Genital warts in children: what do they mean?

HPV and Cervical Cancer: A Review of Epidemiology and Screening Uptake in the UK

Cervical cancer is the fourth most common malignancy in females worldwide, and a leading cause of death in the United Kingdom (UK). The human papillomavirus (HPV) is the strongest risk factor for developing cervical intraepithelial neoplasia and cancer. Across the UK, the national HPV immunisation programme, introduced in 2008, has been successful in protecting against HPV-related infections. Furthermore, the National Health Service (NHS) implemented the cytology-based cervical cancer screening service to all females aged 25 to 64, which has observed a decline in cervical cancer incidence. In the UK, there has been an overall decline in age-appropriate coverage since April 2010. In 2019, the COVID-19 pandemic disrupted NHS cancer screening and immunisation programmes, leading to a 6.8% decreased uptake of cervical cancer screening from the previous year. Engagement with screening has also been associated with social deprivation. In England, incidence rates of cervical cancer were reported to be 65% higher in the most deprived areas compared to the least, with lifestyle factors such as cigarette consumption contributing to 21% of cervical cancer cases. In this article, we provide an update on the epidemiology of cervical cancer, and HPV pathogenesis and transmission, along with the current prevention programmes within the NHS.

Anogenital condylomata acuminata in young children: not always result of sexual transmission

Condylomata acuminata lesions, commonly known as anogenital warts, are caused by human papillomavirus and manifest as flesh-coloured or hyperpigmented papules or plaques in the anogenital region. We report the case of a previously healthy young child that presented with anal condyloma lesions without other accompanying symptoms. His mother had similar lesions in the genital area. After careful investigation, no evidence of sexual abuse was found. Gradual clinical improvement was observed without treatment. This case highlights a disease that, when diagnosed in children, should alert the physician to the possibility of sexual abuse. However, other transmission routes, such as vertical transmission or autoinoculation and heteroinoculation during non-sexual contact, should also be considered.

Photodynamic Therapy for Treatment of Disease in Children—A Review of the Literature

Photodynamic therapy is a mode of treatment whereby local irradiation of an administered photosensitizer with light of a specific wavelength generates cytotoxic reactive oxygen species. Despite the upward trend in the popularity of this method in adults, it is not yet commonly used in the treatment of children. Due to certain limitations, underdeveloped treatment regimens and potential side effects, the use of photodynamic therapy in the pediatric population is still in the initial phases of evaluation in clinical trials. Method: This study is a review of articles in English from the databases PubMed and Web of Science retrieved by applying the search term “photodynamic therapy in children” from 2000–2020. Results: Based on the literature review, we analyze selected pediatric clinical cases in which photodynamic therapy was used for treatment in children. Examples of photodynamic therapy for treatment of dermatological diseases, diseases of the mucosa of the upper respiratory tract, halitosis, eye diseases and brain tumors are described. The paper describes the effectiveness of anti-cancer photodynamic therapy, including its use in antibacterial therapy. Conclusions: The results of the analysis suggest the potential of photodynamic therapy for the treatment of various diseases in children.

Human Papillomavirus-type distribution in anogenital lesions of prepubertal children

BACKGROUND

In contrast to adults, only limited data are available on the human papillomavirus (HPV)-type spectrum in anogenital warts (AGW) of children.

OBJECTIVE

This study aimed to evaluate the HPV-type spectrum in AGW of prepubertal children.

MATERIALS & METHODS

In a retrospective German multicentre study, HPV genotyping was performed in AGW biopsies of 55 1- to 12-year-old children using HPV group-specific PCRs followed by hybridization with type-specific probes or sequence analysis.

RESULTS

Human papillomavirus-DNA was found in 53 of the 55 AGW. In 58.5% (31/53) of the HPV-positive AGW, mucosal HPV types were detected. HPV6 (27/53, 50.9%) was the predominant type. 43.4% (23/53) of the lesions were induced by cutaneous HPV types (HPV2, HPV27, HPV57). Mucosal HPV types were significantly more common in children under 5 years of age than in children 5 years of age and older (22/25, 88.0% [95% CI: 70.0-95.8] vs. 9/28, 32.1% [95% CI: 17.9-50.7], P < 0.001). In contrast, cutaneous HPV types were significantly more prevalent in the 5- to 12-year age group (4/25, 16.0% [95% CI 6.4-34.7] vs. 19/28, 67.9% [95% CI 49.3-82.1], P < 0.001).

CONCLUSION

Anogenital warts in 5- to 12-year-old children are frequently associated with cutaneous HPV types, possibly due to horizontal transmission. HPV typing, in addition to comprehensive clinical and psychosocial evaluation, can potentially help in the assessment of these cases.

Anogenital Papular Lesions in Children Five Year Old and Younger: Gender Differences

Introduction:

Anogenital area is a small compartment in the human body. Recognition of various dermatological conditions affecting this area in children is essential for any physician involved in pediatric examination and evaluation.

Aim:

To assess the nature, diagnoses, and gender differences of Anogenital lesions in pediatric patients presented to Royal Medical Services (RMS) general dermatology clinics, who were five year old and younger.

Methods:

The authors reviewed patients’ medical records in the period between September 2015 and September 2018. The inclusion criteria were children of both genders who were five year old or younger and presented with papular lesions in the Anogenital area. Those patients visited the general dermatology clinics of The Royal Medical Services Hospitals from the Eastern and Southern regions of Jordan.

Results:

Over a period of 3 years, a total of 514 patients were five year old or younger presented with various Anogenital papular lesions were evaluated and treated in general dermatology clinics. 35% of the patients presented with Perianal Psuedoverrucous Papules and nodules, 21% presented with Anogenital warts, 16% presented with Molluscum Contageosum. Moreover, 10% were presented with Epidermal nevi, 6% presented with Pearly Penile Papules, 7% presented with Infantile Perineal Pyramidal Protrusion, 4% presented with Vulvar Vestibular Papillomatosis, 0.2% presented with Juvenile Xanthogranuloma, 0.2% presented with lymphangioma Circumscriptum, and 0.2% presented with median raphe cyst. In addition, gender differences were noticed among Genital Warts, Mollascum Contageosum, Pearly Penile Papules, and Vulvar Vestibular Papillomatosis.

Conclusion:

Anogenital papules in children have variable clinical presentations and can be caused by multiple number of infectious and non-infectious factors. The presence of such lesions can be a source of a major concern for parents, and might be mistakenly assumed as a result of sexual assaults. Proper recognition of these papules is of paramount importance for all physicians involved in children examination, to appropriately reassure parents and avoid unnecessary investigations and psychological distress.

High-risk human papillomavirus in a child with digital pigmented Bowen's disease: Case report and dermoscopic findings

Squamous cell carcinoma in situ, also known as Bowen's disease (BD), is a skin malignancy most commonly seen in middle-aged and elderly adults. Pediatric BD is rare and can be a diagnostic challenge for physicians. Digital BD has largely been associated with human papilloma virus. We report an immunocompetent 11-year-old girl with periungual pigmented BD induced by high-risk human papilloma virus.

Anogenital warts in children: Analysis of a cohort of 34 prepubertal children

Anogenital warts are caused by infection with the human papillomavirus. We reviewed the clinical data of 34 children younger than 13 with anogenital warts referred to the department of dermatovenereology of a tertiary care hospital. Suspicion of sexual abuse was raised in 11 (32.4%). Human papilloma virus testing and genotyping was performed in 19 (55.9%) children, and human papilloma virus type 16 was found in 4, which raises the question regarding what type of follow-up is required for children infected with high-risk oncogenic HPV types. Although the diagnosis of anogenital warts in children raises concerns regarding sexual abuse, our study supports that pediatric anogenital warts can be associated with nonsexual transmission.

Anogenital warts in pediatric population

The approach to children with anogenital warts in the context of sexual abuse is a challenge in clinical practice. This study aims to review the current knowledge of anogenital warts in children, the forms of transmission, and the association with sexual abuse and to propose a cross-sectional approach involving all medical specialties. A systematic review of the literature was conducted in Portuguese and English from January 2000 to June 2016 using the ISI Web of Knowledge and PubMed databases. Children aged 12 years or younger were included. The ethical and legal aspects were consulted in the Declaration and Convention on the Rights of Children and in the World Health Organization. Non-sexual and sexual transmission events of human papillomavirus in children have been well documented. The possibility of sexual transmission appears to be greater in children older than 4 years. In the case of anogenital warts in children younger than 4 years of age, the possibility of non-sexual transmission should be strongly considered in the absence of another sexually transmitted infection, clinical indicators, or history of sexual abuse. The importance of human papillomavirus genotyping in the evaluation of sexual abuse is controversial. A detailed medical history and physical examination of both the child and caregivers are critical during the course of the investigation. The likelihood of an association between human papillomavirus infection and sexual abuse increases directly with age. A multidisciplinary clinical approach improves the ability to identify sexual abuse in children with anogenital warts.

Human Papillomavirus in Thai Women and Men with Anogenital Warts

<b><i>Objective:</i></b> Anogenital warts are caused by human papillomavirus (HPV). Globally, HPV genotypes 6 and 11 are most often associated with anogenital warts. However, the diversity of HPV genotypes found in patients with genital warts in Thailand is unknown. The aim of this study was to investigate HPV-associated anogenital warts in the Thai population and to assess whether genotypes found are represented in the bivalent and quadrivalent HPV vaccine. <b><i>Methods:</i></b> This study included 206 anogenital swab samples from patients who were diagnosed with anogenital warts. Detection of HPV DNA was performed using polymerase chain reaction to amplify the L1 gene and sequencing.<b><i> Results:</i></b> HPV was identified in 88.3% (182/206) of the samples. The majority of HPV genotypes were low-risk genotypes HPV6 (36.9%) and HPV11 (36.4%), which represented the most common infection found in genital warts in this study. <b><i>Conclusion:</i></b> Immunization with the quadrivalent vaccine (HPV6, HPV11, HPV16, and HPV18) could potentially prevent genital warts caused by HPV infection.

Giant Condyloma Acuminate Due to Human Papillomavirus Type 16 in an Infant Successfully Treated with Topical Imiquimod Therapy

Anogenital warts related to human papillomavirus (HPV) have been observed in children. Definition of the transmission mode, therapy, and follow-up for long term potential complications is important. A 27-month old girl was admitted with multiple pedunculated red-purple colored cauliflower-like lesions of 1.5 years duration. Clinical/histopathological and microbiological diagnosis was condyloma acuminate due to HPV type 16. After 12 weeks of imiquimod 5% cream application (pea-sized) overnight three times per week, the perianal warts had completely disappeared. The mode of transmission of HPV 16 in our case was probably horizontal, related to the sharing of common personal hygiene items in the women’s shelter. We report herein the case of an infant living in a women’s shelter with giant condyloma acuminata due to HPV 16, which was successfully treated with topical imiquimod therapy. This patient should be followed up for recurrence and potential malignant lesions related to HPV type 16.

Higher prevalence of human papillomavirus infection in adolescent and young adult girls belonging to different Indian tribes with varied socio-sexual lifestyle

BACKGROUND

Despite high prevalence of human papillomavirus (HPV) infection and cervical cancer in Indian women, no study has been done in tribal populations whose socio-sexual lifestyle is different. Therefore, HPV screening has been carried out in pre-adolescent, adolescent and young adult tribal girls using self-collected urine samples.

METHODS

20-35 ml self-collected midstream urine samples were obtained from a total of 2278 healthy tribal girls (9-25 years) comprising pre-adolescent, adolescent and young adults from three Indian states: Madhya Pradesh, Jharkhand and Chhattisgarh. β-globin positive 2034 samples were employed for HPV detection and genotyping.

RESULTS

The overall prevalence of HPV infection in tribal girls was 12.9% (262/2034). More than 65% (172/262) of them were infected with HR-HPV types of which HPV16 was the most predominant type (54%). Young adult girls aged 18-25 years showed a significantly higher prevalence of HPV infection (19.2%; OR = 3.36; 95% CI 2.97-6.34, P<0.001) as compared to that in adolescent (11.4%; OR = 1.82; 95% CI 1.20-2.76, P<0.01) or pre-adolescent girls (6.6%).

CONCLUSION

This is a first study showing significantly a very high prevalence of HPV infection in adolescent and young adult tribal girls possibly due to different socio-sexual behavior, indicating a serious health concern for Indian tribal women.

Genital warts

Anogenital warts (AGWs) are a very common disease. They are caused mostly by low-risk human papillomaviruses (HPV) 6 and 11, particularly the former. Clinical presentation is mostly of growths in the areas of friction of the anogenital region. The treatment is classified as patient/home applied or administered by a professional. In cases with atypical presentations or resistance to recommended therapies, great care should be taken to establish a differential diagnosis taking into account normal anatomical variations, infectious etiologies, precancers and cancers, as well as benign dermatological growths. The prevention of AGWs can be achieved by the use of the quadrivalent prophylactic HPV vaccine administered prior to sexual debut, as well as the meticulous use of condoms. Where coverage of the quadrivalent vaccine has been high, marked reductions in AGWs are being seen in young women of vaccine-eligible age, as well as in young males (as herd immunity effect).

Is administration of the HPV vaccine during pregnancy feasible in the future?

Despite the strong evidence supporting the efficacy of the HPV vaccine, the uptake rate remains low. One reason for this is that young females do not interact frequently with the healthcare system. In fact, pregnancy is often the first time young women experience multiple scheduled visits to a health provider. We review the data regarding safety of administering the HPV vaccine during pregnancy and consider the possibility of incorporating vaccination into prenatal care. Although the optimal time for vaccination is prior to sexual debut, this does not always occur, and as such, a broader approach to HPV vaccination may be necessary. Increasing the vaccine uptake rate among young women who did not initiate or complete the series earlier may significantly contribute to the decline in HPV-associated diseases.

Diseases associated with human papillomavirus infection

Human papillomaviruses (HPVs) are ubiquitous, well adapted to their host and cleverly sequestered away from immune responses. HPV infections can be productive, subclinical or latent in both skin and mucosa. The causal association of HPV with cervical cancer, and increasingly with rising numbers of squamous cell carcinomas at other sites in both men and women, is increasingly recognised, while the morbidity of cutaneous HPV lesions, particularly in the immunosuppressed population is also significant. This chapter sets out the range of infections and clinical manifestations of the consequences of infection and its persistence and describes why HPVs are both highly effective pathogens and carcinogens, challenging to eliminate.

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.

Medical and legal implications of testing for sexually transmitted infections in children

Testing for sexually transmitted infections (STIs) in children presents a number of problems for the practitioner that are not usually faced when testing adults for the same infections. The identification of an STI in a child can have, in addition to medical implications, serious legal implications. The presence of an STI is often used to support the presence or allegations of sexual abuse, and conversely, the identification of an STI in a child will prompt an investigation of possible abuse. The purpose of this paper is to review the epidemiology of child sexual abuse, including the epidemiology of major STIs including Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, herpes simplex virus (HSV), Trichomonas vaginalis, and human papillomavirus, and the current recommendations for diagnostic testing in this population.

Changes in genital anatomy and microbiology in girls between age 6 and age 12 years: a longitudinal study

STUDY OBJECTIVE

To study changes in genital anatomy and occurrence of human papillomavirus and Gardnerella vaginalis in girls resulting from growth and development.

DESIGN

At age 11-12 years, an invitation was sent to 180 girls to attend a follow-up examination. All girls had previously participated in a study exploring anogenital anatomy and microbiology in children selected for non-abuse at age 5 and 6. The genital area was examined with a colposcope and microbiological samples for Gardnerella vaginalis (GV) and human papillomavirus (HPV) were collected. GV was identified by conventional criteria and HPV by a PCR method.

RESULTS

Thirty-one girls were examined twice, at mean age 5.7 and 12.0 years. At first examination all were pre-pubertal. At second examination 21 girls were B2/P2 or above. Significantly more girls had developed a structure called a fossa groove. A thick and redundant hymen with a tendency of folding outward was more common at the second examination. Two girls had GV and one girl had HPV-16 identified. Another girl was classified to have a deep notch and a probable transection in her hymen, and this girl reported a painful insertion of a tampon. All girls denied sexual activity.

CONCLUSION

The main genital finding in girls entering puberty is the hymen becoming thick and redundant with a tendency of folding out. In the study findings associated with sexual activity were discovered in two girls, and the possibility of alternative explanations is discussed.

Perianal Bowen disease in a child with human immunodeficiency virus

Individuals infected with the human immunodeficiency virus (HIV) are at increased risk for human papillomavirus (HPV)-related cancers of the anogenital region. A majority of these cancers have been reported in adult patients; few reports are available regarding anogenital HPV-associated carcinomas developing in children. We report a case of perianal Bowen disease in an HIV-positive child. An 8-year-old HIV-positive boy with a history of perianal verrucous lesions presented to a clinic in Lesotho because his caregiver noted his lesions were changing in color, texture, and extent. Histologic sections revealed squamous cell carcinoma in situ. Several cases of anogenital condyloma in HIV-positive children have been reported, but very few cases of HPV-associated cancer. Children with vertically transmitted HIV may be uniquely susceptible to persistent infection with strains of HPV acquired perinatally. While the introduction of highly active antiretroviral therapy has resulted in immune restoration, decreased opportunistic infection, and increased life expectancy for children and adults with HIV, it has not affected the incidence of HPV-related cancers in these patients. The increased life expectancy of children with HIV may actually put them at risk for developing an HPV-related anogenital cancer.

Diseases caused by human papillomaviruses (HPV)

Human papillomaviruses (HPV) are non-enveloped tumor viruses with a double stranded DNA approximately 8 kilobases in length. The viral genome is enclosed by a spherical capsid with icosahedral symmetry and a diameter of about 55 nm. More than 100 HPV types have been identified. They infect the squamous epithelia of skin and mucosa and usually cause benign papillomas or warts. Persistent infection with high-risk oncogenic HPV causes all cervical cancers, most anal cancers, and a subset of vulvar, vaginal, penile and oropharyngeal cancers. In recent years cutaneous beta-HPV types have been associated with the pathogenesis of non-melanoma skin cancers. Two prophylactic HPV vaccines based on virus-like particles (VLP) are licensed. These are up to 100% effective in preventing HPV 16 and HPV 18 infections and associated genital lesions in women, who have not been previously infected with these types. One vaccine also prevents genital warts caused by HPV 6 and HPV 11.

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.

Cutaneous mimickers of child abuse: a primer for pediatricians

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.

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.

Update on child maltreatment

PURPOSE OF REVIEW

Recent literature regarding assessment, management and prevention of child maltreatment will be considered. Unexplained infant and child death will also be reviewed.

RECENT FINDINGS

Controversies in the evaluation of unexpected infant death and inflicted traumatic brain injury are ongoing. Evidence continues to accumulate describing the serious long-term sequelae of child maltreatment. Studies have examined the earliest beginnings of these adverse outcomes commencing in childhood. Despite sustained efforts to develop a variety of training and intervention programs, the deployment of these efforts has been hampered by the lack of evidence that they make any difference in improving recognition of child abuse or in preventing recurrent maltreatment. There is a great need in the child abuse field for more formal, rigorous assessment of all manner of intervention programs.

SUMMARY

Efforts to improve the recognition of and management of child abuse need to be sustained. As our understanding of child maltreatment continues to grow, evidence-based interventions will likely improve outcomes for abused children and their families. General pediatricians are often the first to notice signs and symptoms of possible child maltreatment; collaboration with hospital-based Child Protection Teams is critical when considering the possibility of abuse or neglect.

Vacuna frente al virus del papiloma humano: un nuevo reto para el pediatra

Human papillomavirus (HPV) infections are the most common sexually transmitted infections in the world. This infection is a necessary cause of cervical cancer, has been related to other forms of anogenital, airway and digestive cancers, and also causes anogenital warts. The recent advances in HPV prophylactic vaccines and their imminent commercial availability will post a new challenge to pediatricians: the indication and administration of these vaccines for the prevention of HPV infection, and consequently, of cervical cancer and other HPV-related diseases. The present article reviews the essentials of HPV infection, its relationship with cervical cancer, the advances in prophylactic HPV vaccines, and the role of the pediatrician in this context.