Anogenital warts in pediatric population

Prevalence and Type of HPV Genital Infection in Girls: A Systematic Review and Meta-Analysis

OBJECTIVES

This investigation explored the prevalence of human papillomavirus (HPV) infection by subtypes in girls aged up to 12.

METHODS

Four indexed databases, PubMed, EMBASE, Cochrane, and LILACS, were evaluated. Twenty-nine observational studies published between 1992 and 2018 were included.

RESULTS

The prevalence of genital condyloma acuminatum or HPV-positive serology due to prior infection among girls with suspected/confirmed sexual abuse was 25%, and without a history or information about abuse, 8%. The analysis indicated that low-risk HPV types were the most prevalent among this group, corresponding to 86.6% of the identified types. Human papillomavirus 6 and 11 were the most prevalent types, followed by HPV 16 and 2. Moreover, the analysis identified limited epidemiological data on genital warts in children up to 12 years. Several studies focused on convenience sampling, sexually abused girls, or failed to separate data by gender.

CONCLUSION

Findings of our systematic review and prevalence meta-analysis indicate that the occurrence of HPV infection in girls aged 12 or younger is relatively rare, underscoring the significance of understanding the prevalence of HPV in the pediatric population. However, it is essential to be cautious when applying these results to the pediatric population, given cases of girls who are suspected of or have suffered sexual abuse. There is a pressing need for further research to fill the information gap on HPV infection in this vulnerable group.

First-Trimester Pregnancy Loss Due to Condyloma Acuminata: A Twisted Tale of Gravidity

The human papillomavirus can induce condyloma acuminata, a benign papillomatous squamous growth with a fibrovascular core that arises in the vaginal canal. These illnesses typically afflict women who are fertile and are frequently encountered during pregnancy, manifesting with a variety of symptoms. The influences of hormones and vaginal secretions cause the lesion to expand quickly during pregnancy. Viral infections are known to be one risk factor for threatening abortions. Infection with human papillomavirus (HPV) during pregnancy has been associated with a risk for spontaneous abortion, preterm delivery, and abnormalities in the placenta. There are many therapeutic approaches available to address the disease; however, it is still unclear which one is the most successful. Additionally, organogenesis is crucial throughout the first trimester, and treatment during this period may elevate the risk of spontaneous abortion. Here, we describe the case of a young woman who experienced vaginal lesions during the first trimester of her pregnancy.

Treatment of Pediatric Anogenital Warts in the Era of HPV-Vaccine: A Literature Review

Anogenital warts (AWs) represent a therapeutic challenge, especially in infants, due to sensitive skin and frequent disease recurrence. Though the initial wait-and-see approach is often adopted in asymptomatic immunocompetent children, with spontaneous clearing in almost 90% of cases within two years, persistent or symptomatic lesions can be reasonably treated. However, few studies have been conducted on children. Consequently, most treatments on patients under age 12 are not approved by the Food and Drug Administration. Herein, we review possible therapies for pediatric use in AW and report an illustrative case of a two-year-old boy with atopic skin and symptomatic, persistent AWs who was successfully treated with topical podophyllotoxin, without adverse effects or recurrence. Among available therapies for AWs, topical therapies, such as immunomodulating-agents (topical imiquimod 5% and 3.75% cream, sinecatechins 15% ointment) and cytotoxic agents (podophyllotoxin and cidofovir) are considered manageable in children because of their low aggressiveness. In particular, podofillotoxin gel 5% and imiquimod 5% cream have been reported to be safe and efficacious in children. Currently, HPV vaccination is not recommended as a treatment for established HPV infection and AWs, yet a possible therapeutic role of HPV vaccination was recently suggested in the literature and deserves mention.

Clinical observation of laser combined with 5-aminolevulinic acid photodynamic therapy for female vulva condyloma acuminatum

BACKGROUND

Condylomata acuminata, or genital warts (GW), are exceedingly prevalent, with human papilloma virus infection accounting for 90% of cases. It can be treated in a variety of methods, but the high recurrence rate and cervical scars make it difficult to choose the best treatment option. Hence, the study aims to find the effect of laser combined with 5-aminolevulinic acid (ALA) photodynamic therapy for condyloma acuminata in the vulva, vagina, and cervix.

METHODS

A total of 106 female patients with GW of the vulva, vagina, and cervical condyloma acuminata were treated in the Dermatology Department of Subei People's Hospital in Yangzhou from May 2020 to July 2021. All these patients were treated with laser combined with 5-ALA photodynamic therapy to observe the therapeutic effect.

RESULTS

About 84.9% of patients responded to the first session of ALA-photodynamic treatment. Five patients relapsed in the 2nd week, two patients relapsed in the 4th week, one relapsed in the 8th week, one relapsed in the 12th week, and the relapsed patients were given 1-3 times of photodynamic therapy again, and no recurrence was seen in the 24th week. After four courses of treatment in 106 patients, the wart clearance rate was 100%.

CONCLUSION

Laser combined with 5-ALA photodynamic therapy for female vulva, vagina, and cervix condyloma acuminata has a reliable curative effect, low recurrence rate, few adverse reactions, and less pain. It is worth promoting in female vulva, vagina, and cervical condyloma acuminata.

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.

Comprehensive literature review of the applications of surgical laser in benign anal conditions

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO² laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.

Paediatric Anogenital Condylomata Acuminata: An assessment of patient characteristics and the need for surgical intervention

BACKGROUND

Anogenital Condylomata Acuminata (AGCA) are caused by Human Papilloma Virus (HPV), which is one of the most common sexually transmitted illnesses in adults. Although commonly seen in the paediatric population, especially in the setting of immunocompromise, literature regarding transmission, viral type and management in this population is scant. The aim of this study was to assess the profile of patients presenting with anogenital warts in light of associated immunocompromise with Human Immunodeficiency Virus (HIV).

METHODS

Three years of patient records from Chis Hani Baragwanath Academic Hospital were reviewed (January 2017 - December 2019). Information collected included: gender, age of presentation, age at intervention, type and duration of medical treatment, type and number of surgical interventions, HIV status, and histology results. Fisher's and Pearson's test were used to assess correlation between immune status and surgical interventions necessary.

RESULTS

In the time frame considered, we treated 66 patients with AGCA . The average age was 4 years old (1-14). HIV status was recorded in 30 patients (15 positive and 15 negative). Only one patient out of 66 had a history of sexual abuse. Whilst the proportion of patients who required surgical intervention in the HIV negative and HIV positive groups was equal (2:1), the total number of surgical interventions needed to achieve clearance was significantly more in those with HIV (p = 0.03).

CONCLUSIONS

HIV positive patients with AGCA require more surgical interventions compared to HIV negative individuals. Further research will be conducted to ascertain the sub-type of HPV infection in this subset of patients and to assess if this impacts follow-up for future malignancy. Further research also needs to be conducted to ascertain whether surgical intervention should be instituted earlier in the treatment protocol for HIV positive children.

Seroprevalence of mucosal and cutaneous human papillomavirus (HPV) types among children and adolescents in the general population in Germany

Background

In Germany, HPV vaccination of adolescent girls was introduced in 2007. Nationally representative data on the distribution of vaccine-relevant HPV types in the pre-vaccination era are, however, only available for the adult population. To obtain data in children and adolescents, we assessed the prevalence and determinants of serological response to 16 different HPV types in a representative sample of 12,257 boys and girls aged 1–17 years living in Germany in 2003–2005.

Methods

Serum samples were tested for antibodies to nine mucosal and seven cutaneous HPV types. The samples had been collected during the nationally representative German Health Interview and Examination Survey for Children and Adolescents in 2003–2006. We calculated age- and gender-specific HPV seroprevalence. We used multivariable regression models to identify associations between demographic and behavioral characteristics and HPV seropositivity.

Results

We found low but non-zero seroprevalence for the majority of tested HPV types among children and adolescents in Germany. The overall seroprevalence of HPV-16 was 2.6%, with slightly higher values in adolescents. Seroprevalence of all mucosal types but HPV-6 ranged from 0.6% for HPV-33, to 6.4% for HPV-31 and did not differ by gender. We found high overall seroprevalence for HPV-6 with 24.8%. Cutaneous HPV type seroprevalence ranged from 4.0% for HPV-38 to 31.7% for HPV-1. In the majority of cutaneous types, seroprevalence did not differ between boys and girls, but increased sharply with age, (e.g., HPV-1 from 1.5% in 1–3-years-old to 45.1% in 10–11-years-old). Associations between behavioral factors and type-specific HPV prevalence were determined to be heterogeneous.

Conclusions

We report the first nationally representative data of naturally acquired HPV antibody reactivity in the pre-HPV-vaccination era among children and adolescents living in Germany. These data can be used as baseline estimates for evaluating the impact of the current HPV vaccination strategy targeting 9–14-years-old boys and girls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07028-8.

Anogenital warts and relationship to child sexual abuse: Systematic review and meta-analysis

BACKGROUND/OBJECTIVES

In children, distinguishing anogenital warts (AGW) acquired innocently from those acquired by child sexual abuse (CSA) is challenging. High-quality studies examining this relationship are sparse. Here, we sought to evaluate the association between AGW and sexual abuse in children 12 years of age and younger with respect to wart location, age, and gender.

METHODS

A systematic review of Ovid MEDLINE, Embase, and Web of Science was performed for studies published on or before 2/16/2018. Studies were eligible for inclusion if they contained at least 10 patients 12 years old and younger and reported the number of patients who were sexually abused. The principal summary measures were the odds ratios (OR) of reported CSA with respect to subject age, wart location, and gender.

RESULTS

Three hundred twenty-seven studies were identified through record search. Twenty five were included in a summary synthesis (791 subjects); 10 were included in the final statistical analysis (199 subjects). In our overall review, 102 of 468 (21%) females and 36 of 204 (18%) males with AGW were abused or probably abused. Overlapping HPV types were found in abused and non-abused subjects. Perianal location and gender were not significant predictors of abuse. Both age and genital wart location (penis, vulva) did significantly predict CSA (α = .05). The odds ratio for sexual abuse of children aged 3-4 years was 7.45; 6.52 for ages 5-8 years; and 6.93 for ages 9-12 years compared to those 0-2 years of age. Genital location was associated with an OR of CSA of 5.93.

CONCLUSIONS

Our systematic review supports a significant association between AGW in a child greater than 2 years of age and odds of CSA. Genital wart location significantly predicts CSA as well. HPV typing is not a reliable method to ascertain CSA. Male family members and acquaintances were the most likely perpetrators of abuse.

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.

Update on human papilloma virus - part I: epidemiology, pathogenesis, and clinical spectrum

Infection with human papilloma virus (HPV) is related to a great number of cutaneous and mucosal manifestations. The spectrum of HPV ranges from inapparent infections, through various clinical benign presentations including cutaneous and mucosal disease, to malignant and premalignant conditions. New HPV types are currently described in the literature; many of them are characterized as high-risk types due to their oncogenic potential. Knowledge regarding their epidemiology and pathogenesis is important to understand not only infection and disease processes, but also to formulate the clinical and laboratory basis for diagnosis, therapeutics, and prophylactic measures. This non-systematic review aims to discuss and to update those aspects, with an emphasis on relevant topics for dermatologists. HPV infection and related diseases in the Brazilian scenario are highlighted, including common dermatologic conditions seen at clinics as well as the condition of a public health problem as a sexually transmitted infection. The oncogenicity of the virus and the variety of clinical outcomes - especially in the immunocompromised individuals - are addressed.

Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available

Colorectal disease profiles for children in low- and middle-income settings (LMIC) are characterized by late presentation, increased complications and limited follow-up in many cases. There is a high prevalence of infectious conditions causing secondary colorectal disease such as Mycobacterium Tuberculosis(TB), Human Immunodeficiency Virus(HIV) and Human Papilloma Virus(HPV), which also impact the management of other primary colorectal conditions, such as wound-healing and intestinal anastomosis. Perineal trauma from sexual assault, motor vehicle or pedestrian accidents, burns, and traditional enemas are commonly encountered and may require adaptation of principles used in treatment of congenital anomalies such as Hirschsprung's disease and Anorectal Malformations for reconstruction. Endemic conditions in certain LMIC require further research to delineate underlying causes and optimize management, such as "African" degenerative visceral leiomyopathy, congenital pouch colon in the Indian subcontinent, and congenital H-type rectal fistulae prevalent in Asia. These unique disease profiles require creative adaptations of resources within poor healthcare infrastructure settings. These special challenges and pitfalls in colorectal care and complications of adverse socioeconomic conditions, are discussed.

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.

Giant perianal condyloma acuminatum in an infant without sexual abuse

Giant condyloma acuminatum is rare in infants. We report a case of giant perianal condyloma in a 10-month-old infant without sexual abuse. The patient was treated by surgical excision associated with electrocoagulation with no recurrence after 2 years. While both sexual and nonsexual transmissions are possible in patients with condyloma acuminatum, sexual abuse must always be considered in children.

Therapy for anogenital verrucae in preadolescent children with topical and systemic treatment

BACKGROUND/OBJECTIVES

Anogenital verrucae (AV) are benign, human papillomavirus (HPV)-induced tumors of the anogenital skin and mucosa. Medical therapy for AV in preadolescents has not been well studied. We explore the efficacy and safety profile of sinecatechins 15% ointment and imiquimod 5% cream in the treatment of AV, alone and in combination therapy with other commonly used medications.

METHODS

A single-institution, retrospective review of children under 12 years of age with AV treated with imiquimod 5% cream and sinecatechins 15% ointment was performed. Demographic data, side effects, and outcomes of therapy were recorded for each patient, and overall efficacy was determined.

RESULTS

A total of 37 patients met inclusion criteria. Responses were seen in 8 out of 9 patients treated with sinecatechins 15% ointment (5 full, 3 partial, and 1 no response) and 9 out of 17 patients treated with imiquimod 5% cream (4 full, 5 partial, and 8 no response). Combination therapy with one or more of the following treatments (podophyllin, cimetidine, candida antigen injection, and HPV vaccine) were evaluated, but no combination was objectively superior to the others. No significant difference was found in overall efficacy between sinecatechins and imiquimod. Side effects were mild and limited to irritation and erythema.

CONCLUSIONS

Both imiquimod 5% cream and sinecatechins 15% ointment are moderately effective in the treatment of AV in preadolescent children, with a trend toward greater effectiveness of sinecatechins. Combination therapy with other treatments did not significantly increase the effectiveness of topical therapies. Each modality has a tolerable side effect profile with a low risk of serious complications.

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.

Donovanosis in a child victim of sexual abuse: response to doxycycline treatment

Donovanosis is a chronic infectious disease caused by the Gram-negative bacteria Klebsiella granulomatis, which mainly affects the skin and mucous membranes of the genital, perigenital, and inguinal regions. Also known as venereal granuloma or granuloma inguinale, it is endemic in tropical and subtropical regions of the globe and often associated with sexual transmission. We report the case of an 11-year-old female victim of chronic sexual abuse, who was diagnosed with donovanosis and presented a good therapeutic response to doxycycline.