Podofilox (Topical) (Monograph)

Brand name: Condylox
Drug class: Keratolytic Agents
- Antimitotic Agents

Medically reviewed by Drugs.com on May 10, 2024. Written by ASHP.

Introduction

Antimitotic agent.^{1 2 6 31 44}

Uses for Podofilox (Topical)

Human Papillomavirus (HPV) Infections

Treatment of external genital and perianal exophytic warts (condylomata acuminata) caused by HPV.^{1 2 5 7 9 10 12 13 14 16 21 22 23 24 25 26 27 28 44 45 46}

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).^{5 6 15 20 22} Alternative therapies include intralesional interferon alfa or laser surgery.²²

A preferred treatment regimen for external genital HPV warts in HIV-infected adults and adolescents;⁴⁵ response rate may be lower than in those without HIV infection.³⁴ An alternative treatment regimen for external HPV warts in HIV-infected children^{† [off-label]}; topical therapies often are ineffective in such children and a surgical technique (cryotherapy, electrosurgery) usually is preferred.⁴⁶

Primary goal is destruction or clearance of visible, symptomatic warts.^{4 5 6 22} No regimen has been shown to eradicate HPV or affect natural history of HPV infection;^{3 4 6 16 19 22} effect on transmission of HPV unknown.²²

Should not be used to treat subclinical genital HPV infection (without exophytic warts).²² Should not be used to treat squamous cell carcinoma.^{1 2 44}

Safety and efficacy for treatment of urethral, intravaginal, cervical, rectal, anal, or oral HPV warts have not been established.^{1 2 22 32 40} Some clinicians suggest use of podofilox for treatment of distal meatal HPV warts^{† [off-label]}, but data are limited.²²

Molluscum Contagiosum

Has been effective in a limited number of children^{† [off-label]}, adolescents, and adults for treatment of molluscum contagiosum^{† [off-label]}.^{33 35 36}

Podofilox (Topical) Dosage and Administration

Administration

Topical Administration

Apply topically to skin as a 0.5% gel¹ or 0.5% solution.^{2 44}

Topical gel and solution are intended for external use only.^{1 2 44} Topical gel may be applied to genital and anogenital areas;¹ topical solution should be applied only to the genital area.^{2 44}

Suitable for self-administration.^{1 2 44} The initial dose preferably should be applied by a clinician to ensure that patient understands correct administration techniques and to identify specific warts that should be treated.^{1 2 16 22 44}

Apply the gel to external genital and perianal warts using the applicator tip or fingers.^{1 22} Apply the solution to external genital warts using a disposable applicator supplied with the solution;^{2 22 44} use a new applicator each time the solution is applied.^{2 44}

Avoid applying podofilox to surrounding normal tissue; allow the gel or solution to dry before opposing skin surfaces are returned to their normal position.^{1 2 44}

Do not use occlusive dressings or wrappings.^{32 40}

Avoid contact with the eyes.^{1 2 44} If contact occurs, patient should wash affected eye(s) with large amounts of water and consult a clinician.^{1 2 44}

Wash hands before and after applying the gel or solution.^{1 2}

Do not wash podofilox off the treatment area, unless a severe adverse reaction (e.g., bleeding, swelling, excessive pain, burning, or itching) occurs.^{42 43 47}

Dosage

Pediatric Patients

HPV Infections

External Genital HPV Warts

Topical

HIV-infected children^{† [off-label]}: Apply 0.5% gel or solution to affected area twice daily (morning and evening) for 3 consecutive days followed by 4 consecutive days without treatment.⁴⁶ This weekly cycle may be repeated until there are no visible warts or for a maximum of 4 cycles (4 weeks).⁴⁶ If response is incomplete after 4 treatment cycles, discontinue the drug and consider alternative therapy.⁴⁶

Adults

HPV Infections

External Genital and Perianal HPV Warts

Topical

Genital HPV warts: Apply 0.5% gel or solution to affected area twice daily (morning and evening) for 3 consecutive days followed by 4 consecutive days without treatment.^{1 2 22 44} This weekly cycle may be repeated until there are no visible warts or for a maximum of 4 cycles (4 weeks).^{1 2 22 44} If response is incomplete after 4 treatment cycles, discontinue the drug and consider alternative therapy.^{1 2 44}

Perianal HPV warts: Apply 0.5% gel to affected area twice daily (morning and evening) for 3 consecutive days followed by 4 consecutive days without treatment.^{1 22} This weekly cycle may be repeated until there are no visible warts or for a maximum of 4 cycles (4 weeks).^{1 22} If response is incomplete after 4 treatment cycles, discontinue the drug and consider alternative therapy.¹

Follow-up examinations not generally required for patients self-administering podofilox, but may be useful several weeks after initiation of therapy to determine response to treatment, to monitor and treat complications of therapy, and provide additional patient education and counseling.²² A follow-up examination 3 months after completion of treatment may be beneficial since identification of external genital warts may be difficult.²²

Prescribing Limits

Adults

HPV Infections

External Genital and Perianal HPV Warts

Topical

Do not exceed recommended dose, frequency of application, and duration of treatment.^{1 2 44}

There is no evidence that more frequent application will increase efficacy; more frequent application may increase risk of local adverse reactions and increase systemic absorption of the drug.^{1 2 9 30}

Maximum of 4 weeks (4 cycles) of therapy.^{1 2 22 44} Has been used for up to 6–8 consecutive cycles without unusual adverse effects,^{23 27 32} but safety and efficacy of >4 cycles have not been established.^{1 2 22 44}

Total wart area being treated should not exceed 10 cm².^{1 2 22 44}

Apply no more than 0.5 g of the gel or 0.5 mL of the solution daily.^{1 2 22 44}

Special Populations

No special population dosage recommendations.

Cautions for Podofilox (Topical)

Contraindications

• Known hypersensitivity or intolerance to podofilox or any ingredient in the formulation.^{1 2 44}

Warnings/Precautions

Warnings

Differential Diagnosis

Correct diagnosis is essential.^{1 2 44} Differentiating HPV warts from squamous cell carcinoma and bowenoid papulosis is particularly important.^{1 2 44}

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.^{22 45}

General Precautions

Precautions Related to Treatment of External Genital and Perianal HPV Warts

Safety and efficacy for treatment of urethral, intravaginal, cervical, rectal, anal, or oral HPV warts not established.^{1 2 22 32 40}

Follow-up visits are not required for patients self-administering podofilox, but may be useful several weeks after initiation of therapy to determine response to treatment, to monitor and treat complications of therapy, and to provide additional patient education and counseling.²²

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.²²

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.²² 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.²²

HIV-infected individuals^† may not respond as well and may have more frequent recurrences of genital HPV warts after treatment compared with immunocompetent individuals.^{22 34 45 46}

Women with genital HPV warts should be advised to undergo regular Papanicolaou (Pap) tests as recommended for women without genital HPV warts.²²

Specific Populations

Pregnancy

Category C.^{1 2 44}

Lactation

Not known whether topically applied podofilox is distributed into human milk.^{1 2 44} Discontinue nursing or the drug.^{1 2 44}

Pediatric Use

Safety and efficacy not established in children <18 years of age.^{1 2 40 44}

In a study in pediatric patients 2–15 years of age^† with molluscum contagiosum^†, adverse effects reported following topical application of podofilox 0.5% solution to lesions once daily for 7–30 days included local burning, discomfort, pruritus, and erythema (which did not require discontinuance) and perilesional erythema, marked inflammatory reaction, and diarrhea with fever (which resulted in discontinuance in 3 children).³³

Common Adverse Effects

Adverse local reactions (generally mild to moderate burning, pain, inflammation, erosion, pruritus, bleeding, stinging, erythema),^{1 2 7 9 10 12 13 21 23 44} headache.¹

Podofilox (Topical) Pharmacokinetics

Absorption

Bioavailability

Small amounts may be absorbed systemically following topical application.^{1 2 33 39 44}

Topical application of 0.05 mL of podofilox 0.5% solution to external genitalia resulted in undetectable serum concentrations of the drug;^{1 2 39 44} topical application of 0.1–1.5 mL of the solution resulted in peak serum concentrations of 1–17 ng/mL at 1–2 hours after application.^{1 2 8 39 44}

Does not appear to accumulate in serum following repeated topical application.^{1 2 8 33 39 44}

Elimination

Half-life

Following systemic absorption, half-life is 1–4.5 hours.^{1 2 8 39 44}

Stability

Storage

Topical

Gel

15–30°C.^{1 2 8} Keep away from open flames;¹ do not expose to excessive heat; avoid freezing.^{1 2 8}

Solution

15–30°C.^{1 2 8 44} Do not expose to excessive heat; avoid freezing.^{1 2 8 44}

Actions

• Topical application to external genital and perianal HPV warts generally results in necrosis of visible wart tissue.^{1 2 10 44} The effect on HPV warts may be related to interference with microtubular function of the keratinocytes contained in the warts and local vascular structures and also may be related to local immunomodulating effects.^{10 32 40}

• Arrests mitosis in metaphase in a manner similar to that of colchicine.^{10 31} Podofilox reversibly binds to tubulin, thereby preventing polymerization of tubulin into microtubules.^{9 31} As a result of inhibition of microtubule formation, podofilox has a variety of biologic effects and, depending on the cell system, can stimulate or arrest cell proliferation and affect cell differentiation.³¹

• Reportedly inhibits the mitogen response of human lymphocytes, inhibits growth factor-stimulated macrophage proliferation, and induces production of interleukin-1 (IL-1) and interleukin-2 (IL-2).^{10 31}

• May have anti-inflammatory activity related to a decrease in tumor necrosis factor receptors.³¹

Advice to Patients

• Importance of providing patient a copy of the manufacturer’s patient information.^{2 44}

• Advise patients that podofilox is not a cure for HPV infection; new HPV warts may develop during or after therapy with the drug.^{1 2 22} Importance of patient watching for recurrences, particularly during the first 3 months.²²

• Importance of not exceeding the recommended dosage or duration of therapy.^{42 43 44} Do not use more than twice daily, do not use >3 days in a row, and discontinue use and informing clinician if no improvement occurs after 4 weeks of treatment..^{42 43 44}

• Importance of reporting adverse reactions to the clinician.^{1 2} If a severe adverse reaction (e.g., bleeding, swelling, excessive pain, burning, or itching) occurs, wash podofilox from the treatment area, discontinue the drug, and contact clinician.^{32 40 42 43 44 47}

• Importance of carefully instructing the patient regarding proper techniques for application, including washing hands after each use.^{1 2 22 44} (See Topical Administration under Dosage and Administration.)

• Importance of not engaging in sexual intercourse on days when podofilox is applied.^{42 43 47}

• Importance of not using the drug for any disorder other than that for which it was prescribed.^{1 44 47}

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.^{1 2 44}

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{1 2 44}

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

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

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