Pediatric Dermatology Vol. 32 No. 5 679–683, 2015
Children with Warts: A Retrospective Study in an Outpatient Setting Anne M. Kuwabara, B.A., Barbara M. Rainer, M.D., Hatice Basdag, M.S., and Bernard A. Cohen, M.D. Division of Pediatric Dermatology, Departments of Pediatrics and Dermatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
Abstract Background: The purpose is to investigate the demographics and course of common warts in children in an outpatient setting. Methods: A retrospective medical chart review and telephone survey study were completed on an outpatient cohort of children (0–17 yrs) with a clinical diagnosis of warts at a single-center, university-based pediatric dermatology practice. The main outcome measures included management, time to resolution, and associated factors of warts in children. Results: Of the 254 patients we contacted, 214 agreed to participate in the survey. The most commonly involved sites were the hands and the head and neck area. Most children received some form of therapy, but it is unclear that any form of treatment altered the course. However, children with a medical history of childhood infections or more than one anatomic site had significantly greater risk of having a longer time to resolution. Conclusion: Warts resolved in 65% of children by 2 years and in 80% within 4 years, regardless of treatment. With the exception of a history of childhood infections and having more than one anatomic site, time to resolution was not altered by wart or patient characteristics. Thus counseling without aggressive destructive treatment is a reasonable approach to managing warts in most children. Our findings will provide guidance in the process of shared decision making with parents and children.
Warts are common benign tumors of the skin and mucous membranes caused by the human papilloma virus (HPV) (1). Although the prevalence of warts is 5% to 10% in children, there is only limited epidemiologic data on this common viral infection (2,3). Warts in immunocompetent children are usually
harmless and tend to resolve spontaneously without treatment within months to years as a result of natural immunity, although they can be associated with embarrassment and social stigma (4). Practitioners employ a variety of treatments, including topical therapies (e.g., salicylic and squaric acid, duct tape
Address correspondence to Barbara M. Rainer, M.D., Department of Dermatology, Johns Hopkins University School of Medicine, 601 N Caroline Street, Baltimore, MD 21287, or e-mail: [email protected]. DOI: 10.1111/pde.12584
© 2015 Wiley Periodicals, Inc.
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occlusion therapy, imiquimod, tretinoin) and locally destructive measures (e.g., cryotherapy, electrocautery, curettage, carbon dioxide and pulsed dye laser, surgical excision) (5). Most of these interventions are painful, expensive, or time or labor intensive. Highquality data on the efficacy of treatments (6) and whether treatment hastens the resolution of warts are scarce. Thus we conducted a retrospective medical chart review and telephone survey of 214 children with warts to report management, time to resolution, and associated factors to better inform clinical practice.
PATIENTS AND METHODS Study Design The Johns Hopkins Institutional Review Board approved the study protocol, which was a singlecenter, retrospective survey study to determine time to resolution and response to treatment of warts in children. Retrospective medical chart reviews and telephone interviews were conducted at the Johns Hopkins Pediatric Dermatology Clinic in Baltimore, Maryland, between April 2013 and August 2013. Patients and Survey Methods Eligible patients were younger than 18 years of age at the time of clinical diagnosis of warts as assessed by a pediatric dermatologist at the Johns Hopkins Pediatric Dermatology Clinic between January 2008 and December 2012. Patients and their families were first notified by mail that they had been enrolled in the study and could opt out by returning the letter. Each patient’s household was called at different times of the day and on different days to optimize contact with a parent. At least 10 attempts were made to contact a resident of each household between the hours of 8 A.M. and 10 P.M. on all days of the week to minimize selection bias related to availability of respondents who were at home during the day. If the affected individual was a minor, the initial respondent acted as a surrogate for the minor and completed the interview. Telephone interviews were conducted to assess demographic characteristics (age, sex, race), wart characteristics (number, distribution), management, side effects, time to resolution, and personal medical history (atopic dermatitis, asthma, allergies [food, drug, respiratory], and history of childhood infections (e.g., ear, throat, skin, pneumonia, any serious internal infections such as meningitis). The collected
data were verified using the patients’ medical records in the Johns Hopkins Electronic Patient Records database. Duration to diagnosis was defined as the time (in months) from when parents noted warts until an examining pediatrician or dermatologist diagnosed the lesions. Time to resolution of warts was defined as the time (in months) from when the patient or family member first noticed the lesions until their complete resolution. Statistical Analysis Categorical variables were compared using chi-square and Fisher exact tests as appropriate. SPSS Statistics 21 (SPSS, Chicago, IL) was used for data analysis. The significance level was p < .05.
RESULTS Patients Of 252 identified children, 214 (85%) participated in this study. Those who did not participate did not speak English, could not be reached, or did not want to participate in the survey. The median age at diagnosis was 9 years (interquartile range 6– 12 years), 116 (54.2%) were male and 115 (72.4%) were Caucasian. Forty-four (20.6%) children had a history of atopic dermatitis and 16 (7.5%) children had a history of childhood infections. Demographic and medical history characteristics are presented in Table 1. TABLE 1. Patient Characteristics (N = 214) Characteristic Age, years, median (interquartile range) Sex, n (%) Male Female Race, n (%) Caucasian African American Hispanic Asian Other Past medical history, n (%) Atopic dermatitis Asthma History of infections Food allergy Drug allergy Respiratory allergy Molluscum contagiosum Poison ivy
Value 9 (6–12) 116 (54.2) 98 (45.8) 155 (72.4) 31 (14.5) 4 (1.9) 6 (2.8) 18 (8.4) 44 22 16 17 13 9 9 5
(20.6) (10.3) (7.5) (7.9) (6.1) (4.2) (4.2) (2.3)
Kuwabara et al: Retrospective Study of Warts in Children 681
TABLE 2. Wart Characteristics Characteristic
TABLE 3. Management of Warts and Side Effects n (%)
Number of lesions at diagnosis
Children with Warts: A Retrospective Study in an Outpatient Setting Anne M. Kuwabara, B.A., Barbara M. Rainer, M.D., Hatice Basdag, M.S., and Bernard A. Cohen, M.D. Division of Pediatric Dermatology, Departments of Pediatrics and Dermatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
Abstract Background: The purpose is to investigate the demographics and course of common warts in children in an outpatient setting. Methods: A retrospective medical chart review and telephone survey study were completed on an outpatient cohort of children (0–17 yrs) with a clinical diagnosis of warts at a single-center, university-based pediatric dermatology practice. The main outcome measures included management, time to resolution, and associated factors of warts in children. Results: Of the 254 patients we contacted, 214 agreed to participate in the survey. The most commonly involved sites were the hands and the head and neck area. Most children received some form of therapy, but it is unclear that any form of treatment altered the course. However, children with a medical history of childhood infections or more than one anatomic site had significantly greater risk of having a longer time to resolution. Conclusion: Warts resolved in 65% of children by 2 years and in 80% within 4 years, regardless of treatment. With the exception of a history of childhood infections and having more than one anatomic site, time to resolution was not altered by wart or patient characteristics. Thus counseling without aggressive destructive treatment is a reasonable approach to managing warts in most children. Our findings will provide guidance in the process of shared decision making with parents and children.
Warts are common benign tumors of the skin and mucous membranes caused by the human papilloma virus (HPV) (1). Although the prevalence of warts is 5% to 10% in children, there is only limited epidemiologic data on this common viral infection (2,3). Warts in immunocompetent children are usually
harmless and tend to resolve spontaneously without treatment within months to years as a result of natural immunity, although they can be associated with embarrassment and social stigma (4). Practitioners employ a variety of treatments, including topical therapies (e.g., salicylic and squaric acid, duct tape
Address correspondence to Barbara M. Rainer, M.D., Department of Dermatology, Johns Hopkins University School of Medicine, 601 N Caroline Street, Baltimore, MD 21287, or e-mail: [email protected]. DOI: 10.1111/pde.12584
© 2015 Wiley Periodicals, Inc.
679
680 Pediatric Dermatology Vol. 32 No. 5 September/October 2015
occlusion therapy, imiquimod, tretinoin) and locally destructive measures (e.g., cryotherapy, electrocautery, curettage, carbon dioxide and pulsed dye laser, surgical excision) (5). Most of these interventions are painful, expensive, or time or labor intensive. Highquality data on the efficacy of treatments (6) and whether treatment hastens the resolution of warts are scarce. Thus we conducted a retrospective medical chart review and telephone survey of 214 children with warts to report management, time to resolution, and associated factors to better inform clinical practice.
PATIENTS AND METHODS Study Design The Johns Hopkins Institutional Review Board approved the study protocol, which was a singlecenter, retrospective survey study to determine time to resolution and response to treatment of warts in children. Retrospective medical chart reviews and telephone interviews were conducted at the Johns Hopkins Pediatric Dermatology Clinic in Baltimore, Maryland, between April 2013 and August 2013. Patients and Survey Methods Eligible patients were younger than 18 years of age at the time of clinical diagnosis of warts as assessed by a pediatric dermatologist at the Johns Hopkins Pediatric Dermatology Clinic between January 2008 and December 2012. Patients and their families were first notified by mail that they had been enrolled in the study and could opt out by returning the letter. Each patient’s household was called at different times of the day and on different days to optimize contact with a parent. At least 10 attempts were made to contact a resident of each household between the hours of 8 A.M. and 10 P.M. on all days of the week to minimize selection bias related to availability of respondents who were at home during the day. If the affected individual was a minor, the initial respondent acted as a surrogate for the minor and completed the interview. Telephone interviews were conducted to assess demographic characteristics (age, sex, race), wart characteristics (number, distribution), management, side effects, time to resolution, and personal medical history (atopic dermatitis, asthma, allergies [food, drug, respiratory], and history of childhood infections (e.g., ear, throat, skin, pneumonia, any serious internal infections such as meningitis). The collected
data were verified using the patients’ medical records in the Johns Hopkins Electronic Patient Records database. Duration to diagnosis was defined as the time (in months) from when parents noted warts until an examining pediatrician or dermatologist diagnosed the lesions. Time to resolution of warts was defined as the time (in months) from when the patient or family member first noticed the lesions until their complete resolution. Statistical Analysis Categorical variables were compared using chi-square and Fisher exact tests as appropriate. SPSS Statistics 21 (SPSS, Chicago, IL) was used for data analysis. The significance level was p < .05.
RESULTS Patients Of 252 identified children, 214 (85%) participated in this study. Those who did not participate did not speak English, could not be reached, or did not want to participate in the survey. The median age at diagnosis was 9 years (interquartile range 6– 12 years), 116 (54.2%) were male and 115 (72.4%) were Caucasian. Forty-four (20.6%) children had a history of atopic dermatitis and 16 (7.5%) children had a history of childhood infections. Demographic and medical history characteristics are presented in Table 1. TABLE 1. Patient Characteristics (N = 214) Characteristic Age, years, median (interquartile range) Sex, n (%) Male Female Race, n (%) Caucasian African American Hispanic Asian Other Past medical history, n (%) Atopic dermatitis Asthma History of infections Food allergy Drug allergy Respiratory allergy Molluscum contagiosum Poison ivy
Value 9 (6–12) 116 (54.2) 98 (45.8) 155 (72.4) 31 (14.5) 4 (1.9) 6 (2.8) 18 (8.4) 44 22 16 17 13 9 9 5
(20.6) (10.3) (7.5) (7.9) (6.1) (4.2) (4.2) (2.3)
Kuwabara et al: Retrospective Study of Warts in Children 681
TABLE 2. Wart Characteristics Characteristic
TABLE 3. Management of Warts and Side Effects n (%)
Number of lesions at diagnosis
