Bringing basic dermatology to the pediatric medical home session 3 warts

Bringing Basic Dermatology Care
to the Pediatric Medical Home:
A PPOC/CHICO Learning Community
& Integration Program
Warts, Molluscum and Hives
Didactic Webinar
Thursday September 1, 2016
© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact ppoc@childrens.harvard.edu

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We have no financial relationships with commercial
entities producing, marketing, re-selling, or distributing
health care goods or services consumed by, or used on,
patients relevant to the content we are planning,
developing, presenting, or evaluating.
Off-label uses of medications will be discussed.
Disclosure

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Glenn Focht, MD
PPOC Chief Medical Officer
Karen R. Barnett, MD, FAAP
Pediatric Physicians’ Organization at Children’s
Madeleine Kuhn, MPH
CHICO Program Coordinator
Faculty
Stephen E. Gellis, MD
Program Director, Dermatology
Boston Children’s Hospital
Sophie Delano, MD
Dermatology
Boston Children’s Hospital

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Learning Community Schedule
Date Content
Thursday, May 19, 2016 Atopic Dermatitis
Thursday, August 4, 2016 Acne
Thursday, September 1, 2016 Warts, Molluscum, Hives
Thursday, October 27, 2016 Wrap-up
Didactic Webinars
7:30am – 9:00am

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Coursework
• Qstream (Team in the
lead)
• Case Reviews
• Follow the
instructions on the
first page
• Submit on Blackboard
or email or by fax to
Madeleine Kuhn

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Incidence of Warts, Molluscum and Hives
Atopic
Dermatitis
36%
Acne
32%
Warts
9%
Hives
6%
Molluscum
3%
Other
14%
Top Dermatology Diagnosis in PPOC Participating Practices

Dr. Sophie Delano
Boston Children’s Dermatology
Warts, Molluscum and Hives

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Goals of Talk
• Discuss presentations, treatments, and potential
complication of
– Warts/Verruca
– Molluscum
– Hives/Urticaria

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Types of Warts
• Common warts – verruca vulgaris
• Flat warts – verruca plana
• Plantar warts – verruca plantaris
• Genital warts – condyloma accuminatum

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OTC Wart Treatments
• Best initial OTC treatment for warts?
A. Duct tape
B. Salicylic acid preparations
C. Tea-tree oil
D. OTC cryotherapy

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OTC Wart Treatments
• Best initial OTC treatment for warts?
A. Duct tape
B. Salicylic acid preparations
C. Tea-tree oil
D. OTC cryotherapy

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Salicylic Acid = Maceration
• Discuss with families this will
happen and will resolve after
treatment
• Adjacent skin will heal without
scarring

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OTC Wart Treatments
• Salicylic acid
• Duct tape – as often as possible
• Freeze-off/Cryotherapy
• Gentle paring with a dedicated nail file
helpful for plantar warts or any thickened,
scaly wart.
• Patient instructions: Soak 10-15 mins
then file off excess skin

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Preventing spread of common warts
• HPV ubiquitous in the environment
• Avoidance of self-inoculation is main goal
• Discourage touching, picking, biting
– Good deterrent: risk of warts on lips or face

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Provider Cryotherapy
I use liquid nitrogen/cryotherapy in my office to treat warts:
A. Yes
B. No

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CRYO
In my office, I use _____ for cryotherapy:
A. Histofreeze
B. Liquid Nitrogen
C. Histofreeze and liquid nitrogen. They are the same thing.
D. Other cooling device
E. I don’t have in-office cryotherapy

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Liquid Nitrogen vs Histofreeze
• Histofreeze = dimethyl ether and propane (DMEP)
– Typically -41 deg C as
– Crucial to pare down warts if this is what you use
• Liquid nitrogen -196 deg C
– More flexibility in terms of using other methods of
delivery

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In-office Cryotherapy
Which is the best way to do in-office cryotherapy?
A. One single cycle of 5 seconds of freezing
B. One single cycle of 10 seconds of freezing.
C. Two cycles of 7 seconds each with brief pause between
to prevent thawing
D. Two cycles of 7 seconds each, allowing the lesion to
slowly thaw between cycles
E. Three cycles of 2 seconds each with thawing between
each cycle

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In-office Cryotherapy
Which is the best way to do in-office cryotherapy?
A. One cycle of 5 seconds of freezing
B. One cycle of 10 seconds of freezing.
C. Two cycles of 7 seconds each with brief pause between
to prevent thawing
D. Two cycles of 7 seconds each, allowing the lesion to
slowly thaw between cycles
E. Three cycles of 2 seconds each with thawing between
each cycle

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In-Office Cryo Tips
• Cryo gun (older kids), or forceps or q-tips
dipped in LN2 until cold.
• Cold forceps: good for filiform warts
• 2 cycles of 5-7 secs, with slow thaw between
cycles produces that most damage to the
koilocytes (keratinocytes infected with HPV)
• Encourage patient to restart sal acid treatments
5-7 days after freezing.
• Repeat cryotherapy every 3-4 weeks
• Less intensive treatment of periungual warts to
avoid nail dystrophy

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Case 1
Patient noticed sudden
expansion of wart after
treatment. What likely caused
this expansion?
A. Area treated with
cryotherapy was too small
B. Lack of treatment with
salicylic acid
C. Too many cycles of
cryotherapy
D. Allergic response to duct
tape.

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Case 1
Patient noticed sudden
expansion of wart after
treatment. What likely caused
this expansion?
A. Area treated with
cryotherapy was too small
B. Lack of treatment with
salicylic acid
C. Too many cycles of
cryotherapy
D. Allergic response to duct
tape.

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Ring Warts
• Likely caused by too small of a treatment area with
cryotherapy
• Extensor knees and elbows at risk
• If develop, hold on repeat cryo in favor of less destructive
methods of sal acid and duct tape

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Treatment end-points
Which of the following is the best sign that a wart has
resolved and no longer needs treatment?
A. Intact dermatoglyphics (eg. Skin markings)
B. All papules have resolved.
C. Skin is not hyper or hypopigmented.
D. No thrombosed capillaries seen.
E. Wart is no longer increasing in size.
F. Bulk of wart peeled off after therapy.

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Treatment end-points
Which of the following is the best sign that a wart
has resolved and no longer needs treatment?
A. Intact dermatoglyphs (eg. Skin markings)
B. All papules have resolved.
C. Skin is not hyper- or hypopigmented.
D. No thrombosed capillaries seen.
E. Wart is no longer increasing in size.
F. Bulk of wart peeled off after therapy.
Photo source top photo: http://www.iowacitydermatology.com/new-page/

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Topical Rx Wart Medications
• Tretinoin 0.025-0.05% cream
– Good choice for facial flat warts
• Imiquimod / Aldera
– Often first-line for anogenital warts
• 5-fluorouracil cream
– Can be irritating to uninvolved skin
– Families need guidance re its chemotherapeutic uses
– Compounded with sal acid by NuCara pharmacy,
www.wartpeel.com

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Oral Wart Treatments
• Cimetidine/Tagamet, 25-40 mg/kg divided BID/TID, or could
do one single 800 mg tab QHS
– Possibly stimulating IL-2 and INF-gamma
– Conflicting reports on efficacy, has not shown efficacy in
RCT
– Courses range from 6-12 weeks
• Case reports on zinc supplementation, 10mg/kg max
600mg for 2 months

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More Advanced Wart Treatments
Refer to Derm
• Topical squaric acid
• Topical triple acid (trichloroacetic or salicylic acid,
podophyllin, cantharidin)
• Intralesional bleomycin or candida antigen
• Topical cidofovir gel (immunocompromised pts)
• Lasers (not universally done)
• Radiation (rarely done)
• Excision (not recommended)

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Genital Warts Case 2
Photo: Sinclair et al,
Pediatrics in Review
March 2011
20 moF w/genital warts. Which
PMH element may explain how
she developed these warts?
A. Maternal history abnl Pap
smears.
B. Siblings with warts.
C. Patient has wart on hand.
D. Caregiver has wart on
hand.
E. All of the above.

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Genital Warts Case 2
Photo: Sinclair et al,
Pediatrics in Review
March 2011
20 moF w/genital warts. Which
PMH element may explain how
she developed these warts?
A. Maternal history abnl Pap
smears.
B. Siblings with warts.
C. Patient has wart on hand.
D. Caregiver has wart on
hand.
E. All of the above.

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HPV Vaccine and Warts
• Common HPV types for various warts(source Paller):
– Common: 1, 2 ,4, 7
– Plantar: 1
– Flat: 3, 10, 28, 41
– Anogenital: 6 and 11
• Case reports of improvement/resolution in refractory common
& plantar warts after receiving HPV vaccination. (Daniel et al
JAMA Derm 2013)
• Case study of oral papilloma resolving with HPV vaccination
(Cyrus et al)

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U.S. Data
• 79 million Americans currently have HPV.1
• 14 million new HPV infections every year.1
• HPV infection most common in teens and early 20s
• Most people never know they have HPV infection
• ≈ 17,600 women are diagnosed
with cervical cancer each year
• ≈ 9,300 men affected by HPV-
related cancers yearly
That’s 1 case every 20 minutes
1. Centers for Disease Control and Prevention. 2014. “Human Papillomavirus (HPV): Genital HPV Infection—Fact Sheet.” http://www.cdc.gov/std/HPV/STDFact-HPV.htm (June 9, 2014)

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Massachusetts Data
• 26.8% of MA teens have had a sexual encounter by their
14th birthday.
• Young people, ages 15-19, have the highest rate of STIs of
any age group in the US.
• Adolescents, ages 15-24, account for nearly 50% of all
sexually transmitted infection (STI) diagnoses each year.
• 9% of high school students reported having had four or
more sexual partners.
Massachusetts Department of Elementary and Secondary Education. Health and Risk Behaviors of Massachusetts Youth 2013.

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CDC Reports Increasing Teen HPV Vaccination
Rates in the US*
CDC researchers found that 62.8% of girls and 49.8% of boys
ages 13 to 17 received human papillomavirus vaccinations in
2015 compared with 60% and 41.7% in 2014.
Only 42% of girls and 28.1% of boys received all three HPV
vaccine doses, short of the government's 80% target
vaccination rate for adolescents,
*AAP Smart Briefs, 8/26/2016

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HPV Analysis
Outcome: 3 HPV Doses by 13th and 15th Birthday

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Case 3
• 5 yo F w/ lesions on trunk &
legs x 2 months. What
timeframe do you give her
frustrated mother for how
long it will take the lesions to
resolve spontaneously?
A. 3-4 months
B. 6-12 months
C. 6-24 months
D. 24-36 months

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Case 3
• 6 yo F w/ lesions on trunk &
legs x 2 months. What
timeframe do you give her
frustrated mother for how
long it will take the lesions to
resolve spontaneously?
A. 3-4 months
B. 6-12 months
C. 6-24 months
D. 24-36 months

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Molluscum Contagiosum
• Viral papules caused by a poxvirus
• Potential STD in older children/adults
• Potential for widespread eruption in immuno-
compromised patients
• Increasing incidence over last decades

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Non-Rx Molluscum Treatments
• Tea tree oil
• Apple cider vinegar
• Extracting core after soaking in warm
bath
• ZymaDerm – plant-based irritants

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Cantharidin
• Derivative of blister beetle, typically
in 0.7% solution
• Painless application
• Washed off in 4-6 hours or sooner if
pain develops
• Avoid emollients/steroids in area
for 2-3 days
• BCH Derm: Pts given prescription
for cantharidin then followup in 2
weeks for initial treatments

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Advanced Molluscum Tx
• Cryotherapy: older patients, less intensive than for warts
• Curettage after EMLA or LMX
• Tretinoin 0.025-0.05% cream

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7yo M w/hx molluscum x months. Now with
enlarging, red, slightly tender nodule
surrounding a molluscum recently treatment
with cantharidin. No hx staph. Otherwise
well w/o fevers. What is the best treatment
for this inflamed lesion?
A. Incision & drainage
B. Culture & oral antibiotics
C. Culture & topical antibiotics
D. Repeat cantharidin treatment
E. Warm compresses TID and Tylenol for
discomfort
Case 4

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7yo M w/hx molluscum x months. Now with
enlarging, red, slightly tender nodule
surrounding a molluscum recently treatment
with cantharidin. No hx staph. Otherwise
well w/o fevers. What is the best treatment
for this inflamed lesion?
A. Incision & drainage
B. Culture & oral antibiotics
C. Culture & topical antibiotics
D. Repeat cantharidin treatment
E. Warm compresses TID and Tylenol for
discomfort
Case 4

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Molluscum Abscess
• BOTE sign : “Beginning of the end” sign
• Tx:
– Warm compresses multiple times a day,
– Reassurance (inflammatory vs infectious)
– Review warning signs of cellulitis & need for follow-up

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Case 5
7 yoF with hx of atopic dermatitis
now w/flare along flanks and
popliteal fossa. How should you
treat these lesions?
A. Tretinoin 0.025% cream QHS to
molluscum
B. Avoidance of emollients in
affected areas until molluscum
have resolved.
C. Cantharidin 0.7% to all areas.
D. Hydrocortisone 2.5% ointment
BID plus emollients for 2-3
weeks or until improved.

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Case 5
7 yoF with hx of atopic dermatitis
now w/flare along flanks and
popliteal fossa. How should you
treat these lesions?
A. Tretinoin 0.025% cream QHS to
molluscum
B. Avoidance of emollients in
affected areas until molluscum
have resolved.
C. Cantharidin 0.7% to all areas.
D. Hydrocortisone 2.5% ointment
BID plus emollients for 2-3
weeks or until improved.

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Molluscum Dermatitis
• = eczema triggered or worsened by MC.
• Eczema patients may have overall worsening of
eczema with molluscum, even in non-involved areas
• Controversy over treatment with
moisturizers/steroids: spreading virus vs repairing
barrier
– Hydrolatum BID-TID, Hydrocortisone 2.5% ointment BID for
2-3 weeks
– May need to increase to Triamcinolone 0.1% ointment BID
for 3-5 days if severe/thickened eczema

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Preventing Molluscum Spread
• Treat molluscum dermatitis and discourage
manipulation.
• Virus is ubiquitous in environment/pools/schools
• Avoid shared towels/baths (sibs probably already
exposed)
• Postpone full contact sports (wrestling) until clear.
• School, daycare and recreational activities likely ok.

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• 2 yoF recently diagnosed with acute
otitis media by outside urgent care
clinic and started on amox 5 days
prior now presents with widespread,
edematous pink papules and
plaques. Parents report rapid change
in locations of lesions.
Photo credit: Mathur

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Which of the following would be a
symptom not consistent with urticaria in
this patient?
A. Fever
B. Joint pains
C. Vesicles on lips
D. Lesions with dusky-appearing centers
E. Eruption persisting > 3 weeks.
F. Targetoid lesions
Case 6

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Which of the following would be a
symptom not consistent with urticaria in
this patient?
A. Fever
B. Joint pains
C. Vesicles on lips
D. Lesions with dusky-appearing centers
E. Eruption persisting > 3 weeks.
F. Targetoid lesions
Case 6

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Urticaria
• IgE dependent hypersensitivity
reaction (sometimes independent)
• Transient wheals, can have bulla
• Dusky, resolves with treatment
• Urticaria multiforme = hives
• Angioedema of face and acral edema
• Low grade, recent fever (days)
• 4 months-4 years of age
• Labs: mild leukocytosis, ESR/CRP

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Urticaria with peripheral pallor

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Urticaria: Can look targetoid

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Urticaria Dermatographism
Photo credit: Paller 20-9

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Causes of Acute Urticaria
• 80% infection: Viral, viral, viral
• Strep infections
• Meds: PCN, cephalosporins, sulfa, TCN, ASA,
NSAIDS, contrast media
• Dairy, nuts, seafoods

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Urticaria Multiforme
• Coalescing hives in an annular or serpiginous patterns
• Can be extensive
• Often confused with erythema multiforme  SJS/TEN
• Tx same as typical urticaria

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Urticaria doesn’t have
Mucosal involvement
Necrosis
Sick-appearing kids

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Angioedema
• Deeper edema presenting as
swelling of face, hands, feet,
genitalia, GI tract
• 10% kids with urticaria have at
least mild angioedema (Paller et al)
• Can also occur without urticaria
• Causes: deficiency in CI-inhibitor,
ASA/NSAIDS, allergens

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Urticaria Workup/TX
• Labs (+/-) CBC, culture if vesicles
• Reassurance
• H1 blockers
– QAM nonsedating (cetirizine)
– QHS sedating (hydroxyzine)
• H2 blockers, monteleukast
• Avoidance of NSAIDS
• Systemic meds for
symptomatic/debilitating cases
• Topical steroids (desonide 
triamcinolone) if symptomatic

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Chronic Urticaria
• > 6 weeks duration
• Potential triggers
– Tight clothing/localized pressure within 4-6 hrs symptom onset
– Emotional stress
– Exercise
– Water
– Sun exposure
– Cold temps or water (must always have epi-pen/swim buddy)
– Potential Workup: CBC, ESR, ANA, CH50, free-T4, TSH, anti-
thyroglobulin and antimicrosomal antibodies, PO and cutaneous
allergy testing, stool O&P

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Case 7
8 yoM recently diagnosed with hives by
outside provider presented with fixed, non-
blanching papules, eroded papules on legs
&buttocks. Mild fever & abd pain, but well-
appearing. Work up should include? (May
select >1)
A. BP
B. CBC, UA, Bun/Cre
C. Blood culture
D. Testicular exam

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Case 7
8 yoM recently diagnosed with hives by
outside provider presented with fixed, non-
blanching papules, eroded papules on legs
&buttocks. Mild fever & abd pain, but well-
appearing. Work up should include? (May
select >1)
A. BP
B. CBC, UA, Bun/Cre
C. Blood culture
D. Testicular exam

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Case 7
• Henoch-Schonlein Purpura (HSP)/Acute
hemorrhagic edema of infancy
– Vasculitis: petechial or purpuric
rash, arthritis, abd pain,
glomuleronephritis, and orchitis
– Renal involvement typically self-
resolving, but some will require
systemic meds/Nephro referral
– Monitoring BP, UA, Bun/Cre
– Warning signs: hematuria, edema

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Additional Urticaria
Differential
• Serum-Sickness like reaction
– urticaria + systemic symptoms
– malaise, fever, LAD,
arthralgias (knees, MCPS),
splenomegaly
• Erythema Multiforme
– Fixed lesions, acral
distribution
• Urticarial Vasculitis
– Lesions >24 hrs, tender, leave
hyperpigmentation
Photo credit: Paller 20-33

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References
• Mathur et al. Urticaria mimickers in children.
Dermatologic Therapy. 2013;26: 467–75.
• Paller et al. Clinical Pediatric Dermatology: A Textbook
of Skin Disorders of Childhood and Adolescence, 5e,
2015.
• Sinclair et al. Venereal warts in children. Pediatrics in
Review March 2011.

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Learning Community Schedule
Date Content
Thursday, May 19, 2016 Atopic Dermatitis
Thursday, August 4, 2016 Acne
Thursday, September 1, 2016 Warts, Molluscum, Hives
Thursday, October 27, 2016 Wrap-up
Didactic Webinars
7:30am – 9:00am
You will receive the slides, handouts, the webinar recording
and the survey via email. All course information will be posted
on Blackboard by 9/5/2016 at 5 pm.

90
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Please take a moment to fill out the session
evaluation Survey you will receive via email and
provide us with your feedback so that we can
continue to improve and meet your expectations!
Survey is also a CME / MOC requirement

Thank you!
For questions please email Madeleine Kuhn,
Course Director
Madeleine.kuhn@childrens.harvard.edu

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