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Warts, Pediatric


Basics


Description


  • Warts (verrucae) are common, benign, and frequently self-limited epithelial growths caused by human papillomavirus (HPV) infection of keratinocytes.
  • Types of warts
    • Cutaneous
      • Common warts (verruca vulgaris)
      • Flat warts (verruca plana)
      • Plantar warts (weight-bearing)
    • Anogenital
    • Laryngeal (laryngeal papillomatosis)

Epidemiology


Prevalence
  • Cutaneous warts
    • Mostly affect children and young adults
    • Affect girls more than boys
    • 5.3% prevalence from age 6 to 15 years of age
    • Up to 1/3 of school-aged children have had warts.
  • Anogenital warts
    • Exact prevalence in children and adolescents is unknown.
    • Approximately 1% of sexually active adults have external genital warts.
  • Laryngeal warts
    • Rare with no known cure; transmission occurs in utero or through birth canal

Risk Factors


  • Direct or indirect contact
  • Autoinoculation can cause persistent infection and spread.
  • Use of communal pool surfaces, bathrooms, and shower rooms increases risk.
  • Areas of skin trauma and breakdown have increased susceptibility to HPV infection.
  • Regularly walking barefoot outside also increases risk.
  • Excessive foot perspiration
  • Immunosuppressed patients, particularly transplant patients, are highly vulnerable.
  • Individual susceptibility factors related to developing warts after exposure to HPV are less clear.

General Prevention


  • Cutaneous warts
    • Use protective footwear in warm, moist environments and communal areas.
    • Wear cotton socks and change twice a day, especially if significant perspiration.
    • Avoid sharing nail files.
    • Avoid scratching and nail-biting to prevent autoinoculation.
  • Anogenital warts
    • Avoid sexual contact with multiple partners.
    • Condoms may be protective.
    • Quadrivalent HPV vaccine protects against HPV subtypes 6, 11, 16, and 18.
    • Recommended universally for males and females, ages 9 " “26 years

Pathophysiology


  • Warts are caused by HPV infection of the epithelium.
  • HPV replication leads to cell proliferation and formation of characteristic lesions.

Etiology


  • Over 150 subtypes of HPV exist.
  • Certain subtypes have a predilection for particular body sites and produce characteristic lesions:
    • Plantar and common palmar warts often caused by HPV 1 and 2
    • Anogenital warts commonly caused by HPV 6, 11, 16, 18, 31, and 45
    • Laryngeal papillomatosis is associated with HPV 6 and 11.

Diagnosis


History


  • Ask about risk factors for warts.
  • Assess history of warts in close contacts (caregiver).
  • Assess for immunosuppression.
  • For anogenital warts: Take detailed sexual history and assess risk for sexual abuse.
  • Assess symptoms: Warts are usually asymptomatic with the exception of plantar warts or warts near nails, which may be painful.
  • Assess duration: Warts may be present for months to years without intervention.

Physical Exam


  • Common warts (verruca vulgaris)
    • Rough keratotic papules and nodules that can be single or grouped
    • Often dome-shaped
    • Appear anywhere but most often affect fingers, hands, knees, and elbows
  • Flat warts (verruca plana)
    • Generally 2 " “4 mm, slightly elevated, flat-topped lesions with minimal scale
  • Plantar warts (weight-bearing warts)
    • Thick, hyperkeratotic lesions that may be tender to palpation
    • Tend to occur at pressure points on soles of feet
    • May have punctate black dots representing thrombosed capillaries
    • Disrupt normal skin markings
  • Anogenital warts
    • Usually multiple, clustered soft lesions that are pink or gray
    • 4 morphologic types: condyloma acuminata (cauliflower-shaped), smooth papules (dome-shaped, flesh-colored), keratotic papules (resemble common warts), flat warts
  • Laryngeal warts (laryngeal papillomatosis)
    • Visible only under direct airway examination
    • Children may present with stridor, hoarseness, and signs of airway obstruction.
    • In children, laryngeal warts are diagnosed most often between 2 and 3 years, with most children presenting before age 5 years.

Diagnostic Tests & Interpretation


  • Diagnosis is based on visual identification.
  • Biopsy may be indicated when the diagnosis is uncertain or warts are resistant to treatment.
  • In anogenital warts, testing for other sexually transmitted infections is recommended.

Differential Diagnosis


  • Common warts
    • Molluscum contagiosum
    • Moles
    • Skin tag
    • Squamous cell carcinoma or melanoma
  • Flat warts
    • Lichen planus
    • Lichenoid keratosis
  • Plantar warts
    • Callus
    • Corns
    • Squamous cell carcinoma or melanoma
    • Foreign body
  • Anogenital warts
    • Pearly penile papules
    • Molluscum contagiosum
    • Condylomata lata (secondary syphilis lesions)
    • Vulvar carcinoma
    • Lichen planus
    • Squamous cell carcinoma

Alert
  • Any child or adolescent with anogenital warts should prompt consideration for sexual abuse and consultation with a child abuse specialist as necessary.
  • Testing for other sexually transmitted infections should occur in any pediatric patient with anogenital warts.
  • In any patient with extensive HPV infection, consideration must be given to underlying immunodeficiencies including HIV.

Treatment


  • General
    • Warts are often self-limited and resolve without treatment.
    • 2/3 of warts will resolve within 2 years with no treatment.
    • Earlier treatment may be warranted for warts that are painful or cause significant social stigma.
  • Cutaneous warts
    • Salicylic acid
      • 1st-line therapy for cutaneous warts
      • Over-the-counter (OTC) formulations contain 5 " “27% salicylic acid and are applied topically 1 " “2 ƒ — daily for up to 12 weeks.
      • Prescription strength 40% adhesive plaster is available to be applied for 24 " “48 hours and are particularly useful for plantar warts.
      • Repetitive filing of the wart with either an emery board, pumice stone, or metal file and soaking the wart for 10 " “20 minutes prior to treatment may improve response to topical salicylic acid.
      • Applying a thin layer of petrolatum around the wart to protect the surrounding healthy tissue may prevent pain during treatment.
    • Duct tape or moleskin
      • Used as 1st-line therapy
      • May be helpful, although studies on effectiveness are mixed
      • To use, cut tape or moleskin approximately ‚ ¼ inch larger than wart and cover for 6 days.
      • After 6 days, remove, soak wart, and file with an emery board, pumice stone, or metal file; leave uncovered overnight.
      • Reapply duct tape in 6 day cycles until resolution.
    • Cryotherapy
      • 2nd-line therapy
      • Involves freezing the wart using one of several methods, the most commonly used being liquid nitrogen
      • Can be painful and is more expensive than 1st-line agents
      • Fewer data support its efficacy as compared to salicylic acid.
      • Most commonly used in the office although newer OTC cryotherapy products are available.
    • 3rd-line therapies are generally performed in conjunction with a pediatric dermatologist.
      • Phototherapy
      • Immunotherapies
      • Intralesional therapies
      • Antimitotic therapies
      • Curettage
      • Laser ablation
  • Anogenital warts
    • Treatment issues
      • Main goal of treatment is to remove symptomatic warts.
      • Most warts will clear within 3 months after initiation of therapy.
      • Treatment does not eradicate HPV, prevent recurrence, or reduce cancer risk.
    • Podofilox (0.5% gel) or imiquimod (5% cream) are 1st-line therapy (avoid in pregnancy).
      • Podofilox gel is applied topically q12h for 3 days; no treatment for 4 days; then repeat cycles until warts disappear; avoid unprotected sexual activity during treatment due to possible irritant effect.
      • Imiquimod: for patients aged 12 years and older; apply 3 ƒ —/week at bedtime; wash off 6 " “10 hours later; treat until resolution
    • Cryotherapy for anogenital warts is an option for experienced providers.
    • 2nd-line options include podophyllin resin, intralesion treatments, trichloroacetic acid, surgical removal, laser therapy, and photodynamic therapy.

Ongoing Care


Follow-up Recommendations


Patient Monitoring
Patients should be seen at regular intervals to assess clearance of the lesions and monitor for side effects. ‚  
Issues For Referral
Consider referral to pediatric dermatology if ‚  
  • Lesions are atypical or extensive.
  • Lesions progress during therapy.
  • Multiple failed treatment occurs.
  • Lesions are located on the face.
  • Frequent or prompt recurrence occurs.
  • Warts are pigmented, indurated, ulcerated, or fixed to underlying structures.
  • Individual warts are greater than 1 cm.
  • Patients are immunocompromised.

Consider referral to a child abuse specialist if anogenital warts are present AND ‚  
  • Caregivers suspect sexual abuse.
  • A sexual predator has access to the child.
  • Child discloses abuse.
  • Child is older than 48 months of age.
  • Any other sexually transmitted infection is detected.
  • Physical exam suggests any type of abuse.
  • Provider is uncomfortable with evaluating for sexual abuse.

Prognosis


  • 2/3 of warts clear without treatment within 2 years.
  • However, early treatment is recommended while warts are small and few in number to prevent enlargement and spread.

Complications


  • Bacterial infection such as cellulitis or abscess can occur if patients pick at warts.
  • Other complications are generally related to treatment and can include pain and scarring.
  • Malignant transformation to squamous cell carcinoma can rarely occur for both cutaneous and anogenital warts; this is most problematic in immunosuppressed patients.

Additional Reading


  • Boull ‚  C, Groth ‚  D. Update: treatment of cutaneous viral warts in children. Pediatr Dermatol.  2011;28(3):217 " “229. ‚  [View Abstract]
  • Kwok ‚  C, Holland ‚  R, Gibbs ‚  S. Efficacy of topical treatments for cutaneous warts: a meta-analysis and pooled analysis of randomized controlled trials. Brit J Dermatol.  2011;165(2):233 " “246. ‚  [View Abstract]
  • Kwok ‚  CS, Gibbs ‚  S, Bennett ‚  C, et al. Topical treatments for cutaneous warts. Cochrane Database Syst Rev.  2012;9:CD001781. ‚  [View Abstract]
  • Mulhem ‚  E, Pinelis ‚  S. Treatment of nongenital cutaneous warts. Am Fam Physician.  2011;84(3):288 " “293. ‚  [View Abstract]
  • Sinclair ‚  K, Woods ‚  C, Sinal ‚  S. Veneral warts in children. Pediatr Rev.  2011;32(3):115 " “121. ‚  [View Abstract]

Codes


ICD09


  • 078.10 Viral warts, unspecified
  • 078.12 Plantar wart
  • 078.11 Condyloma acuminatum
  • 078.19 Other specified viral warts

ICD10


  • B07.9 Viral wart, unspecified
  • B07.0 Plantar wart
  • A63.0 Anogenital (venereal) warts
  • B07.8 Other viral warts

SNOMED


  • 57019003 Verruca vulgaris (disorder)
  • 63440008 Verruca plantaris (disorder)
  • 240542006 Anogenital warts (disorder)
  • 402908003 oral wart (disorder)
  • 266113007 Genital warts (disorder)
  • 240539000 Plane wart (disorder)
  • 19138001 epidermodysplasia verruciformis (disorder)

FAQ


  • Q: Do condoms protect against HPV?
  • A: Condoms lower the risk of HPV; however, HPV can infect areas not covered by the condom and so condoms are not fully protective.
  • Q: Does a patient with cutaneous warts need to be excluded from school or sports?
  • A: No. Exclusion is not fully effective because asymptomatic transmission can occur. In addition, risk of transmission is low.
  • Q: How can a callous and wart be differentiated?
  • A: Careful paring with a #15 scalpel of a callous shows preserved skin markings and no bleeding. Paring of a wart often reveals black dots, which are thrombosed blood vessels.
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