Irritant Therapies
Duct tape is a classic agent that produces maceration and irritation of warts. Application of duct tape over warts has been described in cycles of 6 days on, 1 day off with weekly repetition for a few months but usually not on the palms or soles due to difficulty maintaining occlusive tape in these locations over an extended period of time. In one trial, 85% (22/26) of duct tape–treated cases cleared versus 60% (15/25) of cryotherapy-treated cases over a 2-month maximum therapeutic period.39
Vascular Destructive Therapies
The pulsed dye laser is a classic modality that induces localized destruction of blood supply to warts in children. A case series of 61 children treated with the pulsed dye laser revealed 75% overall clearance in an average of 3.1 sessions. The usage of this therapy often is limited to institutions where the technology is readily available for usage.40
Nitric Oxide–Releasing Therapies
Nitric oxide release may increase local blood flow, thereby increasing immune response, or may have a primary mechanism of antimicrobial activity, which is why these agents have been investigated for wart treatment. Topical garlic has been described anecdotally as a therapy for thin childhood warts with the putative mechanism being nitric oxide release.42 A new investigational drug recently has had phase 2 data published. Berdazimer sodium plus carboxymethyl cellulose hydrogel has demonstrated benefit in adult warts, but data in children is lacking.41
Therapeutic Ladder for Childhood Warts
The therapeutic ladder (Table) for childhood warts starts with first doing no harm. Although many parents are disturbed by their child’s condition, the natural history of resolution is spontaneous and therefore no therapy is required in many cases. The child and his/her caregivers should be engaged to determine if he/she is emotionally disturbed or uncomfortable with their lesions and to address any fears and concerns that some children may experience (eg, contagion risk, pain with ambulation, ostracism). For example, children with hand warts may report that other children will not hold their hand while in line at school. Prominent facial lesions can be particularly problematic for children due to teasing and bullying.
Conclusion
Warts are a common infection in childhood caused by the ubiquitous HPV virus. Therapeutic options abound, but most cases are either ignored or treated with over-the-counter salicylic acid or in-office cryotherapy. The decision to employ alternative therapeutic options requires agreement by the child, his/her caregiver, and the treating physician and can be tailored to suit the desires and needs of the child. Whether or not therapy is offered, spontaneous clearance is frequently seen in common warts. On the other hand, genital warts are associated with later conversion to malignancies of the genital tract; therefore, encouragement of HPV vaccination is needed in the adolescent population to best ensure long-term genital health.