PEDIATRIC DERMATOLOGY

PEDIATRIC DERMATOLOGY

What's your DX?

By Bernard A. Cohen, MD.

At a routine visit you note multiple skin tags in the perianal area ofan otherwise healthy 12-month-old girl. Her mother first noticed a smallbump near the anus when the child was 2 months old but didn't mention itto you because it did not seem to bother the child. Now the little girlscratches at the area when she has her diaper off.

What's your diagnosis, and how would you manage the condition?

See below for discussion.

Discussion

This child has anogenital warts (condylomata acuminata) caused by infectionwith human papillomavirus type 6. No other abnormalities were found, andher growth and development were normal for her age.

Her mother reported no changes in the child's behavior, which might raiseconcern about child abuse,and the little girl has never been to day careoutside the home, a possible setting for abuse. Her father and grandparents,who help with child care, deny a history of genital or common warts. However,questioning reveals that the mother had genital warts, which were treatedwith carbon dioxide laser, six months before the child's birth.

A thorough evaluation of this little girl showed no evidence of sexualabuse. Although difficult to prove, the most likely source of the child'spapillomavirus infection is maternal cervical and genital warts at the timeof delivery.

Before 1980 only a few cases of anogenital warts were reported in youngchildren. Since then, multiple cases have appeared in the literature.^1­4This undoubtedly represents a true increase in incidence, paralleling theepidemic of anogenital warts in adults.

Routes of transmission. Although most early reports in children wereassociated with sexual abuse, a number of studies demonstrate that mostanogenital HPV infections in prepubertal children, particularly infantsand young children, are acquired without sexual contact.^5­7However, parents must be advised of all potential sources of HPV: maternalcervical and genital warts at delivery; common warts on the hands of caretakersand patients themselves, which may touch the genitals during bathing andtoileting; and sexual abuse.^5,7 Careful evaluation to rule outabuse should include a complete physical examination, a neurodevelopmentalexamination, cultures for other sexually transmitted diseases as indicated,and a review of medical records. When the index of suspicion for child abuseis high, the appropriate protective services organization in your communityshould also be involved in the evaluation.

Treatment. Although many cases of anogenital warts in young childrenresolve without therapy, symptomatic infections require intervention. Topicaltreatment with imiquimod 5% cream (Aldara) or podofilox 0.5% solution orgel (Condylox)have been approved for home use in adults. Although thesemedications are not approved yet for use in children, I have used them bothsuccessfully. They are clearly safer than painful destructive measures suchas electrocautery, laser, and liquid nitrogen.^8,9 Large, bleeding,infected condylomata acuminata--especially those that have not respondedto conservative measures--should be evaluated for surgical intervention.

This 12-month-old's anogenital warts disappeared after three months oftherapy with imiquimod cream applied three times a week. Although the long-termrisk of genital skin and cervical carcinoma in this child is unknown, sheshould receive lifelong follow-up and screening from her primary care providers.

The next installment of "Pediatric Dermatology: What's your DX?"will appear in April.

REFERENCES

1. Stumpf PG: Increasing occurrence of condylomata acuminata in premenarchalchildren. Obstet Gynecol 1980;56:262

2. Tang CK, Shermeta D, Wood C: Congenital condylomata acuminatum. AmJ Obstet Gynecol 1978;131:912

3. Seidel J, Zonana J, Totten E: Condylomata acuminata as a sign of sexualabuse in children. J Pediatr 1979;95:553

4. De Jong AR, Weiss JC, Brent RL: Condylomata acuminata in children.Am J Dis Child 1982;136:704

5. Cohen BA, Honig P, Androphy E: Anogenital warts in children: Clinicaland virologic evaluation for sexual abuse. Arch Dermatol 1990;126:1575

6. Frasier LD: Human papillomavirus infections in children (Review).Pediatr Ann 1994;61:357

7. Obalek S, Jablonska S, Favre M, et al: Condylomata acuminata in children:Frequent association with human papillomaviruses responsible for cutaneouswarts. J Am Acad Dermatol 1990;23:205

8. Edwards L, Ferenczy A, Eron L, et al: Self-administered topical 5%imiquimod cream for external anogenital warts.Arch Dermatol 1998;134:25

9. Tyring S, Edwards L, Cherry LK, et al: Safety and efficacy of 0.5%podofilox gel in treatment of anogenital warts. Arch Dermatol 1998;134:33

By Bernard A. Cohen, MD.
THE AUTHOR is Director, Pediatric Dermatology and Cutaneous Laser Center, and Associate Professor of Pediatricsand Dermatology at Johns Hopkins University School of Medicine, Baltimore.He is a Contributing Editor for Contemporary Pediatrics.