Podophyllum Resin (Monograph)

Brand name: Podocon-25
Drug class: Skin and Mucous Membrane Agents, Miscellaneous
- Antimitotic Agents
VA class: DE500
CAS number: 8050-60-0

Introduction

Antimitotic; caustic agent.^{100 117 118}

Uses for Podophyllum Resin

Human Papillomavirus (HPV) Infections

Topical treatment of external genital and perianal exophytic warts (condylomata acuminata) caused by HPV.^{100 101 102 103 104 105 106 107 111 112 116}

CDC and others recommend that external HPV warts be treated with a self-administered topical therapy (podofilox, imiquimod), a topical therapy administered by a health-care provider (podophyllum resin, trichloroacetic acid [TCA], bichloroacetic acid [BCA]), or a surgical technique (cryotherapy, electrosurgery, surgical excision).^{101 111 112 116} Alternative therapies include intralesional interferon alfa or laser surgery.¹⁰¹

A preferred treatment for external genital HPV warts in adults and adolescents with HIV infection when complex or multicentric lesions are present or lesions are inaccessible to patient-applied treatments (e.g., podofilox 0.5%, imiquimod 5%).¹²⁰ An alternative treatment for external genital HPV warts in HIV-infected children^{† [off-label]}; topical therapies often are ineffective in such children, and a surgical technique (cryotherapy, electrosurgery) may be preferred.¹²¹

Primary goal is destruction or clearance of visible, symptomatic warts.^{101 110 111 112} No regimen has been shown to eradicate HPV or affect natural history of HPV infection; effect on transmission of HPV unknown.^{101 110 112 114}

Do not use to treat subclinical genital HPV infection (without exophytic warts).¹⁰¹

Topical treatment of urethral meatus HPV warts^{† [off-label]}.¹⁰¹ CDC recommends cryotherapy or topical podophyllum resin (10–25% solution in benzoin tincture).¹⁰¹

Not included in CDC recommendations for treatment of intravaginal, cervical, rectal, or anal HPV warts.¹⁰¹

Related/similar drugs

cimetidine, imiquimod topical, Aldara, resorcinol topical

Podophyllum Resin Dosage and Administration

Administration

Topical Administration

Apply topically as a solution containing 10–25% podophyllum resin in benzoin tincture.^{100 101 109 120 121}

Solutions containing 10–25% podophyllum resin in benzoin tincture should only be applied by a health-care provider^{100 101 109 120 121} and should not be dispensed to the patient.¹⁰⁰ Solutions containing lower concentrations of podophyllum resin (e.g., 0.5–2% ethanolic solutions) have been prepared extemporaneously for self-administration by patients,^{103 106} but safety and efficacy not established.^{103 104}

For external use only; avoid contact with eyes.¹⁰⁰ (See Administration Precautions under Cautions.)

Prior to application, wash affected area.¹⁰⁰ Shake solution well prior to each use.¹⁰⁰

Apply solution sparingly to intact HPV warts and allow to air dry.^{100 101} Do not apply to bleeding warts, moles, birthmarks, unusual warts with hair growing from them, or warts that have recently been biopsied.^{100 101 109} Do not apply to normal tissue or mucous membranes.^{100 101 109}

Adjacent skin may be protected by applying petrolatum or flexible collodion prior to application of the drug.^a

Immediately following prescribed period of treatment, thoroughly remove dried drug from application site using alcohol or soap and water.¹⁰⁰

To determine patient sensitivity to the drug, remove the drug 30–40 minutes after the first application.¹⁰⁰ For subsequent applications, remove drug after the minimum time period required to produce the desired result (usually 1–4 hours).^{100 120 121}

Warts generally become blanched within a few hours after application, become necrotic within 24–48 hours, and begin to slough and gradually disappear without scarring after about 72 hours.^a

Dosage

Pediatric Patients

HPV Infections

External Genital and Perianal HPV Warts

Topical

HIV-infected children^{† [off-label]}: Apply 10–25% solution of podophyllum resin in benzoin tincture sparingly to each HPV wart once weekly for up to 3–6 weeks.^{101 121}

Adults

HPV Infections

External Genital and Perianal HPV Warts

Topical

Apply 10–25% solution of podophyllum resin in benzoin tincture sparingly to each HPV wart^{100 101 120} once weekly for up to 3–6 weeks.^{101 120}

For each treatment session, CDC and others recommend a maximum treatment area of 10 cm² and a total of <0.5 mL of the solution.^{101 120}

Although safety and efficacy not established, some clinicians recommend lower concentrations (e.g., 5% solution) for treatment of large (i.e., >10–20 cm²) genital and perianal warts.^a

Urethral Meatus HPV Warts† [off-label]

Topical

Apply 10–25% solution of podophyllum resin in benzoin tincture; may be repeated once weekly if necessary.¹⁰¹ Ensure treatment area has dried completely before making contact with surrounding normal mucosa.¹⁰¹

Prescribing Limits

Adults

HPV Infections

External Genital and Perianal HPV Warts

Topical

Maximum recommended treatment area is 10 cm².^{101 120} Maximum volume of solution for each treatment session is <0.5 mL.¹⁰¹

Avoid excessive amounts because of risk of systemic toxicity.^{101 a} (See Systemic Effects under Cautions.)

Special Populations

No special population dosage recommendations.¹⁰⁰

Cautions for Podophyllum Resin

Contraindications

• Diabetes mellitus or poor circulation.^{100 a}

• Corticosteroid therapy.^{100 a}

• Application to bleeding warts, moles, birthmarks, or unusual warts with hair growing from them.^{100 a} (See Systemic Effects under Cautions.)

• Pregnancy.^{100 101 120} (See Pregnancy under Cautions.)

• Breast-feeding.¹⁰⁰ (See Lactation under Cautions.)

Warnings/Precautions

Warnings

Fetal/Neonatal Morbidity and Mortality

Birth defects, fetal death, and stillbirths reported when topical podophyllum resin used to treat external genital HPV warts in pregnant women.^{100 a} (See Contraindications under Cautions.)

Systemic Effects

Potentially serious adverse systemic effects (GI, hematologic, CNS) reported.^{100 101 108 109 112} At least one fatality occurred because of systemic toxicity following topical application to extensive areas of exophytic HPV warts.¹⁰⁹

Use only under close medical supervision.^{100 101 108 109} Risk of systemic toxicity may be increased if applied to friable, bleeding, or recently biopsied skin or inadvertently applied to normal skin and mucous membranes surrounding a wart being treated.¹⁰⁹ Use caution to ensure drug is applied as recommended.^{100 101 108 109} (See Administration Precautions under Cautions.)

Initial manifestations of systemic toxicity include dizziness, lethargy, nausea, vomiting, abdominal pain, and diarrhea (sometimes severe and protracted).^{108 109}

Adverse CNS effects may be delayed in onset and prolonged in duration.^a Cerebral toxicity (altered sensorium ranging from mild confusion to coma) may persist for 7–10 days; ataxia, hypotonia, and areflexia can occur and generally improve more slowly than effects on sensorium.^a

Delayed nervous system toxicity involving peripheral nervous system may occur.^a If sensorimotor polyneuropathy occurs, it usually appears about 2 weeks after application of the drug, may progressively worsen for up to 3 months, and may persist for up to ≥9 months.^a

Electrodiagnostic determinations (i.e., nerve conduction studies and electromyelography) indicate an axonal neuropathy.^a Signs and symptoms of peripheral neuropathy including autonomic neuropathy, include paralytic ileus, urinary retention, sinus tachycardia, symptomatic orthostatic hypotension, paresthesias of the extremities, absent ankle reflexes, stocking-and-glove sensory loss, weakness of the extremities, and decreased response to painful stimuli.^a

Other adverse nervous system effects include stupor, increased CSF protein, hyperventilation, decreased respiration and apnea, agitation, lethargy, and seizures.^a

Adverse hematologic effects (e.g., leukopenia, thrombocytopenia) reported,^{100 108 109} especially after application to extensive areas.^{108 109}

Renal failure and hepatotoxicity (increased serum concentrations of LDH, AST, and alkaline phosphatase) reported.^a

Administration Precautions

Should only be applied by a health-care provider.^{100 101 109 120 121} Close medical supervision required because of the risk of systemic effects.^{100 101 108 109}

Use caution to ensure drug is not applied to extensive areas or in excessive amounts^{100 101 108 109} and is removed from the treatment area within the prescribed period of time.^{100 101 108 109} (See Administration under Dosage and Administration.)

A powerful caustic and severe irritant.¹⁰⁰ Avoid contact with eyes.¹⁰⁰ If eye contact occurs, wash affected eye(s) with large amounts of warm water and consult a clinician or regional poison control center (800-222-1222).¹⁰⁰

Do not use if wart or surrounding tissue is inflamed or irritated.¹⁰⁰ Do not apply to bleeding warts, moles, birthmarks, unusual warts with hair growing from them, or warts that have recently been biopsied.^{100 101 109}

Do not apply to normal tissue or mucous membranes.^{100 101 109}

General Precautions

Precautions Related to Treatment of External Genital and Perianal HPV Warts

Follow-up examinations not mandatory if visible genital and perianal warts have cleared after treatment, but may be beneficial 3 months after treatment is completed since identification of external genital warts may be difficult.¹⁰¹

Examination of sexual partners is not necessary for the management of genital HPV warts because data do not indicate that reinfection plays a role in recurrences and, in the absence of curative therapy, treatment to reduce transmission is not realistic.¹⁰¹ However, sexual partners of patients with genital HPV warts may benefit from examination to assess the presence of HPV warts or other sexually transmitted diseases and also may benefit from counseling about the implications of having a partner who has HPV warts.¹⁰¹

Immunosuppressed individuals (including patients with HIV) may not respond as well and may have more frequent recurrences of genital HPV warts after treatment compared with immunocompetent individuals.^{101 120 121}

Because HPV genital warts have a characteristic appearance, biopsy generally is necessary only if the diagnosis is uncertain, warts do not respond to standard therapies, the disease worsens during therapy, the patient is immunocompromised (e.g., HIV infection), and/or warts are pigmented, indurated, fixed, and ulcerated.^{101 120}

Women with genital HPV warts should be advised to undergo regular Papanicolaou (Pap) tests as recommended for women without genital HPV warts.¹⁰¹

Specific Populations

Pregnancy

Category X.¹⁰⁰ Contraindicated in pregnant women.^{100 101 120} (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Not known whether topically applied podophyllum resin is distributed into milk.¹⁰⁰ Contraindicated in breast-feeding women.¹⁰⁰

Pediatric Use

Safety and efficacy not established in pediatric patients.^b

Common Adverse Effects

Local reactions (erythema, tenderness, pruritus, burning, pain, swelling).^{104 112}

Drug Interactions

Specific Drugs

Podophyllum Resin Pharmacokinetics

Absorption

Bioavailability

Absorbed systemically following topical application.¹⁰⁰ (See Systemic Effects under Cautions.)

Stability

Storage

Topical

Solution

Tight, light-resistant container at 15–30°C.¹⁰⁰ Darkens when exposed to light or temperatures >25°C.¹¹⁸

Actions

• Topical application to external genital and perianal exophytic HPV warts generally results in necrosis of visible wart tissue.^a

• Podophyllum resin is prepared from rhizomes and roots of certain plants, including Podophyllum peltatum (known as American mandrake, May apple, Duck's foot, Indian apple).^{100 117 118} It is a crude mixture containing a nonstandardized amount of podofilox (also known as podophyllotoxin), other lignans (e.g., α-peltatin, β-peltatin), and various known and unknown caustic and cytotoxic materials.^{117 118}

• Exact mechanism(s) of action of podophyllum resin in the topical treatment of HPV warts has not been elucidated, but may be related to the antimitotic effects of podofilox, the major biologically active lignan contained in the resin.¹¹⁷

• Podofilox has antimitotic activity and arrests mitosis in metaphase in a manner similar to colchicine; it reversibly binds to tubulin, the protein subunit of the spindle microtubules, thereby preventing polymerization of tubulin into microtubules.¹¹⁷

• Has cathartic effects.^{109 117} (See Systemic Effects under Cautions.)

Advice to Patients

• Advise patients of the importance of the administration precautions related to the drug, including instructions regarding immediate removal from application sites using alcohol or soap and water following the prescribed period of treatment.^{100 101 109} (See Administration under Dosage and Administration.)

• Importance of avoiding contact with eyes.¹⁰⁰ If eye contact occurs, importance of washing affected eye(s) with large amounts of warm water and consulting a clinician or regional poison control center (800-222-1222).¹⁰⁰

• Advise patients that podophyllum resin is not a cure for HPV; new HPV warts may develop during or after therapy with the drug.^{101 110 112 114} Importance of patients watching for recurrences, particularly during the first 3 months.¹⁰¹

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹⁰⁰ (See Contraindications under Cautions.)

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.¹⁰⁰

• Importance of informing patients of other important precautionary information.¹⁰⁰ (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

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