Starting With Warts, the Questions Parents Ask : Dr. Sheila F. Friedlander uses the 'triple whammy': salicylic acid, salicylic bandage, and then duct tape.


MAUI, HAWAII — Questions that are commonly asked of pediatric dermatologists by parents range from how to get rid of warts to what to do about community-acquired methicillin-resistant Staphylococcus aureus infections, reported Dr. Sheila F. Friedlander.

The director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego, Dr. Friedlander gave some examples of the top questions asked, together with her answers, at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics:

How can you get rid of my child's warts? Warts account for 8% of dermatology visits; up to 20% of school-age children are affected. Many warts just go away. The average cure rate for warts with placebo is 27% at 15 weeks, Dr. Friedlander said.

For treatment of warts, the best evidence available comes from five trials supporting the use of salicylic acid. A 6-week study of wart treatment with duct tape on 103 children found a modest but insignificant effect: 16% duct tape vs. 6% placebo.

Although cryotherapy is not well supported by studies, and the manner of application varies widely, empirically it works. Dr. Friedlander said she uses an approach she calls the "triple whammy": salicylic acid, salicylic bandage, and then duct tape.

If you try immunotherapy, skin test allergens are used: Candida, mumps, or Trichophyton. For the largest warts, inject 0.1–0.3 cc directly into the wart. Repeat the immunotherapy treatment every 3 weeks for 3–5 treatments.

The adult cure rate with Candida is 88% for local warts and 66% for distal ones. The relapse rate at 2 years is 5%, compared with 39% for cryotherapy, and 10% for laser.

Genital warts are now preventable by the quadrivalent human papillomavirus (HPV) vaccine Gardasil (Merck). It protects against HPV 6/11/16/18 and is 95% effective for as long as 4.5 years.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends routine vaccination of all girls ages 11–12 years with 3 doses, but it can be given at ages 9–26. The goal is to administer the vaccine prior to sexual contact.

About 30% of 9th graders and 60% of 12th graders are estimated to be sexually active. Cervical cancer, caused by HPV, is the second most common cancer in women worldwide, with 233,000 deaths per year, Dr. Friedlander said.

What can be done about head lice? Dislodged by towels and hair dryers, lice can be transmitted by fomites, with eggs landing on fabrics, bedding, and furniture. These all need to be cleaned. For treatment, Dr. Friedlander recommends starting with topical over-the-counter (OTC) pyrethrin or permethrins.

The use of malathion is an option, but be aware that it is flammable—the patient should avoid the use of hairdryers and flames during treatment. Also, she observed, "It stinks to high heaven."

Another option, used in England and Israel, is to wash the hair, add hair conditioner (which makes the hair slippery and hard for eggs to adhere), and comb with a fine-tooth comb.

The use of Cetaphil cleanser is yet another option. The OTC cleanser is applied on a dry scalp and spread over the head until the hair is wet. Then the hair is blow-dried, and the cleanser is washed out the next day. The procedure is repeated in 7–10 days.

An effective hair dryer treatment is LouseBuster. It is slightly cooler than a standard blow dryer, but provides twice the volume of air, which kills head lice. Its effectiveness is 100% ovicidal, with 80% mortality of hatched lice (Pediatrics 2006;118:1962–70).

Use of oral ivermectin is another option, she said, "But I certainly wouldn't go with it for first-line therapy."

Dr. Friedlander suggested using the Cetaphil cleanser treatment combined with the use of a hair dryer.

How can varicella infection be avoided? "We need to remember that chicken pox is tamed, but not conquered," Dr. Friedlander said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

Varivax, the live attenuated varicella vaccine available since 1995, has a protection rate of 85%; it is 97% effective in preventing moderate to severe disease. Hospitalization rates for varicella have decreased from 2.3/100,000 in 1994 to 0.3/100,000 in 2002, and mortality also has decreased (N. Engl. J. Med. 2005;352:450–8).

But there has been a problem with more severe disease developing in children who have not been vaccinated for more than 5 years. Therefore, children should receive two vaccinations, with the first dose given at 12–15 months, and the second between ages 4 and 6 years. All others should receive "catch-up" doses. Quadrivalent vaccines (MMRV, Proquad) are options, she said.


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