The natural history of condyloma in children

Consideration of underlying immunodeficiency in refractory or recalcitrant warts: A review of the literature

Although the exact mechanisms have yet to be elucidated, it is clear that cellular immunity plays a role in clearance of human papillomavirus (HPV) infections as it relates to the development of warts. Patients with extensive, recalcitrant, or treatment‐refractory warts may have an underlying immune system impairment at the root of HPV susceptibility. Early recognition of genetic disorders associated with immunologic defects that allow for recalcitrant HPV infection may expedite appropriate treatment for patients. Early recognition is often pivotal in preventing subsequent morbidity and/or mortality that may arise from inborn errors of immunity, such as WHIM (Warts, Hypogammaglobulinemia, Infections, Myelokathexis) syndrome. Among these, cervical cancer is one of the most common malignancies associated with HPV, can be fatal if not treated early, and is seen more frequently in patients with underlying immune deficiencies. A review of diseases with susceptibility to HPV provides clues to understanding the pathophysiology of warts. We also present diagnostic guidance to facilitate the recognition of inborn errors of immunity in patients with extensive and/or recalcitrant HPV infections.

Phase II, Double-Blind, Vehicle-Controlled Study to Determine the Cantharidin Dose Regimen, Efficacy, Safety, and Tolerability of VP-102 in Subjects with External Genital Warts

BACKGROUND

External genital warts are caused by various subtypes of the human papilloma virus and spread through direct skin-to-skin contact. Approximately 1% of the US population have external genital warts. Although cantharidin has been used to treat external genital warts for decades, there are no US Food and Drug Administration-approved cantharidin products and no reliable or controlled sources of cantharidin available. VP-102 is a drug-device combination product containing cantharidin (0.7% w/v) in a single-use shelf-stable applicator.

OBJECTIVE

The objective of this randomized, double-blind, vehicle-controlled, phase II clinical trial was to determine the optimal regimen for the treatment, safety, and efficacy of VP-102 in external genital warts.

METHODS

The study was conducted in two parts. Part A was dose finding and Part B was performed following the completion of Part A for a safety and efficacy evaluation. Following completion of Part A, 6-h and 24-h VP-102 regimens under occlusion were selected to be evaluated in Part B.

RESULTS

Pooled results from Part B and Part A of the 6-h and 24-h VP-102 treatment regimens showed that 36.7% and 33.3% of participants achieved complete clearance of all treatable external genital warts at the end of treatment vs 4.2% (p < 0.0048) and 0% (p < 0.0075) with the vehicle. Adverse events experienced by the VP-102-treated participants were consistent with the pharmacodynamic action of cantharidin as a vesicant and were primarily mild to moderate in severity. The most common adverse events included application-site vesicles, pain, and erythema. No participants discontinued the study because of adverse events and no serious adverse events were deemed treatment related.

CONCLUSIONS

The adverse event profile and efficacy of VP-102 under occlusion demonstrated in this study support the conclusion that a 6-h or up to 24-h exposure regimen represents an acceptable risk:benefit profile and justifies the conduct of a larger vehicle-controlled phase III study in external genital warts.

CLINICAL TRIAL REGISTRATION

NCT03981822, actual study start date: 25 June, 2019; actual primary completion date: 21 May, 2020; actual study completion date: 8 July, 2020.

Intralesional immunotherapy for the treatment of anogenital warts in pediatric population

BACKGROUND

The prevalence of anogenital warts is increasing in adults as well as in pediatric population. The treatment of anogenital warts is challenging, particularly in children as most conventional modalities are painful and associated with high recurrence rates.

OBJECTIVES

To evaluate the efficacy and safety of intralesional immunotherapy for the treatment of anogenital warts in pediatric patients.

METHODS

Forty child presenting with multiple anogenital warts were randomly assigned into 3 groups. The first group (15 patients) received intralesional MMR vaccine, the second group (15 patients) received intralesional Candida antigen and the third group (10 patients) received intralesional saline as a control. Each modality was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions.

RESULTS

Highly significant difference was found between the therapeutic response of anogenital warts to both MMR vaccine and Candida antigen compared to intralesional saline (p = .005). No significant difference was observed between MMR vaccine and Candida antigen groups (p = .885). Side effects were mild and no recurrence was detected in the 6 month follow-up period.

CONCLUSIONS

Intralesional immunotherapy is a promising effective and well-tolerated treatment modality for multiple anogenital warts in children.

Penile warts: an update on their evaluation and management

Background

Penile warts are the most common sexually transmitted disease in males. Clinicians should be familiar with the proper evaluation and management of this common condition.

Objective

To provide an update on the current understanding, evaluation, and management of penile warts.

Methods

A PubMed search was completed in Clinical Queries using the key terms 'penile warts' and 'genital warts'. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews.

Results

Penile warts are caused by human papillomavirus (HPV), notably HPV-6 and HPV-11. Penile warts typically present as asymptomatic papules or plaques. Lesions may be filiform, exophytic, papillomatous, verrucous, hyperkeratotic, cerebriform, fungating, or cauliflower-like. Approximately one-third of penile warts regress without treatment and the average duration prior to resolution is approximately 9 months. Active treatment is preferable to watchful observation to speed up clearance of the lesions and to assuage fears of transmission and autoinoculation. Patient-administered therapies include podofilox (0.5%) solution or gel, imiquimod 3.75 or 5% cream, and sinecatechins (polypheron E) 15% ointment. Clinician-administered therapies include podophyllin, cryotherapy, bichloroacetic or trichloroacetic acid, oral cimetidine, surgical excision, electrocautery, and carbon dioxide laser therapy. Patients who do not respond to first-line treatments may respond to other therapies or a combination of treatment modalities. Second-line therapies include topical/intralesional/intravenous cidofovir, topical 5-fluorouracil, and topical ingenol mebutate.

Conclusion

No single treatment has been shown to be consistently superior to other treatment modalities. The choice of the treatment method should depend on the physician's comfort level with the various treatment options, the patient's preference and tolerability of treatment, and the number and severity of lesions. The comparative efficacy, ease of administration, adverse effects, cost, and availability of the treatment modality should also be taken into consideration.

Human-papillomavirus-related disease in pediatrics

PURPOSE OF REVIEW

Human papillomaviruses (HPVs) account for a number of distinct disease entities in pediatrics, ranging from common warts to the stigmatizing condyloma acuminata to life-threatening respiratory papillomatosis. Although there is still a lack of consensus on treatment for each of these HPV-related diseases, scientific investigation continues to progress. Increasing prevention of HPV-related disease with further vaccination and development of new vaccines continues to be the best medical strategy.

RECENT FINDINGS

Although high-quality evidence for treatment of HPV-related disease is still lacking, several new studies have been published in recent years that have refined opinions on therapy. Novel treatments continue to be developed, including new vaccines to further coverage for other strains.

SUMMARY

HPV-related disease in pediatrics is associated with societal stigmatization and a high level of morbidity. Greater understanding of the distinct diseases and high-quality research is necessary to enhance treatment selection in the coming future.

A Discussion of High-Risk HPV in a 6-Year-Old Female Survivor of Child Sexual Abuse

Background

Human papilloma viruses (HPVs) cause a variety of clinical manifestations in children including skin warts, laryngeal papillomas, and condyloma acuminatum. Whereas the mode of transmission is well understood and management of HPV infection is clearly defined by guidelines in adults, less is known about the mode of transmission, natural history of disease, and appropriate management of high-risk anogenital HPV infections in children.

Case

The patient is a previously healthy 6-year-old female who presented with multiple vaginal lesions causing pain and discomfort and was diagnosed with HPV 18 positive CIN I.

Summary and Conclusion

Children infected with high-risk HPV subtypes remain a vulnerable patient population, and there is minimal literature on the natural history of disease and effects of overtreatment. Based on a literature review, conservative management, HPV vaccination, and consideration of the cervical cancer screening guidelines for adolescent females are an appropriate treatment course until more studies are reported on cervical cancer screening in survivors of child sexual abuse.

Differential Diagnosis of Diaper Dermatitis

Mild diaper dermatitis often occurs in children before toilet training is complete, particularly from 9 to 12 months of age, and the most common presentation is an irritant contact dermatitis. Diaper dermatitis may account for up to 25% of dermatology visits to health care providers during the first year of life. Fortunately, since the introduction of hypoallergenic, superabsorbent modern disposable diapers, the incidence and severity of irritant and allergic contact dermatitis has decreased dramatically. Diaper dermatitis broadly refers to skin disorders that occur in the diaper area, such as skin eruptions triggered by diapers, rashes exacerbated by the diaper, and other events that occur in the diaper area. A number of skin conditions that can occur anywhere on the skin may present with distinctive findings in the diaper area. The following discussion will review the most common triggers of diaper dermatitis and contact irritant dermatitis, while focusing on the skin conditions that may be associated or overlap clinically with contact dermatitis.

Mucocutaneous warts in Middle Anatolia, Turkey: clinical presentations and therapeutic approaches

Introduction

Viral warts are common skin condition caused by the human papilloma virus.

Aim

To determine the clinical features of warts and therapeutic approaches to warts and compare them with the literature.

Material and methods

A cross-sectional survey was conducted on 362 consecutive patients presenting to a dermatology clinic in Ankara, Middle Anatolia, Turkey. Age, gender, anatomic localization, clinical types, number of warts, and medical therapy histories were recorded.

Results

In our study 139 (38.4%) children and 223 (61.6%) adults had warts. Warts were seen in 191 men, and 171 women. The mean age was 24.7 ±13.5. In all groups the incidence and the number of warts were higher in men. Clinical types of warts were vulgar, anogenital, plantar, verruca plana, filiform, and mosaic. Thirty-six (9.9%) of 362 cases had more than one type. The locations of warts were as follows extremities (n = 233, 64.4%), anogenital (n = 86, 23.7%) and head and neck (n = 73, 20.2%). The incidence of anogenital warts was statistically higher in men than women (p < 0.05). Topical medical treatment was the first choice (n = 60, 57.1%).

Conclusions

In our study, the incidence and the number of warts were higher in men, which is different than in previous reports. The anogenital wart (AW) was ranked second in all types of warts. According to this finding, we can say that the frequency of AW has been increased in Turkey. To our knowledge recently there have been no studies investigating the clinical features of viral warts in all ages in the literature.

Imiquimod 5% cream treatment for rapidly progressive genital condyloma in a 3-year-old girl

BACKGROUND

The incidence of genital warts in children has increased in the last 50 years. Although pediatric genital warts may resolve spontaneously, the treatment of extensive perianal genital warts in children can be challenging. Imiquimod, although not approved in the pediatric population, may avoid the pain or extensive scarring associated with other treatment modalities.

CASE

A 3-year-old female was scheduled for surgical resection of genital warts. At surgery, she had extensive condylomas that had progressed rapidly from initial presentation. They were not amenable to surgical treatment due to concerns of incomplete resection, post-operative pain, and genital scarring. After 6 weeks of imiquimod treatment, the condylomatous lesions had completely resolved with minimal side effects.

SUMMARY AND CONCLUSION

Imiquimod 5% cream is an effective treatment option for children with extensive and rapidly progressive perianal warts and is associated with minimal side effects. Its use should be considered in children with extensive condyloma in order to avoid the pain and possible scarring associated with other approved treatment modalities.

Surgical implications of human immunodeficiency virus infections

Pediatric HIV (human immunodeficiency virus) is a pandemic predominantly in sub-Saharan Africa. Approximately 2.2 million children aged less than 15 years are infected with HIV, representing almost 95% of the total number of children globally infected with HIV. Therefore, increasing numbers of HIVi or -exposed but uninfected children can be expected to require a surgical procedure to assist in the diagnosis of an HIV/acquired immune deficiency syndrome-related complication, to address a life-threatening complication of the disease, or for routine surgery encountered in HIV-unexposed children. HIVi children may present with both conditions unique to HIV infection and surgical conditions routine in pediatric surgical practice. HIV exposure confers an increased risk of complications and mortality for all children after surgery, whether they are HIV infected or not. This risk of complications is higher in the HIVi group of patients. These findings seem to be independent of whether patients undergo an elective or emergency procedure, but the risk of an adverse outcome is higher for a major procedure. Surgical implications of HIV infection are comprehensively reviewed in this article.

Human papillomavirus in infants: transmission, prevalence, and persistence

Human Papillomavirus (HPV) is very common in reproductive age women. It has been demonstrated that this infection can be transmitted from mother to infant. Evidence of HPV infection can be seen in infant and toddlers. A review of the literate was undertaken to examine the manner in which HPV can be transmitted, the rate at which transmission occurs, and if HPV can persist. The manifestations of HPV were also reviewed. It is not clear what effect the quadravalent HPV vaccine, given to mothers will have on HPV infections in infants.

Condylomata acuminata in children

We describe a study on 38 children from 1 to 11 years of age, with anogenital warts, 25 were girls. The disease was primarily perianal. Sexual abuse was confirmed in one 9-year-old boy. Most responded to monotherapy with podophyllotoxin, imiquimod 5%, or cryotherapy in a 3-month follow-up period.

Human papilloma virus (HPV) infection in children and adolescents

Human papilloma viruses (HPV) are common pathogens associated with a wide range of cutaneous and mucosal infections in childhood. Different HPV types can cause common warts, genital warts, low-grade as well as high-grade squamous intraepithelial lesions. Anogenital warts represent an issue with legal and clinical implications and evaluation of children for the possibility of sexual abuse should be considered in all cases. Recurrent respiratory papillomatosis has also been associated with HPV infection in a variety of studies. The recently introduced HPV vaccination is expected to prevent HPV-related cervical cancer in adulthood; however, HPV infection will continue to affect children.

A practical approach to warts in the emergency department

Although cutaneous warts are one of the most common skin conditions affecting children, their management can be challenging, especially in complex cases and even more so during a single emergency department encounter. Anogenital warts require particular attention because of their possible but nonspecific association with sexual abuse. This review will focus on cutaneous warts and anogenital warts, with a discussion of their recognition and treatment, especially in the emergency department. The medicolegal implications of anogenital warts in children are also reviewed.

[Treatment of pediatric genital condyloma]

Condyloma, also known as venereal warts, are caused by human papillomavirus (HPV). Conventional wart therapies destroy infected keratinocytes rather than directly inhibiting viral infection or replication. No available drug therapy effectively eliminates HPV. Treatments are often disappointing for the patient, the family and the physician due to the duration of the disease and the frequency of recurrences in spite of treatment.

[Carbon dioxide laser therapy for anogenital warts in children]

BACKGROUND

Management of anogenital condylomas in children can be delicate especially in the event of profuse lesions and raises the issue of identification of the mode of contamination.

PATIENTS AND METHODS

The dossiers of all children referred to the laser unit of "La Conception" University Teaching Hospital in Marseille between 1995 and 2005 for treatment of profuse anogenital condylomas were studied retrospectively. The main objective was to evaluate the efficacy and tolerability of CO2 laser treatment for anogenital condylomas. The secondary objective was to invstigate the mode of contamination.

RESULTS

Seventeen children aged 2-11 years were treated. All were examined in routine fashion, as were their parents and siblings, for signs of PVH infection and sexual abuse. Laser was performed by the same operator under general anaesthesia. For all of these children, healing was rapid and without complication or functional sequelae. Two children were lost to follow-up. Ten children (66.7% of the treated children) presented no recurrence after only one session of CO2 laser. Vertical transmission was diagnosed for 6 children and horizontal transmission for 7 children. For 4 children, the mode of contamination remained unknown. No cases of sexual abuse were proven.

CONCLUSION

Due to its painless nature, rapid healing, low rate of complications and recurrence, and minimal risk of scarring, CO2 laser is an effective treatment for the management of profuse anogenital condylomas in children. Vertical transmission is the most frequent mode of contamination and sexual abuse remains rare, although clinicians must keep this possibility in mind.

Human papilloma virus in hyperplastic tonsillar and adenoid tissues in children

BACKGROUND

Human papillomavirus (HPV) in childhood causes skin and anogenital warts as well as the recurrent respiratory papillomatosis, a life-threatening cause of upper airway obstruction in children. To date, the information on HPV infection in tonsillar and adenoid hyperplasia in children is limited.

PURPOSE

The purpose of this study was to investigate the presence of HPV DNA in children with benign tonsillar and/or adenoid hyperplasia.

METHODS

One hundred six samples of paraffin-embedded adenoid and/or tonsillar tissues from 102 children, 57 girls and 45 boys (age range, 2-14 years), were tested for the presence of HPV DNA using polymerase chain reaction (PCR) with general primers GP5+/GP6+. HPV typing was performed by PCR with specific primers for HPV-16, -18, -33 and -11.

RESULTS

HPV DNA was detected in 9 (8.5%) of the 106 collected specimens. The frequencies of HPV typing were 6 of 9 (66.7%) for HPV-16, 2 of 9 (22.2%) for HPV-11, zero of 9 (0%) for HPV-33 and HPV-18, whereas one HPV-positive sample remained untyped. No multiple HPV infection was detected. HPV was detected in 6 (9.4%) children with tonsillar hyperplasia and in 3 (7.1%) with adenoid hyperplasia. The mean age of children with HPV-positive specimens was lower than that of HPV-negative children (P = 0.006). No statistical correlation in the prevalence of HPV infection was observed according to children's sex, origin or residence (urban or rural).

CONCLUSION

Although the significance of the presence of HPV DNA in tonsillar and adenoid hyperplasias remains obscure, the PCR detection of high-risk HPV DNA should be evaluated cautiously.

An armamentarium of wart treatments

Patients and clinicians experience the frustration of cutaneous viral warts caused by infection with the human papilloma virus (HPV).Warts appear in various forms on different sites of the body and include common warts (verruca vulgaris), plane or flat warts, myrmecia, plantar warts, coalesced mosaic warts, filiform warts, periungual warts, anogenital warts (venereal or condyloma acuminata), oral warts and respiratory papillomas. Cervical infection with HPV is now known to cause cervical cancer if untreated. A review of the medical literature reveals a huge armamentarium of wart monotherapies and combination therapies. Official evidence-based guidelines exist for the treatment of warts, but very few of the reported treatments have been tested by rigorous blinded, randomized controlled trials.Therefore, official recommendations do not often include treatments with reportedly high success rates, but they should not be ignored when considering treatment options. It is the purpose of this review to provide a comprehensive overview of the wart treatment literature to expand awareness of the options available to practitioners faced with patients presenting with problematic warts.

Human Papillomavirus Infections of the Genital and Respiratory Tracts in Young Children

Human papillomavirus (HPV) causes papillomas (warts) on the skin and respiratory mucosal surfaces (laryngeal and oral papillomas) in addition to condyloma acuminata (anogenital warts). HPV has become one of the most common sexually transmitted diseases in adults. Vertical transmission from mother to infant during birth is well recognized. Laryngeal papillomas are the most common tumors of the larynx in children worldwide, and recurrent lesions are common occurrences. Anogenital warts in children are problematic in that child sexual abuse is a potential means of acquisition, but many cases are acquired perinatally. Postnatal acquisition by nonsexual means also can occur. The likelihood of sexual abuse as the mode of acquisition increases with increasing age in childhood. The virus infects primarily epithelial cells, where it can exist as a long-term latent infection that can reactivate or persist actively (even subclinically), with resultant accumulation of host chromosomal mutations. The latter accounts for the oncogenic potential of a number of HPV types, and childhood infections may lead to neoplasia later in life. Regression of papillomas over the course of months to years is the usual natural course. Numerous treatments are available, but most do not prevent persistent infection or problematic recurrences. Multivalent HPV vaccines have been developed, and early results of clinical trials appear to be very promising.

Therapy of pediatric genital diseases

Infants and children have special issues with regard to genital disease. Infants are incontinent, and have an increase in local irritation and infection risk. In addition, the adult sex hormones which enhance the health of genital skin are deficient. Also, the choice of therapy must be modified to take into account the more fragile nature of prepubertal skin, the tolerance of children to painful treatments, and the lack of experience of some medications in children.

Anecdotal reports of 3 cases illustrating a spectrum of resistant common warts treated with cryotherapy followed by topical imiquimod and salicylic acid

Imiquimod is an immunomodulator with indirect antiproliferative and antiviral properties known to be effective against anogenital warts. However, its use for common warts has not been validated in prospective, controlled trials. We present 3 anecdotal case reports illustrating one treatment approach for a spectrum of resistant, common warts with combination therapy consisting of cryosurgery followed by administration of imiquimod and salicylic acid. The efficacy of this combined destructive and immunomodulatory therapy proved to be 50% to 100% effective after 6 to 9 weeks.

Anogenital warts in children: sexual abuse or unintentional contamination?

Anogenital warts (AGW) were recently recognized in children, and their significance as an index of childhood sexual abuse is controversial. We report our transdisciplinary approach (including a pediatric surgeon, psychologist, social worker, ethics expert, and occasionally law enforcement agents) and its results in a group of 17 children with AGW treated at the public pediatric referral hospital in Rio de Janeiro, Brazil, during a 3-year period (1996-1999). All children were treated by electrocauterization of the warts, tested for other STDs, and submitted to perineal examination under anesthesia. Families received psycho-social counseling as necessary and cases were referred to child protection and law enforcement agents when indicated according to Brazilian legislation. We identified a high incidence of sexual abuse (8 children, 5/7 > 5 years old), with 3 patients inconclusive as to sexual abuse and 7 cases of perinatal transmission (5/8 < 4 years old). We conclude that AGW are indeed a strong sign of suspicion for sexual abuse in children, especially but not exclusively > 5 years of age. However, strong support and a transdisciplinary approach to the children and their families is necessary to identify it.

Treatment of human papilloma virus in a 6-month-old infant with imiquimod 5% cream

A healthy female infant was diagnosed with genital warts at six months of age. She was the product of an uncomplicated vaginal delivery to a mother who was diagnosed with genital warts during the pregnancy, but did not undergo any treatment. The infant's warts were clinically resolved following a three week course of 5% imiquimod cream, an immunomodulating agent that has been demonstrated to be a potent inducer of several cytokines promoting an antiviral cell-mediated immune response.

Pruritus vulvae in prepubertal children

BACKGROUND

Vulvar pruritus is a common complaint in females of all ages. However, little has been published on pruritus vulvae in children as a primary symptom.

OBJECTIVE

Our purpose is to review the causes and treatments of vulvar pruritus in prepubertal girls and to retrospectively evaluate the causes and outcomes of the premenarchal children we studied.

METHODS

The records of 44 premenarchal girls with vulvar pruritus were reviewed, and follow-up interviews were performed by telephone.

RESULTS

Thirty-three patients (75%) had nonspecific pruritus. Lichen sclerosus, bacterial infections, yeast infection, and pinworm infestation were seen in a minority of patients. At follow-up, pruritus had cleared in 15 patients, been alleviated in 13, and remained the same in 4.

CONCLUSION

Most of our patients had nonspecific pruritus, which was alleviated by or cleared with better hygiene and avoidance of irritants. In prepubertal girls, poor hygiene and irritants such as soap are major contributors to pruritus vulvae. All patients may benefit from following hygienic measures and irritant precautions in addition to specific therapy directed at underlying causes.

What's new in human papillomavirus infection

Warts continue to be a therapeutic challenge, especially widespread warts on children. A single, most effective treatment has not been defined. Conventional methods attempt to nonspecifically destroy infected tissue. Most of these procedures are painful, poorly tolerated by children, and often require multiple treatments. The efficacy of destructive techniques is impossible to verify in controlled clinical trials. Uncontrolled success rates are suboptimal and often no better than that seen with placebos. Alternative pharmacologic approaches have been designed to stimulate immunologic responses or provide anti-viral activity. Further study is needed to establish efficacy of these treatments.

Cimetidine therapy for recalcitrant warts in adults: is it any better than placebo?

Three open-label, uncontrolled studies have documented successful treatment of warts with cimetidine, whereas two placebo-controlled, double-blind studies and two open-label comparative trials have failed to demonstrate efficacy. This double-blind, placebo-controlled study was designed with stringent enrollment and outcome criteria to minimize the confounding issue of spontaneous remission. Efficacy was not statistically superior to that of placebo, but a trend toward efficacy was suggested for younger subjects.