BAL HARBOUR, FLA. — Warts and molluscum in children are often more troubling to their parents, and it is acceptable to wait for them to resolve on their own, Dr. Anthony J. Mancini said at the annual Masters of Pediatrics meeting sponsored by the University of Miami.
However, warts and molluscum are cosmetically unpleasant and can create social stigma. Some families insist on treatment, said Dr. Mancini, of the pediatrics and dermatology departments at Northwestern University Feinberg School of Medicine and head of pediatric dermatology at Children's Memorial Hospital in Chicago.
When treating warts and molluscum, use the specific reimbursement codes, he said. Use code 17000 for treatment of 1 wart, 17003 for each wart when there are 2–14 warts, and 17004 for more than 15 warts. When treating molluscum, use 17110 for treatment of fewer than 15 lesions, and 17111 for 15 or more lesions.
Warts
Warts occur in nearly 10% of children, Dr. Mancini said.
Skin-to-skin contact from other individuals with warts, or skin contact with public surfaces with moisture (such as locker room floors and showers), are among the most common sources of warts in children. In addition, autoinoculation (spreading the wart virus on one's own skin by scratching, or skin-to-skin contact) is a common way that warts spread.
There are two schools of thought regarding warts. Some doctors say treat them, while others suggest leaving them alone, he said. Much depends on the desires of the patient or, more commonly, the parents.
Arguments for leaving warts alone include the fact that they are generally benign, rarely symptomatic, and usually resolve spontaneously. Also, the most effective treatments can be traumatic for young children.
Arguments for treating warts include the social stigma, especially if the wart is on the face or another obvious location, and the contagious nature of warts, which may cause concern with regard to the child's socializing and playing with friends.
Categories of wart treatment include chemovesicants, cryotherapy, immunotherapy, intralesional injections, laser or ablative therapy, and even hypnosis, as well as homeopathic remedies. “Homeopathic remedies may have as much effect as anything that we can offer medically,” Dr. Mancini noted.
Chemovesicants include podophyllin and trichloroacetic acid, which are often tried for anogenital warts. “Salicylic acid is probably one of the most effective treatments for warts,” Dr. Mancini said. “But we need to teach parents that they may have to treat the wart for weeks or months.” Most over-the-counter (OTC) salicylic acid liquids are the same, and contain about 17% salicylic acid.
Some parents may ask about the use of duct tape for warts. “I think that duct tape is a useful adjunct,” Dr. Mancini said.
His strategy is to use duct tape in conjunction with salicylic acid. “I have parents apply the salicylic acid to the wart, let it dry for 30 seconds or so, then occlude with a piece of duct tape overnight and remove it in the morning,” he said. This method probably works via a debridement effect, but only if duct tape is used. “Scotch tape and masking tape aren't strong enough.” Some researchers have suggested that occlusion with duct tape alone is useful, possibly via an immune mechanism.
Cryotherapy is very effective against warts, but it can be quite painful. “We spray the skin and create a large, hemorrhagic blister, with the hope that when the blister falls off, the wart falls off with it,” Dr. Mancini said. “If the patient doesn't develop a blister, the treatment is usually not effective.”
Overzealous treatment of warts can result in significant wounds, he cautioned. Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area.
OTC cryotherapy has been available since 2003, and these products can be effective for small warts, but they are not nearly as effective as liquid nitrogen, he said. These over-the-counter methods utilize dimethyl ether/propane, the same ingredient found in Histofreeze, but the OTC methods don't reach the same temperature, and thus they are significantly less effective.
Liquid nitrogen is a good choice for older children, such as a 10-year-old with one or two warts who says, “I want these gone.”
However, Dr. Mancini has a “no hold” policy regarding cryotherapy. “If we would have to hold the child down to do it, I generally recommend against it.”
Patients who do not want cryotherapy may consider oral or topical immunotherapy or injection therapy.
Cimetidine is the most common oral therapy used for warts. “The bottom line is that it is worth a try,” Dr. Mancini said. “It does work in some patients; the success rate is probably near 30%.” He generally prescribes a relatively high dose, 30–40 mg/kg per day, divided and given twice daily.