Genital Warts in Infants and Children
—Re-Evaluation of Podophylline 15% as an Effective Topical Therapy

Khalifa E. Sharquie, Adil A. Noaimi, Mohammed N. Almallah

Department of Dermatology and Venereology, Baghdad Teaching Hospital, Baghdad, Iraq.
Department of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq.

DOI: 10.4236/jcdsa.2014.44035                

Abstract

Background: Condylomataacuminata is an infection caused by Human Papilloma Virus, rarely reported in infants and children. Podophylline as a treatment for this condition has been used cautiously in this age group. Objective: To report the cases of anogenital warts including condy lomataacuminata in infants and children and to evaluate the effectiveness and side effects of 15% podophyllin in treatment of genital warts. Patient and Methods: Thirty infants and young children were seen in Department of Dermatology and Venereology—Baghdad Teaching Hospital in this case descriptive and therapeutic trial, in the period from January 2011 to August 2012. Their ages ranged from 8 - 72 (30.43 ± 15.85) months, 20 females and 10 males with a female:male ratio of 2:1. The duration of the disease ranged from 1 - 12 (5.26 ± 4.00) months. All demographics data were recorded in this study. History and examination were carried out to all patients. Family members including mothers were assessed about the presence of any type of viral warts in other location of body. Podophyllin (15%) in tincture benzoin was applied once weekly to all viral warts and the parents advised to wash out after 2 hours of application. The number of applications was repeated until full recovery. Follow-up after recovery was carried out for 6 months to watch for any relapse and to record local or systemic side effects. Results: The clinical pictures were mostly acondylomata acuminata in a form of cauliflower like warts in 20 (73.33%) patients, while in 10 (26.77%) patients there were ordinary verruca vulgaris like warts. The location of warts was perianal in 23 (76.66%) patients, genital only in 2 (6.66%) patients, and mixed in 5 (16.66%) patients. Topical applications of podophyllin 15% gave a full recovery in 27 (90%) patients, while in 3 (10%) patients there was partial response. The number of applications ranged from 1 - 4 (2.7 ± 1.42) applications. Follow up for 6 months after recovery showed relapse in only one patient, and no side effects were reported in any patients. Conclusion: There is upsurge of cases of anogenital warts among infants and children. Podophyllin (15%) in tincture benzoin is an effective therapy and no local or systemic side effects were recorded in any case.

Keywords

Genital Warts in Infants and Children, Podophylline, Topical Therapy

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Cohen, B.A. (1997) Warts and Children: Can They Be Separated? Contemporary Pediatrics, 14, 128-149.
[2]	Siegfried, E., Conley, R., Cook, J., Leonardi, C. and Monteleone, J. (1998) Human Papillomavirus Screening in Pediatric Victims of Sexual Abuse. Pediatrics, 101, 43-47. http://dx.doi.org/10.1542/peds.101.1.43
[3]	Syrjanen, S. and Puranen, M. (2000) HPV Infections in Children: The Potential Role of Maternal Transmission. Critical Reviews in Oral Biology Medicine, 11, 259-274. http://dx.doi.org/10.1177/10454411000110020801
[4]	Garland, S. (2002) Human Papillomavirus Update with a Particular Focus on Cervical Disease. Pathology, 34, 213-224. http://dx.doi.org/10.1080/00313020212469
[5]	Munoz, N., Bosch, F.X., de Sanjosé, S., Herrero, R., Castellsagué, X., Shah, K.V., et al. (2003) Epidemiologic Classification of Human Papilloma Virus Types Associated with Cervical Cancer. New England Journal of Medicine, 348, 518-527.
[6]	Syrjanen, K. and Syrjanen, S. (2000) Papillomavirus Infections in Human Disease. Wiley & Sons, New York, 1-615.
[7]	Syrjanen, S. (2003) HPV Infections in Children. Invited Review. Papillomavirus Report, 14, 93-110. http://dx.doi.org/10.1179/095741903235001425
[8]	Hornor, G. (2004) Ano-Genital Warts in Children: Sexual Abuse or Not? Journal of Pediatric Health Care, 18, 165-170. http://dx.doi.org/10.1016/j.pedhc.2003.01.001
[9]	Gutman, L.T., Claire, K., Herman-Giddens, M.E., Johnston, W.W. and Phelps, W.C. (1992) Evaluation of Sexually Abused and Non-Abused Young Girls for Intravaginal Human Papillomavirus Infection. American Journal of Diseases of Children, 146, 694-699.
[10]	Gutman, L.T., Claire, K.K., Everett, V.D., Ingram, D.L., Soper, J. and Johnston, W.W. (1994) Cervical-Vaginal and Intra Anal Human Papillomavirus Infection of Young Girls with External Genital Warts. The Journal of Infectious Diseases, 170, 339-344. http://dx.doi.org/10.1093/infdis/170.2.339
[11]	Gutman, L.T. (1990) Sexual Abuse and Human Papillomavirus Infection. Journal of Pediatrics, 116, 495-496. http://dx.doi.org/10.1016/S0022-3476(05)82863-X
[12]	Muram, D. (1989) Anal and Perianal Abnormalities in Prepubertal Victims of Sexual Abuse. American Journal of Obstetrics & Gynecology, 161, 278-281. http://dx.doi.org/10.1016/0002-9378(89)90498-5
[13]	Tseng, C.J., Lin, C.Y., Wang, R.L., Chen, L.J., Chang, Y.L., Hsieh, T.T. and Pao, C.C. (1992) Possible Transplacental Transmission of Human Papillomaviruses. American Journal of Obstetrics & Gynecology, 166, 35-40. http://dx.doi.org/10.1016/0002-9378(92)91825-U
[14]	Alberico, S., Pinzano, R., Comar, M., Toffoletti, F., Maso, G., Ricci, G. and Guaschino, S. (1996) Maternal-Fetal Transmission of Human Papillomavirus. Minerva Ginecologica, 48, 199-204.
[15]	Roman, A. and Fife, K. (1986) Human Papillomavirus DNA Associated with Foreskins of Normal Newborns. Journal of Infectious Diseases, 153, 855-861. http://dx.doi.org/10.1093/infdis/153.5.855
[16]	Handley, J., Hanks, E., Armstrong, K., Bingham, A., Dinsmore, W., Swann, A., Evans, M.F., McGee, J.O.D. and O’Learj, J. (1997) Common Association of HPV 2 with Anogenital Warts in Prepubertal Children. Pediatric Dermatology, 14, 339-343. http://dx.doi.org/10.1111/j.1525-1470.1997.tb00976.x
[17]	Bergeron, C., Ferenczy, A. and Richart, R. (1990) Underwear: Contamination by Human Papillomaviruses. American Journal of Obstetrics & Gynecology, 162, 25-29. http://dx.doi.org/10.1016/0002-9378(90)90813-M
[18]	Frazier, L. (1998) Genital Warts in Children. The American Professional Society of the Abuse of Children Advisor, 11, 9-12.
[19]	Armstrong, D.K. and Handley, J.M. (1997) Anogenital Warts in Prepubertal Children: Pathogenesis, HPV Typing and Management. International Journal of STD & AIDS, 8, 78-81. http://dx.doi.org/10.1258/0956462971919598
[20]	Joyasinghe, Y. and Garland, S.M. (2006) Genital Warts in Children: What Do They Mean? Archives of Disease in Childhood, 91, 696-700. http://dx.doi.org/10.1136/adc.2005.092080
[21]	Singlair, K., Woods, C., Kirse, D. and Sinal, S.H. (2005) Anogenital and Respiratory Tract Human-Papillomavirus Infections among Children: Age Gender and Potential Transmission through Sexual Abuse. Pediatrics, 116, 815-825. http://dx.doi.org/10.1542/peds.2005-0652
[22]	Culton, D.A., Morrell, D.S. and Burkhart, C.N. (2009) The Management of Condyloma Acuminata in the Pediatric Population. Pediatric Annals, 38, 368-372. http://dx.doi.org/10.3928/00904481-20090622-05
[23]	Allen, A.L. and Siegfried, E.C. (1998) The Natural History of Condyloma in Children. Journal of the American Academy of Dermatology, 39, 951-955. http://dx.doi.org/10.1016/S0190-9622(98)70268-3
[24]	Sinclair, K.A., Woods, C.R. and Sinal, S.H. (2011) Venereal Warts in Children. Pediatrics in Review, 32, 115-121. http://dx.doi.org/10.1542/pir.32-3-115
[25]	Stefanaki, C., Barkas, G., Valari, M., Bethimoutis, G., Nicolaidou, E., Vosynioti, V., Kontochristopoulos, G., Papadogeorgaki, H., Verra, P. and Katsarou, A. (2012) Condylomata Acuminata in Children. The Pediatric Infectious Disease Journal, 31, 422-424.
[26]	Moresi, J.M., Herbert, C.R. and Cohen, B.A. (2001) Treatment of Anogenial Warts in Children with Topical 0.05% Podophilox Gel and Imiquimod Cream. Pediatric Dermatology, 18, 448-450. http://dx.doi.org/10.1046/j.1525-1470.2001.1980a.x
[27]	Sharquie, K.E., Al-Waiz, M.M. and Al-Nuaimy, A.A. (2005) Condylomata Acuminata in Infants and Young Children. Topical Podophyllin an Effective Therapy. Saudi Medical Journal, 26, 502-503.
[28]	Moscicki, A. (1998) Genital Infections with Human Papillomavirus (HPV). Pediatric Infectious Disease Journal, 17, 651-652. http://dx.doi.org/10.1097/00006454-199807000-00014
[29]	Atabaki, S. and Paradise, J. (1999) The Medical Evaluation of the Sexually Abused Child: Lessons Learned from a Decade of Research. Pediatrics, 104, 178-186.
[30]	Berenson, A.B., Chacko, M.R., Wiemann, C.M., Mishaw, C.O., Friedrich, W.N. and Grady, J.J. (2000) A Case-Control Study of Anatomic Changes Resulting from Sexual Abuse. American Journal of Obstetrics & Gynecology, 182, 820-834. http://dx.doi.org/10.1016/S0002-9378(00)70331-0
[31]	Zakon, S. (1952) Discovery of Podophyllum Resin. JAMA Dermatology, 65, 620-622. http://dx.doi.org/10.1001/archderm.1952.01530240112022
[32]	Sharquie, K.E. and Noaimi, A.A. (2012) Basal Cell Carcinoma: Topical Therapy versus Surgical Treatment. Journal of the Saudi Society of Dermatology and Dermatologic Surgery, 16, 41-51. http://dx.doi.org/10.1016/j.jssdds.2012.06.002
[33]	United States Pharmacopeia Committees (2004) Podophyllin. In: Drug Information for the Health Care Professional, 24th Edition, Rev. US Convention Inc., Thomason Micromedex, 2341-2348.
[34]	Oslen, D.G. and Dart, R.C. (2004) Skin and Mucous Membrane Agents. In: Medical Toxicology, 3rd Edition, Vol. 165, Walters Kluwer Company, Philadilphia, 1003-1004.
[35]	Moore, M.M. and Strober, B.E. (2008) Topical and Intralesional Cytotoxic Agent. In: Wolff, K., Goldsmith, L.A., Katz, S.I., Gilchrest, B.A., Paller, A.S. and Leffell, D.J., Eds., Fitzpatrick’s Dermatology in General Medicine, 7th Edition, McGraw-Hill-Company, New York, 220, 224.
[36]	Thiersch, J.B. (1963) Effect of Podophyllin and Podophyllotoxin on the Rat Litter in Utero. Proc. Soc. Exp. Biol. Med., 113, 124.
[37]	Joneja, M.G. and Leliever, W.C. (1974) Effects of Vinblastine and Podophyllin on DBA Mouse Fetuses. Toxicology and Applied Pharmacology, 27, 408-414. http://dx.doi.org/10.1016/0041-008X(74)90211-7
[38]	Cullis, J.E. (1962) Congenital Deformities and Herbal “Slimming Tablets”. Lancet, 280, 511-512. http://dx.doi.org/10.1016/S0140-6736(62)90387-2
[39]	Karol, M., Conner, C., Watanabe, A.S. and Murphrey, K. (1980) Podophyllum: Suspected Teratogenicity from Topical Application. Clinical Toxicology, 16, 283-286. http://dx.doi.org/10.3109/15563658008989950
[40]	Chamberlein, M.J., Reynolds, A.L. and Yeoman, M.B. (1972) Toxic Effect of Podophyllum Application in Pregnancy. British Medical Journal, 3, 391-392. http://dx.doi.org/10.1136/bmj.3.5823.391
[41]	Bargman, H. (1988) Is Podophyllin a Safe Drug to Use and Can It Be Used in Pregnancy? JAMA Dermatology, 124, 1718-1729. http://dx.doi.org/10.1001/archderm.1988.01670110074020
[42]	Fisher, A. (1981) Sever Systemic and Local Reaction to Topical Podophyllin Resin. Cutis, 28, 233-236.
[43]	Miller, R.A. (1985) Podophyllin. International Journal of Dermatology, 24, 491-498. http://dx.doi.org/10.1111/j.1365-4362.1985.tb05535.x
[44]	Von Krogh, G. (1983) Condylomata Acuminate 1983 an Updated Review. Semin Dermatol, 2, 109-129.