices, while a sign is something observed by the health care provider (see Annex 1 for a review of history-taking and physical examination). Three clinical situations are common:

• A person comes to the clinic with a spontaneous complaint of STI/RTI symptoms.
• A patient admits to symptoms when asked by the provider (elicited symptoms).
• The health care provider detects signs of STI/RTI when examining a patient for other reasons.

Health care providers should be able to recognize STI/RTI symptoms and signs in these different clinical situations. They should know when it is possible to tell the difference between STIs and non-sexually transmitted conditions. Women with genital tract symptoms may be concerned about STI, even though most symptomatic RTIs in women are not sexually transmitted. Providers and patients should also understand that STIs/RTIs are often asymptomatic, and that the absence of symptoms does not necessarily mean absence of infection. Screening for asymptomatic STI/RTI should be done where possible (Chapter 3).

 

FLOWCHART 1. Vaginal discharge (for non-pregnant women)

 

Vaginal discharge

A spontaneous complaint of abnormal vaginal discharge�abnormal in terms of quantity, colour or odour�most commonly indicates a vaginal infection or vaginitis. Vaginal discharge due to bacterial vaginosis (multiple organisms) or yeast infection (Candida albicans) is not sexually transmitted, while trichomoniasis (Trichomonas vaginalis) usually is. Much less often, vaginal discharge may be the result of mucopurulent cervicitis due to gonorrhoea (Neisseria gonorrhoeae) or chlamydia (Chlamydia trachomatis). Detection of cervical infection in women with or without vaginal discharge is discussed in Chapter 3.

All women presenting with abnormal vaginal discharge should receive treatment for bacterial vaginosis and trichomoniasis. Additional treatment for yeast infection is indicated when clinically apparent (white, curd-like discharge, redness of the vulva and vagina, and itching). Yeast infection is a common cause of vaginitis during pregnancy and a separate flowchart for management of vaginal discharge in pregnant women is given in Chapter 9.

 

Therapy for bacterial vaginosis and trichomoniasis PLUS Therapy for yeast infection if curd-like white discharge, vulvo-vaginal redness, and itching are present
Coverage	First choice Choose one from BV/TV box below, or one from each box if yeast infection is suspected	Effective substitutes	If woman is pregnant or breastfeeding Choose one from BV/TV box below, or one from each box if yeast infection is suspected
Bacterial vaginosis	metronidazolea 2 g orally in a single dose, or metronidazolea 400 or 500 mg orally twice a day for 7 days	clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days, or clindamycin 300 mg orally twice a day for 7 days	Preferably after first trimester metronidazolea 200 or 250 mg orally 3 times a day for 7 days, or metronidazolea gel 0.75%, one full applicator (5 g) intra-vaginally twice a day for 5 days, or clindamycin 300 mg orally twice a day for 7 days
Trichomo-niasis		tinidazolea 2 g orally in a single dose, or tinidazolea 500 mg orally twice a day for 5 days
Candida albicans (yeast)	miconazole 200 mg vaginal suppository, one a day for 3 days, or clotrimazoleb 100 mg vaginal tablet, two tablets a day for 3 days, or fluconazole 150 mg oral tablet, in a single dose	nystatin 100 000 unit vaginal tablet, one a day for 14 days	miconazole 200 mg vaginal suppository, one a day for 3 days, or clotrimazoleb 100 mg vaginal tablet, two tablets a day for 3 days, or nystatin 100 000 unit vaginal tablet, one a day for 14 days

^a. Patients taking metronidazole or tinidazole should be cautioned to avoid alcohol. Use of metronidazole is not recommended in the first trimester of pregnancy.

^b. Single-dose clotrimazole (500 mg) available in some places is also effective for yeast infection (CA).

 

Cervical infection

Treatment for cervical infection should be given in situations where infection seems likely or the risk of developing complications is high (see cervical infections in Chapter 3 and transcervical procedures in Chapter 2). Treatment for cervical infection should be added to the treatment for vaginitis if suspected (for example, if the patient�s partner has a urethral discharge), or if signs of cervical infection (mucopurulent cervical discharge or easy bleeding) are seen on speculum examination. Treatment table 2 indicates the treatment of cervical infection.

 

Treatment table 2. Recommended treatment for cervical infection

Therapy for uncomplicated gonorrhoea PLUS Therapy for chlamydia
Coverage	First choice Choose one from each box below (= 2 drugs)	Effective substitutes	If woman is pregnant, breastfeeding or under 16 years old Choose one from each box below (= 2 drugs)
Gonorrhoea	cefixime 400 mg orally as a single dose, or ceftriaxone 125 mg by intramuscular injection	ciprofloxacin a,b 500 mg orally as a single dose, or spectinomycin 2 g by intramuscular injection	cefixime 400 mg orally as a single dose, or ceftriaxone 125 mg by intramuscular injection
Chlamydia	azithromycin 1 g orally as a single dose, or doxycyclinea 100 mg orally twice a day for 7 days	ofloxacin a,b,c 300 mg orally twice a day for 7 days, or tetracyclinea 500 mg orally 4 times a day for 7 days, or erythromycin 500 mg orally 4 times a day for 7 days	erythromycind 500 mg orally 4 times a day for 7 days, or azithromycin 1 g orally as a single dose, or amoxycillin 500 mg orally 3 times a day for 7 days

^a. Doxycycline, tetracycline, ciprofloxacin, norfloxacin and ofloxacin should be avoided in pregnancy and when breastfeeding.

^b. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

^c. Ofloxacin, when used as indicated for chlamydial infection, also provides coverage for gonorrhoea.

^d. Erythromycin estolate is contraindicated in pregnancy because of drug-related hepatotoxicity; only erythromycin base or erythromycin ethylsuccinate should be used.

 

See Annex 4 for more information on alternative treatments for gonorrhoea.

 

FLOWCHART 2. Lower abdominal pain (In women)

 

Lower abdominal pain

All sexually active women presenting with lower abdominal pain should be carefully evaluated for signs of pelvic inflammatory disease. In addition, women with other genital tract symptoms should have routine abdominal and bimanual examinations when possible, since some women with PID will not complain of lower abdominal pain. Symptoms suggestive of PID include lower abdominal pain, pain on intercourse (dyspareunia), bleeding after sex or between periods, and pain associated with periods (if this is a new symptom). Vaginal discharge, pain on urination (dysuria), fever, nausea and vomiting may also be present.

Clinical signs of PID are varied and may be minimal. PID is highly probable when a woman has lower abdominal, uterine or adnexal tenderness, evidence of lower genital tract infection, and cervical motion tenderness. Enlargement or induration of one or both fallopian tubes, a tender pelvic mass, and direct or rebound abdominal tenderness may also be present. The patient�s temperature may be elevated but is often normal.

Because of the serious consequences of PID, health care providers should have a high index of suspicion and treat all suspected cases. Treatment should be started as soon as the presumptive diagnosis has been made, because prevention of long-term complications is more successful if appropriate antibiotics are administered immediately.

Etiological agents found in PID include N. gonorrhoeae, C. trachomatis, anaerobic bacteria, Gram-negative facultative bacteria, and streptococci. As it is impossible to differentiate between these clinically and a precise microbiological diagnosis is difficult, the treatment regimens must be effective against this broad range of pathogens. Several recommended regimens are given in Treatment table 3 and Treatment table 4.

Partners of patients with PID should be treated for gonorrhoea and chlamydia (see Treatment table 8.

Note: other causes of lower abdominal pain should be considered�e.g. acute appendicitis, urinary tract infection, ectopic pregnancy�and the history-taking and physical examination should rule out other causes.

 

Treatment table 3. Recommended outpatient treatment for PID

Single-dose therapy for gonorrhoea PLUS Single-dose or multidose therapy for chlamydia PLUS Therapy for anaerobic infections
Coverage	Choose one from each box (= 3 drugs)
Gonorrhoea	ceftriaxone 250 mg by intramuscular injection, or cefixime 400 mg orally as a single dose, or ciprofloxacina 500 mg orally as a single dose, or spectinomycin 2 g by intramuscular injection
Chlamydia	doxycyclineb 100 mg orally twice a day for 14 days, or tetracyclineb 500 mg orally 4 times a day for 14 days
Anaerobes	metronidazolec 400�500 mg orally, twice a day for 14 days

^a. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

^b. These drugs are contraindicated for pregnant or breastfeeding women. PID is uncommon in pregnancy � see Chapter 9 for recommendations on management of endometritis and related infections in pregnancy and the postpartum period.

^c. Patients taking metronidazole should be cautioned to avoid alcohol. Metronidazole should also be avoided during the first trimester of pregnancy.

 

Note: Hospitalization of patients with acute pelvic inflammatory disease should be seriously considered when:

• a surgical emergency, such as appendicitis or ectopic pregnancy, cannot be excluded;
• a pelvic abscess is suspected;
• severe illness precludes management on an outpatient basis;
• the patient is pregnant;
• the patient is an adolescent;
• the patient is unable to follow or tolerate an outpatient regimen; or
• the patient has failed to respond to outpatient therapy.

 

Treatment table 4. Recommended inpatient treatment for PID

Therapy for gonorrhoea PLUS Therapy for chlamydia PLUS Therapy for anaerobic infections
Coverage	Option 1 Choose one from each box (= 3 drugs), and follow with oral outpatient therapy below	Option 2 Give both drugs and follow with oral outpatient therapy below	Option 3 Commonly available. Give all 3 drugs plus oral outpatient therapy below
Gonorrhoea	ceftriaxone 250 mg by intramuscular injection, once a day, or ciprofloxacina 500 mg orally as a single dose, or spectinomycin 2 g by intramuscular injection	gentamicin 1.5 mg/kg of body weight by intravenous injection every 8 hours PLUS clindamycin 900 mg by intravenous injection every 8 hours	ampicillin 2 g by intravenous or intramuscular injection, then 1 g every 6 hours PLUS gentamicin 80 mg by intramuscular injection every 8 hours PLUS metronidazole, 500 mg or 100 ml by intravenous infusion every 8 hours
Chlamydia	doxycyclineb,c 100 mg orally or by intravenous injection, twice a day, or tetracyclinec 500 mg orally 4 times a day
Anaerobes	metronidazole 400�500 mg orally or by intravenous injection, twice a day, or chloramphenicolc 500 mg orally or by intravenous injection, 4 times a day
For all three options, therapy should be continued until at least 2 days after the patient has improved and should then be followed by one of the following oral treatments for a total of 14 days: doxycyclinec 100 mg orally twice a day, or tetracyclinec 500 mg orally 4 times a day

^a. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

^b. Intravenous doxycycline is painful and has no advantage over the oral route if the patient is able to take medicine by mouth.

^c. Contraindicated for pregnant or breastfeeding women. PID is uncommon in pregnancy � see Chapter 9 for recommendations on management of endometritis and related infections in pregnancy and the postpartum period.

 

Follow-up

Outpatients with PID should be followed up no later than 72 hours after starting treatment (24 hours for women with fever) and admitted to hospital if their condition has not improved. Patients should show substantial clinical improvement (absence of fever, reduction in abdominal tenderness, and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days of starting treatment. Patients who do not improve within this period may require hospitalization, additional diagnostic tests, or surgical intervention.

 

FLOWCHART 3. Genital ulcer (for both men and women)

 

Genital ulcer

Genital ulcer disease (GUD) patterns vary in different parts of the world, but genital herpes, chancroid and syphilis are the most common. Differential diagnosis of genital ulcers using clinical features is inaccurate, particularly where several types of GUD are common. Clinical manifestations and patterns of genital ulcer disease may be different in people with HIV infection.

If examination confirms the presence of genital ulcers, treatment appropriate to local causes should be given. For example, in areas where both syphilis and chancroid are prevalent, patients with genital ulcers should be treated for both conditions at the time of their initial presentation, to ensure adequate therapy in case they do not come back. In areas where granuloma inguinale (donovanosis) is prevalent, treatment for this should also be included. In many parts of the world, genital herpes has become the most frequent cause of genital ulcer disease. Where HIV infection is prevalent, an increasing proportion of cases of genital ulcer disease is likely to be due to herpes simplex virus. Herpetic ulcers (and ulcerative STIs in general) in HIV-infected patients may be atypical and persist for a long time. Although there is no cure for HSV-2, treatment with antivirals, such as acyclovir, can shorten the duration of active disease and may help reduce transmission. In places where these drugs are scarce, treatment should be reserved for patients with severe HSV-2 or herpes zoster infection, both of which are often associated with HIV infection (Box 8.1).

Laboratory-assisted differential diagnosis of GUD is rarely helpful at the initial visit and may even be misleading. In areas of high prevalence of syphilis, a person may have a reactive serological test from a previous infection, even when chancroid or herpes is the cause of the present ulcer.

 

Management of genital ulcer disease

• Treat for syphilis and chancroid.
• Provide genital herpes management, including HSV-2 treatment, where HSV-2 prevalence is 30% or greater.
• Depending on local epidemiological patterns, add treatment for granuloma inguinale (donovanosis) and/or lymphogranuloma venereum.
• Advise on basic care of the lesion (keep clean and dry).
• Aspirate any fluctuant glands (surgical incision should be avoided).
• Educate and counsel on compliance with treatment and risk reduction.
• Promote and provide condoms.
• Offer HIV serological testing where appropriate facilities and counselling are available.
• Advise the patient to return in 7 days if the lesion is not fully healed, and sooner if the clinical condition becomes worse.
• Assist with partner treatment.

 

Treatment table 5. Recommended treatment for genital ulcers

Single-dose therapy for syphilis PLUS Single-dose or multidose therapy for chancroid
Coverage	First choice Choose one from each box below (= 2 drugs)	Effective substitutes	If patient is pregnant, breastfeeding or under 16 years old Choose one from each box below (= 2 drugs)
Syphilis	benzathine penicillin 2.4 million units by single intramuscular injection Note: patients with a positive syphilis test and no ulcer, administer the same dose at weekly intervals for a total of 3 doses	doxycyclinec 100 mg orally twice a day for 14 days, or tetracyclinec 500 mg orally 4 times a day for 14 days	benzathine penicillin 2.4 million units by single intramuscular injection, or erythromycinb 500 mg orally 4 times a day for 15 days
Chancroid	ciprofloxacina 500 mg orally twice a day for 3 days, or azithromycin 1 g orally as a single dose, or erythromycinb 500 mg orally 4 times a day for 7 days	ceftriaxone 250 mg as a single intramuscular injection	erythromycinb 500 mg orally 4 times a day for 7 days, or azithromycin 1 g orally as a single dose, or ceftriaxone 250 mg as a single intramuscular injection

Additional therapy for HSV-2 where HSV-2 is common (see Flowchart 3).
Genital herpes	Primary infection acyclovirc 200 mg orally 5 times a day for 7 days, or acyclovirc 400 mg orally 3 times a day for 7 days	Primary infection famciclovirc 250 mg orally 3 times a day for 7 days, or valaciclovirc 1 g twice a day for 7 days	Use acyclovir only when benefit outweighs risk (see Annex 4). Dosage is the same as for primary infection.
	Recurrent infection acyclovirc 200 mg orally 5 times a day for 5 days, or acyclovirc 400 mg orally 3 times a day for 5 days	Recurrent infection famciclovirc 125 mg orally 3 times a day for 5 days, or valaciclovirc 500 mg twice a day for 5 days

^a. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

^b. Erythromycin estolate is contraindicated in pregnancy because of drug-related hepatotoxicity; only erythromycin base or erythromycin ethylsuccinate should be used.

^c. These drugs are contraindicated for pregnant or breastfeeding women.

 

See Treatment table 6 for additional GUD treatment that may be needed in some regions.

 

Treatment table 6. Recommended additional treatment for genital ulcers

In areas where granuloma inguinale or lymphogranuloma venereum are important causes of genital ulcers, the following treatments can be added (or, in some cases, the treatments given in Treatment table 5 can be chosen to cover these infections)
Coverage	First choice	Effective substitutes	If patient is pregnant, breastfeeding or under 16 years old
Granuloma inguinale (donovanosis) (treatment should be continued until all lesions have completely epithelialized)	azithromycin 1 g orally as a single dose followed by 500 mg once a day, or doxycyclinea 100 mg orally twice a day	erythromycinb 500 mg orally 4 times a day, or tetracyclinea 500 mg orally 4 times a day, or trimethoprim (80 mg)/ sulfamethoxazole (400 mg), 2 tablets orally twice a day	azithromycin 1 g orally as a single dose, or erythromycinb 500 mg orally 4 times a day
Lympho- granuloma venereum	doxycyclinea 100 mg orally twice a day for 14 days, or erythromycinb 500 mg orally 4 times a day for 14 days	tetracyclinea 500 mg orally 4 times a day for 14 days	erythromycinb 500 mg orally 4 times a day for 14 days

a. These drugs are contraindicated for pregnant or breastfeeding women.

b. Erythromycin estolate is contraindicated in pregnancy because of drug-related hepatotoxicity; only erythromycin base or erythromycin ethylsuccinate should be used.

 

Box 8.1. Genital ulcers and HIV infection

Genital ulcers facilitate the spread of HIV more than other STIs/RTIs. Chancroid, genital herpes and syphilis are common in regions where HIV prevalence is high, and control of these infections is an important component of HIV prevention. The presence of HIV infection may also change the presentation of genital ulcers making their diagnosis more difficult. Lesions of primary and secondary syphilis may be atypical. Chancroid lesions may be more extensive, and rapidly aggressive lesions have been noted. This reinforces the need for early treatment, especially in HIV-infected individuals. Treatment of genital ulcers is the same for HIV-positive and HIV-negative patients. All patients should be seen one week after starting treatment, and treatment should be continued if significant improvement is not apparent. Herpes simplex lesions may present as persistent multiple ulcers that require medical attention. Antiviral treatment may reduce symptoms. The nature and purpose of treatment should be properly explained to the patient in order to avoid false expectations of cure.

 

 

FLOWCHART 4. Inguinal bubo (in men and women)

 

Inguinal bubo

Inguinal and femoral buboes are localized enlargements of the lymph nodes in the groin area, which are painful and may be fluctuant (soft with a feeling of liquid inside). When buboes rupture, they may appear as ulcers in the inguinal area. Buboes are frequently associated with lymphogranuloma venereum and chancroid. In most cases of chancroid, a genital ulcer is also visible, but internal vaginal ulcers in women may be missed. Where granuloma inguinale (donovanosis) is common, it should also be considered as a cause of inguinal bubo.

The genital ulcer flowchart and treatment table should always be used when buboes are seen with a genital ulcer. Treatment table 7 is for patients with inguinal bubo but without genital ulcer. Non-sexually-transmitted local and systemic infections (e.g. infections of the lower limb) can also cause swelling of inguinal lymph nodes.

 

Treatment table 7. Recommended treatment for inguinal bubo

Single-dose or multidose therapy for chancroid PLUS Multidose therapy for lymphogranuloma venereum (LGV)
Coverage	First choice Choose one from each box (= 2 drugs)	Effective substitutes	If patient is pregnant, breastfeeding or under 16 years old
Chancroid	ciprofloxacina,b 500 mg orally twice a day for 3 days, or erythromycinc 500 mg orally 4 times a day for 7 days	azithromycin 1 g orally as a single dose, or ceftriaxone 250 mg as a single intramuscular injection	erythromycinc 500 mg orally 4 times a day for 14 days (covers both chancroid and LGV)
LGV	doxycyclinea 100 mg orally twice a day for 14 days	tetracyclinea 500 mg orally 4 times a day for 14 days

^a. These drugs are contraindicated for pregnant or breastfeeding women.

^b. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

^c. Erythromycin estolate is contraindicated in pregnancy because of drug-related hepatotoxicity; only erythromycin base or erythromycin ethylsuccinate should be used.

Note: Some cases may require longer treatment than the 14 days recommended. Fluctuant lymph nodes should be aspirated through healthy skin. Incision and drainage or excision of nodes may delay healing and should not be attempted.

 

Flowchart 5. Urethral discharge (in men)

 

Urethral discharge

Male patients complaining of urethral discharge or pain on urinating (dysuria) should be examined for evidence of discharge. If none is seen, the urethra should be gently massaged from the base of the penis towards the urethral opening (�milking�). It is sometimes difficult to confirm the presence of discharge, especially if the man has recently urinated, and treatment should be considered if symptoms suggest infection.

The major pathogens causing urethral discharge are Neisseria gonorrhoeae and Chlamydia trachomatis. In syndromic management, treatment of a patient with urethral discharge should cover these two organisms. Where reliable laboratory facilities are available, a distinction may be made between the two organisms and specific treatment instituted. Patients should be advised to return if symptoms persist 7 days after the start of therapy.

Any sexual partners in the preceding two months should also be treated. This is an opportunity to treat asymptomatic women who may have gonorrhoea or chlamydial infection. Female partners should be treated as for cervical infection (Treatment table 2).

 

Treatment table 8. Recommended treatment for urethral discharge (males only)

Therapy for uncomplicated gonorrhoea PLUS Therapy for chlamydia
Coverage	First choice Choose one from each box below (= 2 drugs)	Effective substitutes
Gonorrhoea	cefixime 400 mg orally as a single dose, or ceftriaxone 125 mg by intramuscular injection	ciprofloxacina 500 mg orally as a single dose, or spectinomycin 2 g by intramuscular injection
Chlamydia	azithromycin 1 g orally as single dose, or doxycycline 100 mg orally twice a day for 7 days	ofloxacina,b 300 mg orally twice a day for 7 days, or tetracycline 500 mg orally 4 times a day for 7 days, or erythromycin 500 mg orally 4 times a day for 7 days

^a. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

^b. Ofloxacin, when used as indicated for chlamydial infection, also provides coverage for gonorrhoea.

 

Epididymitis is an occasional complication of untreated urethral infection. Symptoms are abrupt onset of one-sided testicular pain and swelling (differential diagnosis is also testicular torsion which must be ruled out and which is an emergency).

Scrotal swelling in men under 35 is commonly a complication of RTI and can be treated in the same way as urethral discharge. It is important to recognize that scrotal swelling can be due to other causes and can be an emergency. If the patient reports a history of trauma or if the testicle appears elevated or rotated, refer immediately for surgical evaluation.

 

Management of other STIs/RTIs

Other common STIs/RTIs include anogenital warts, and infestations such as pubic lice and scabies. Available treatments for these conditions can be found in Treatment table 9 and Treatment table 10. See Guidelines for the management of sexually transmitted infections (Geneva, World Health Organization, 2001) for more details on management of these and other syndromes.

 

Treatment table 9. Recommended treatment for anogenital warts

Patient-applieda	Provider-administered
podophyllotoxinb 0.5% solution or gel by a cotton-tipped swab twice a day for 3 days followed by 4 days of no treatment. The cycle can be repeated up to 4 times. The total amount of podophyllotoxin should not exceed 0.5 ml per day.	podophyllinb 10�25% in compound tincture of benzoin, applied carefully to the warts, avoiding normal tissue. External genital and perianal warts should be washed thoroughly 1�4 hours after application of podophyllin. Podophyllin applied to warts on vaginal or anal epithelial surfaces should be allowed to dry before the speculum is removed. Treatment should be repeated at weekly intervals.
imiquimodb 5% cream applied with a finger at bedtime, left on overnight, 3 times a week for as long as 16 weeks. (The treatment area should be washed with soap and water 6�10 hours after application.)	trichloracetic acid (TCA) (80�90%) applied carefully to the warts avoiding normal tissue followed by powdering of the treated area with talc or sodium bicarbonate (baking soda) to remove unreacted acid. Repeat application at weekly intervals.

^a. �Patient-applied�: refers to self-treatment of external anogenital warts that can be identified and reached by the patient. The first treatment must be applied by the prescribing provider.

^b. Should not be used in pregnancy.

Genital warts can also be treated by cryotherapy, electrosurgery or surgical removal. The choice of method will depend on what is available and on the anatomical location of the warts. With all chemical methods, care should be taken to protect healthy tissue. Cervical warts should be managed together with a specialist who can evaluate for cervical dysplasia with Pap smear or other tests. Patients should be advised that warts often reappear even after treatment.

 

Treatment table 10. Recommended treatment of scabies and pubic lice

Scabies	Pubic lice
lindanea 1% lotion or cream, applied thinly to all areas of the body from the neck down and washed off thoroughly after 8 hours. Resistance to lindane has been reported in some areas	lindanea 1% lotion or cream, rubbed gently but thoroughly into the infested area and adjacent hairy areas and washed off after 8 hours; as an alternative, lindane 1% shampoo, applied for 4 minutes and then thoroughly washed off
benzyl benzoate 25% lotion, applied to the entire body from the neck down, nightly for 2 nights; patients may bathe before reapplying the product and should bathe 24 hours after the final application	pyrethrins 1% plus piperonyl butoxide 10% shampoo applied to the infested and adjacent hairy areas and washed off after 10 minutes; re‑treatment is indicated after 7 days if lice are found or eggs are observed at the hair�skin junction
permethrin 5% cream applied to the entire body from the neck down, nightly for 3 nights; patients may bathe before reapplying the product and should bathe 24 hours after the final application	permethrin 1% lotion or cream, as for pyrethrins above
crotamiton 10% lotion, applied to the entire body from the neck down, nightly for 2 nights; washed off thoroughly 24 hours after the second application; an extension to 5 nights may be necessary in some geographical locations (crotamiton has the advantage of an antipruritic action)
sulfur 6% in petrolatum applied to the entire body from the neck down, nightly for 3 nights; patients may bathe before reapplying the product and should bathe 24 hours after the final application

^a. Lindane is not recommended for pregnant or breastfeeding women.

Scabies and pubic lice are easily transmitted between sex partners. They are often transmitted in other ways�through infested bedclothes (fomites) or close body contact�so care must be taken not to stigmatize patients. Especially for people living at close quarters, treatment of the entire household is advised. All clothing, sheets and towels should be washed, preferably in very hot water, and dried well.

 

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