REVIEW

CURRENT
OPINION Childhood skin and soft tissue infections: new
discoveries and guidelines regarding the
management of bacterial soft tissue infections,
molluscum contagiosum, and warts
Jessica Rush a and James G. Dinulos b,c

Purpose of review
Pediatric skin and soft tissue infections (SSTIs) constitute a significant number of office-based pediatric visits.
With SSTIs on the rise, it is not only important to effectively treat the individual, but to do so appropriately
and cost-consciously. In this article, we highlight new research related to the treatment of bacterial skin
infections, molluscum contagiosum, and cutaneous warts, with the goal of guiding pediatricians in their
practice against these common skin conditions.
Recent findings
Recent data supports the use of topical antibiotics for noncomplicated impetigo. Systemic antibiotics
covering gram-positive cocci are recommended for complicated cases of impetigo and deeper nonpurulent
SSTIs. Localized purulent bacterial SSTIs can be treated with incision and drainage alone but more systemic
involvement warrants treatment with systemic antibiotics covering Staphylococcus aureus species, especially
community acquired methicillin-resistant S. aureus. For the treatment of molluscum contagiosum, topical
cantharidin has a high satisfaction rate among patients and providers. Potassium hydroxide solution is a
potentially effective and cheap form of molluscum contagiosum treatment. Imiquimod, however, has an
unfavorable efficacy and safety profile as a therapy for molluscum contagiosum. Regarding warts, high-risk
human papilloma virus strains have been detected in cutaneous warts in children.
Summary
The high-risk human papilloma virus vaccine may play a role in treating pediatric cutaneous warts in the
future, and topical squaric acid dibutylester may effectively treat recalcitrant warts. Finally, both molluscum
contagiosum and warts have a high rate of resolution after an extended period of time without any
intervention.
Keywords
impetigo, molluscum contagiosum, skin infections, verruca vulgaris

INTRODUCTION BACTERIAL INFECTIONS

Pediatric cutaneous infections represent a signifi-
cant number of all pediatric office-based visits. Some
of these infections include purulent and nonpuru-
lent bacterial skin and soft tissue infections (SSTIs)
and viral skin infections, including molluscum con-
tagiosum and warts. With pediatric SSTIs on the rise,
there are growing health and economic burdens
placed on both society and the individual. This
article aims to highlight new discoveries and evi-
dence regarding certain SSTIs to guide office-based
pediatricians in their management of common
pediatric cutaneous infections in a way that maxi-
mizes benefit to the patient and minimizes harm
to society.
Background information
A US national study between 1997 and 2005 dem-
onstrated a significantly increased incidence of
bacterial SSTIs presenting to primary care practices
a
Dartmouth Medical School, bGeisel School of Medicine at Dartmouth,
Hanover, New Hampshire and cUniversity of Connecticut, Farmington,
Connecticut, USA
Correspondence to James G. Dinulos, MD, Seacoast Dermatology, 330
Borthwick Avenue, Suite 303, Portsmouth, NH 03801, USA. Tel: +1 603
431 5205; fax: +1 603 436 4257; e-mail: jdinulos@gmail.com
Curr Opin Pediatr 2016, 28:250–257
DOI:10.1097/MOP.0000000000000334

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Simple cases of impetigo should be treated with topical
antibiotics while complicated cases of impetigo and
other nonpurulent SSTIs affecting deeper subcutaneous
tissues should be treated with systemic antibiotics.
 Noncomplicated purulent SSTIs can be treated with I&D
alone but evidence of systemic involvement requires the
use of systemic antibiotics covering S. aureus,
especially CA-MRSA in severe cases.
 Cantharidin is a noninvasive, safe, and efficacious
therapy against molluscum contagiosum. With more
research, potassium hydroxide solution may prove to
be a cheap and effective treatment against molluscum
contagiosum.
 Imiquimod is not a preferred therapy for molluscum
contagiosum because of its limited efficacy and
unfavorable safety profile.
 HPV-16, a high risk HPV strain, has been identified in
cutaneous warts in children.
 The HPV vaccine may prove to be an important
treatment against extragenital cutaneous warts among
children in the future.
and emergency departments, with a disproportion-
ate increase in patients younger than 18 years old
[1]. Numerous other studies have confirmed the
increased incidence of SSTI visits paralleling an
increased incidence of community acquired methi-
cillin-resistant Staphylococcus aureus (CA-MRSA)
since it emerged in the 1990s [2,3]. A retrospective
study of US SSTI hospitalizations found that the
incidence of S. aureus SSTIs increased by 105%
between 2001 and 2009, with persons less than
18 years old representing the age group with the
greatest relative rise of S. aureus SSTI-related hospi-
talizations. S. aureus SSTI-associated hospitalizations
of children less than 18 years old cost an estimated
4.22 billion dollars, representing a 61% increase in
cost since 2001 [4]. Furthermore, as prescribers are
tailoring their antibiotics of choice to the growing
number of CA-MRSA SSTIs [3], there is increasing
concern and evidence for resistance to these com-
monly prescribed medicines. Therefore, using the
appropriate therapy for bacterial SSTIs has import-
ant implications not only for the patient but also for
public health.
Workup of bacterial infections
When working up a presumed bacterial skin infec-
tion in a child, it is important to determine whether
the infection is purulent or nonpurulent not only to
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Childhood skin and soft tissue infections Rush and Dinulos
establish the need to perform an incision and
drainage (I&D) procedure but also as a guide in
selecting the appropriate antibiotic. Although this
first step may seem straightforward, detecting an
occult abscess can sometimes be a challenge. In the
pediatric emergency department setting, when the
clinician is confident of the lesion being purulent or
not, the clinical exam alone is highly accurate in
determining the need for I&D with sensitivity 95%
and specificity 84%. The accuracy is not improved
with the addition of bedside ultrasound. However,
when there is uncertainty of the lesion requiring
I&D, addition of bedside ultrasound by trained
emergency department physicians improved the
sensitivity and specificity of correctly diagnosing
the lesion from 44 to 78% and 42 to 61%, respect-
ively [5]. Thus, for appropriately trained physicians,
using an ultrasound enhances the initial workup of
an SSTI when there is a question of whether the
lesion is purulent versus nonpurulent.
If a lesion is determined to be purulent, it is
recommended to culture and gram-stain the pus or
&
exudates [6 ]. Obtaining a blood culture has been
shown to be of low yield in uncomplicated SSTIs in
an immune-competent child. A blood culture, how-
ever, may be required in a complicated SSTI, which
is defined as a lesion that arises from a surgical or
traumatic wound infection, one that requires surgi-
cal intervention beyond an I&D, or an infected ulcer
or burn [7,8].
Management of nonpurulent soft tissue
infections: impetigo, ecthyma, cellulitis,
staph scalded skin syndrome, erysipelas,
and necrotizing fasciitis
Impetigo, classified as either bullous or nonbullous,
is caused by pathogens invading the epidermis.
Ecthyma is a nonpurulent SSTI that occurs when
pathogens invade the dermis and it can be treated
&
similarly to nonbullous impetigo [6 ].
Nonbullous impetigo accounts for more than
70% cases of impetigo. S. aureus and group A strep-
tococcus (GAS) are responsible for the vast majority
of these cases. Glomerulonephritis may arise after
cutaneous GAS infections, occurring in up to 5% of
patients with impetigo. Although treating GAS
impetigo does not reduce the risk of developing
glomerulonephritis, it reduces the risk of spreading
the nephritic strains throughout the community
[9,10].
Bullous impetigo most commonly affects
children 2–5 years old in intertriginous regions. It
is almost exclusively caused by S. aureus, which
produces exfoliative toxins that can hydrolyze
intracellular adhesion molecules located in the
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Office pediatrics
epidermal granular layer. These exfoliative toxins
can lead to blister formation, seen in both bullous
impetigo and staph-scalded skin syndrome [11]. CA-
MRSA possesses the Panton-Valentine Leukocidin
gene rather than the exfoliative toxin gene, making
CA-MRSA less likely to cause exfoliative infections
such as impetigo and more likely to cause suppu-
rative infections such as abscesses [12]. Con-
sequently, there is less need to cover CA-MRSA
when treating bullous impetigo.
Both bullous and nonbullous impetigo can be
treated with topical antibiotics, unless the disease is
associated with numerous lesions or associated with
an outbreak in the community in which case
&
systemic antibiotics are recommended [6 ]. A 2012
Cochrane review demonstrated that topical mupir-
ocin and topical fusidic acid, two commonly used
agents in treating impetigo, were found to be as
good or even better than oral treatment for impetigo
and with fewer side-effects. The study could not
discern whether or not oral antibiotics were superior
to topical antibiotics in systemic disease [13].
Topical agents used for impetigo should be
directed against gram-positive cocci, specifically
S. aureus and GAS, such as mupirocin, retapamulin,
or fusidic acid outlined by Table 1. It should be
cautioned that recent studies have documented
increasing resistance to these agents [14,15 ,16,17]
and that increased use of these agents is related to
growing resistance [16,17]. A study using in-vitro S.
aureus isolated from healthy children with SSTIs in
Texas demonstrated that 9.5% isolates were resistant
to retapamulin and 9.8% were resistant to mupir-
&
ocin [15 ]. Fusidic acid, although not marketed in
the United States, has also demonstrated S. aureus
resistance. Resistance was positively correlated to
recent prior use of fusidic acid [17]. Clearly, there
is a growing need for new therapies in the age of
increasing antibiotic resistance.
Table 1. Commonly used topical antibiotic agents used for uncomplicated impetigo and compares mechanism of action and
cost in the United Statesa
Topical Mechanism of Action
Mupirocin Competitive inhibitor of bacterial
isoleucyl-tRNA synthetase
Retapamulin Inhibition of protein synthesis by
selectively binding to bacterial
ribosomes
Fusidic acid Inhibits bacterial protein synthesis;
bacteriostatic
a
Adapted from Pereira [10].
252 www.co-pediatrics.com
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Other emerging topical therapies for impetigo
include ozenoxacin 1% cream, a new quinolone
antibiotic, and clary sage oil. A recent randomized,
double blind, multicenter study revealed that oze-
noxacin 1% used twice daily for 5 days was superior
to placebo in treating impetigo. Its use even pro-
duced a more rapid microbiological clearance than
retapamulin, the control [18]. Authors of an in-vitro
study demonstrated that clary sage oil was active
against S. aureus, S. epidermidis, and S. xylosus and
therefore suggest its use in skin infections [19].
Other nonpurulent infections, including cellu-
litis, erysipelas, and necrotizing fasciitis, represent
pathogen invasion of the deeper subcutaneous tis-
sue. Systemic antibiotics are warranted for these
infections and are appropriately outlined in Fig. 1,
taken from the 2014 SSTI Executive Summary by the
Infectious Diseases Society of America. Recent stud-
ies have shown that nonpurulent cellulitis is most
commonly caused by Streptococcus species and is
sufficiently treated by antibiotics targeting GAS
and methicillin susceptible S. aureus (MSSA), that
is, cephalexin use alone rather than cephalexin in
addition to TMP–SMX [20–22].
Staph-scalded skin syndrome (SSSS) is a toxin-
mediated skin disease commonly affecting children
less than 5 years of age that causes painful desqua-
&
mation around orifices and flexural surfaces. It is a
pediatric emergency because it can be complicated
by sepsis, superinfection, and electrolyte imbalances
with a 5% mortality rate [23]. A recent study per-
formed in a US city suggests that clindamycin and a
penicillinase-resistant penicillin should be provided
as empiric treatment for SSSS until culture suscepti-
bility data are available to dictate therapy [24].
Another study in China advised the immediate
treatment with cephalosporins, b lactamase-resist-
ant semisynthetic penicillins, or both when suspi-
cious for SSSS [25]. It is important that one considers
Comment Cost (in US)
Active against most gram-positive and some Ointment 2% (22 g) $42.75
gram-negative bacilli
Bacteriostatic, so bacterial eradication may not Ointment 1% (15 g) $181.97
occur after clinical cure
Can be used in children >9 months
Active against S. aureus, less so against Not available in US
Streptococcus and Propionibacterium acnes
Not active against gram-negative bacilli
Not marketed in the United States
Volume 28  Number 2  April 2016
 Childhood skin and soft tissue infections Rush and Dinulos

Management of
Nonpurulent SSTIs Purulent
Necrotizing infection/cellulitis/erysipelas furuncle/carbuncle/abscess

Severe Moderate Mild Severe Moderate Mild

 Emergent surgical Intravenous Rx Oral Rx I&D I&D I&D

Inspection / debridement • Penicillin or • Penicillin VK or C&S C&S
 Rule out necrotizing process • Ceftriaxone or • Cephalosporin or
 EMPIRIC Rx • Cefazolin or • Dicloxacillin or
• Vancomycin PLUS • Clindamycin • Clindamycin
piperacillin/tazobactam
Empiric Rx1
• Vancomycin or Empiric Rx
• Daptomycin or • TMP/SMX or
C&S
• Linezolid or • Doxycycline
• Telavancin or
Defined Rx (necrotizing infections) • Ceftaroline
monomicrobial Streptococcus
pyogenes Defined Rx
Defined Rx MRSA
• Penicillin PLUS clindamycin MRSA • TMP/SMX
Clostridial sp. • See empiric
MSSA
• Penicillin PLUS clindamycin MSSA • Dicloxacillin or
Vibrio vulnificus • Nafcillin or
• Cephalexin
• Doxycycline PLUS ciprofloxacin • Cefazolin or
Aeromonas hydrophila • Clindamycin
• Doxycycline PLUS ciprofloxacin
Polymicrobial 1Since daptomycin and telavancin are not approved for use in children,
• Vancomycin PLUS vancomycin is recommended; clindamycin may be used if clindamycin
piperacillin/tazobactam resistance is <10–15% at the institution.

FIGURE 1. Purulent skin and soft tissue infections (SSTIs). Mild infection: for purulent SSTI, incision, and drainage is indicated.
Moderate infection: patients with purulent infection with systemic signs of infection. Severe infection: patients who have failed
incision and drainage plus oral antibiotics or those with systemic signs of infection such as a temperature >388C, tachycardia
(heart rate >90 beats/min), tachypnea (respiratory rate >24 breaths/min) or abnormal white blood cell count, or
immunocompromised patients. Nonpurulent SSTIs. Mild infection: typical cellulitis/erysipelas with no focus of purulence.
Moderate infection typical cellulitis/erysipelas with systemic signs of infection. Severe infection: patients who have failed oral
antibiotic treatment or those with systemic signs of infection (as defined above under purulent infection), or those who are
immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence
of organ dysfunction. C&S, culture and sensitivity; I&D, incision and drainage; MRSA, methicillin-resistant Staphylococcus
aureus; MSSA, methicillin-susceptible Staphylococcus aureus; Rx, treatment; TMP/SMX, trimethoprim-sulfamethoxazole.
Adapted from Stevens et al. [6 ]. &

the local strains and resistance patterns of his or her who have failed initial antibiotic treatment, or those
community prior to selecting empiric therapy for with impaired host defenses. Table 2 lists appropri-
presumed SSSS. ate antibiotic therapy for both MSSA and MRSA
SSTIs.

Management of purulent soft tissue

infections
Purulent SSTIs include furuncles, carbuncles, and
abscesses. Incision and drainage is warranted in all
purulent SSTIs. Current research suggests that unless
there is evidence of systemic symptoms or a com-
plicated SSTI, children should not be treated with
additional antibiotics [26,27]. As outlined in Fig. 1,
oral antibiotic treatment for MRSA is warranted in
patients with signs of systemic inflammatory
response syndrome and hypotension, patients
VIRAL INFECTION
Molluscum contagiosum
Molluscum contagiosum, a common skin condition
seen by pediatricians, is caused by the pox-virus
known as the molluscum contagiosum virus. A
recent review found that molluscum contagiosum
is most common in children aged 1–4 and is associ-
ated with swimming and eczema without a clear
causal relationship. There was inconclusive

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Office pediatrics

Table 2. Appropriate treatment and dosing for impetigo, methicillin susceptible S. aureus soft tissue infections, and methicillin-
resistant S. aureus soft tissue infections
Disease entity Antibiotic: dosage, children Comment

Impetigo (Staphylococcus Dicloxacillin: N/A N/A

and Streptococcus) Cephalexin: 25–50 mg/kg/day in 3–4 divided
doses PO
Erythromycin: 40 mg/kg/day in 3–4 divided doses
PO
Clindamycin: 20 mg/kg/day in three divided
doses PO
Amoxicillin–clavulanate: 25 mg/kg/day of the
amoxicillin component in two divided doses PO
Retapamulin ointment: apply to lesion BID
Mupirocin ointment: apply to lesion BID
MSSA SSTI Nafcillin or oxacillin: 100–150 mg/kg/day in four
divided doses
Cefazolin: 50 mg/kg/day in three divided doses
Clindamycin: 25–40 mg/kg/day in three divided
doses IV or 25–30 mg/kg/day in three divided
doses PO
Dicloxacillin: 25–50 mg/kg/day in four divided
doses PO
Cephalexin: 25–50 mg/kg/day in four divided
doses PO
Doxycycline, minocycline: not recommended for
age <8 years
Trimethoprim–sulfamethoxazole: 8–12 mg/kg
(based on trimethoprim compound) in either four
divided doses IV or two divided doses PO
MRSA SSTI Vancomycin: 40 mg/kg/day in four divided doses
IV
Linezolid: 10 mg/kg every 12 h IV or PO for
children <12 years
Clindamycin: 25–40 mg/kg/day in three divided
doses IV or 30–40 mg/kg/day in three divided
doses PO
Daptomycin: N/A
Ceftaroline: N/A
Doxycycline, minocycline: not recommended for
age <8 years
Trimethoprim–sulfamethoxazole: 8–12 mg/kg/day
(based on trimethoprim component) in either four
divided doses IV or two divided doses PO
N/A
Some strains of S. aureus and S. pyogenes may be
resistant
N/A
N/A
For patients with limited number of lesions
For patients with limited number of lesions
Parental drug of choice; inactive against MRSA
For penicillin-allergic patients except those with
immediate hypersensitivity reactions. More
convenient than nafcillin with less bone marrow
suppression
Bacteriostatic: potential of cross-resistance and
emergence of resistance in erythromycin-resistant
strains; inducible resistance in MRSA
Oral agent of choice for methicillin-susceptible
For penicillin-allergic patients except those with
immediate hypersensitivity reactions
Bacteriostatic: limited recent clinical experience
Bactericidal; efficacy poorly documented
For penicillin allergic patients; parenteral drug of
choice for treatment of infections caused by
MRSA
Bacteriostatic; limited clinical experience; no cross-
resistance with other antibiotic classes; expensive
Bacteriostatic: potential of cross-resistance and
emergence of resistance in erythromycin-resistant
strains; inducible resistance in MRSA. Important
option for children
Bactericidal; possible myopathy
Bactericidal
Bacteriostatic; limited recent clinical experience
Bactericidal; limited published efficacy data

BID, twice daily; IV, intravenous; MRSA, methicillin-resistant S. aureus; MSSA, methicillin susceptible S. aureus; PO, by mouth; SSTIs, soft tissue infections.
a &
Adapted from Stevens et al. [6 ].

evidence regarding risk factors, duration of symp-
toms, transmission between family members, or
temporal and geographic incidence of molluscum
contagiosum [28]. Occasionally, molluscum conta-
giosum can be symptomatic in children with atopic
dermatitis and can manifest as a hypersensitivity
reaction known as ‘molluscum dermatitis’ [29].
Severe cases of molluscum contagiosum can also
present in immunocompromised patients who are
often recalcitrant to standard therapy. Most of the

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time however, molluscum contagiosum is con-
sidered a benign and self-limited disease for which
treatment is sought for cosmetic purposes and to
prevent the spread of the virus [30].
Despite numerous studies looking into mollus-
cum contagiosum therapy, there is no consensus
on the best treatment. Forms of therapy include
destructive therapies and techniques, immune-
modulating therapies, and antiviral therapies. Treat-
ment should in part be guided by a child’s personal
tolerance to the mode therapy.
Cryotherapy, curettage, and cantharidin are
three forms of destructive therapy that demonstrate
clinical response. Among them, cantharidin is the
least intrusive. It is an extract from blister beetles
and acts as a protein phosphatase inhibitor. It is
applied directly to lesions and covered for 2–6 h
after which it should be washed off with soap and
water. It can be repeated every 2–4 weeks until
resolution occurs. A prospective double-blinded,
placebo-controlled, randomized controlled trial
(RCT) found that after 2 months, the effects of
cantharidin treatment on molluscum contagiosum
lesions were not much better than the placebo [31].
The study, however, was small and was shown to be
underpowered to yield a statistically significant
result [32,33]. Although there are no other double
blind RCTs comparing cantharidin to placebo, there
is numerous retrospective and anecdotal data sup-
porting cantharidin’s efficacy in treating molluscum
contagiosum [32,33]. A comprehensive literature
review of studies looking at cantharidin treatment
for molluscum contagiosum concluded that can-
&
tharidin is a safe and effective treatment [34 ]. In
a study that sought to create a safety profile for
cantharidin, the authors found that 86% parents
reported satisfaction with the treatment and 11%
endorsed adverse effects with pain being most com-
mon (7%) and severe blistering being second most
common (2%) [35].
Potassium hydroxide (KOH) solution is another
form of destructive therapy that has demonstrated
promise as a potential treatment for molluscum
contagiosum. In a recent trial, children with mol-
luscum contagiosum lesions were treated with
either 10% KOH solution or 5% imiquimod, an
immune-modulating topical therapy intended to
induce an inflammatory response against mollus-
cum contagiosum lesions. After 12 weeks, 17 out of
20 patients who received KOH therapy showed com-
plete resolution, whereas only 10 out of 20 patients
receiving imiquimod showed total clearance of the
lesions. Patients receiving KOH, however, had more
frequent adverse effects, specifically pigmentary
disturbances. With these data, the authors suggest
that KOH 10% may be an inexpensive and effective
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Childhood skin and soft tissue infections Rush and Dinulos
therapy for molluscum contagiosum despite the
adverse effects [36]. In another small study of 30
children with molluscum contagiosum, KOH was
found to be equally effective to cryotherapy with
fewer rates of postinflammatory hyperpigmenta-
tion. In total, 15 patients were treated with KOH
10% solution applied twice daily until the lesions
disappeared completely and 15 patients were treated
with weekly cryotherapy for 4 weeks [37]. KOH has
yet to be studied against cantharidin. Although
more studies need to better evaluate the efficacy
of KOH and determine the optimal solution
required for treatment, it is a potentially inexpen-
sive alternative form of therapy for molluscum con-
tagiosum.
Imiquimod has been a longstanding, commonly
prescribed, and expensive form of treatment for
molluscum contagiosum that has recently been
shown to be neither efficacious nor safe in the treat-
ment of molluscum contagiosum. A recent article
revealed that two unpublished RCTs performed in
2006 demonstrated poor therapeutic efficacy of imi-
quimod in treating molluscum contagiosum. The
RCTs also highlighted imiquimod side effects such
as application-site reactions, leukopenia, and lym-
&
phadenopathy [38 ]. Imiquimod is therefore out of
favor as a first-line treatment against molluscum
contagiosum.
Finally, in a retrospective review performed at
Johns Hopkins Medical Center, treatment, sex, race,
diagnosing physician (dermatologist versus pedia-
trician), number of lesions at diagnosis, number of
anatomic locations, or history of atopic dermatitis
did not predict time to resolution, nor did treatment
shorten time to resolution. Regardless of treatment
or not, molluscum contagiosum lesions completely
resolved in about 50% of children within 1 year and
70% of children within 18 months [39]. Foregoing
treatment is a reasonable approach to molluscum
contagiosum in healthy children who cannot toler-
ate therapy because of adverse effects and who do
not desire an immediate response.
Warts
Cutaneous warts are caused by the human papillo-
mavirus virus (HPV). Cutaneous warts are com-
monly caused by HPV strains with low malignant
potential including 1, 2, 3, 4, 27, and 57. Up until a
recent study in Greece, only low-risk HPV strains
had been detected in the warts of immune-compe-
tent children. However, the study in Greece found
that HPV 16, a high-risk strain found in mucosal
warts, was detected in 33% of the cutaneous warts
that were positive for HPV. Although the malignant
potential of these warts is unclear, the authors
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Office pediatrics
suggest that these data may be important when
determining who should receive HPV vaccines
and which strains should be included in these
vaccines [40].
There is also emerging research regarding the
utility of the HPV vaccine in the treatment of
cutaneous warts. A 2015 study in Germany showed
that six out of six children aged 9–11 years old
who had therapy-resistant extragenital warts for
at least 32 months demonstrated a complete
recovery after three doses of the quadrivalent HPV
vaccine targeted against HPV-6, 11, 16, and 18. Not
included in the study were three out of six adoles-
cents 14–17 years old and three out of four adults
who did not experience resolution of their extra-
genital warts after vaccination. The authors pro-
posed that the vaccine induces a cross-protective
effect against various HPV strains explaining why
children cleared their warts despite vaccination with
four strains not typically associated with cutaneous
warts. The authors also hypothesized that the
vaccine was more effective in children compared
to adolescents and adults because the major histo-
compatibility complex class I molecule of the HPV-
infected cell disappears with puberty, resulting in a
decrease in the vaccine-induced HPV-specific cyto-
toxic T-cell immune response in adolescence and
adults [41]. More studies must be performed to
further evaluate the efficacy of the HPV vaccine in
treating recalcitrant cutaneous warts.
Currently, the treatment options for warts are
numerous and include physically destructive or
immunomodulating modes of therapy. Examples
of destructive methods include cryotherapy, sali-
cylic acid, cantharidin, and paring or excision.
Topical immunotherapy examples include 5-fluo-
rouracil, imiquimod, and intralesional antigens. A
recent study looked at the efficacy of a contact
sensitizer known as squaric acid dibutylester
(SADBE), which causes a type IV hypersensitivity
reaction leading to cell-mediated response against
the hapten-bound viral proteins. Full long-term fol-
low-up was obtained in 48 children with recalcitrant
warts who were treated with SADBE. In total, 83% of
those patients reported complete resolution of warts
and 60% reported no side-effects, suggesting its
efficacy and safety in treatment of recalcitrant warts
&
in children [42 ].
Finally, in a retrospective medical chart review
and telephone survey among an outpatient cohort
of 214 children less than 18 years old with a clinical
diagnosis of warts, researchers found that warts
resolved in 65% of children by 2 years and 80%
within 4 years, regardless of treatment. Only history
of childhood infections and having more than
one anatomic site involved influenced time to
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
resolution. Therefore, the authors suggest that coun-
seling without aggressive treatment is a reasonable
&
approach to managing warts in most children [43 ].
CONCLUSION
Cutaneous infections account for a significant num-
ber of office-based pediatric visits. Recent data sup-
port the use of topical antibiotics for limited cases of
impetigo and systemic antibiotics covering gram-
positive cocci (GAS and MSSA) for more complicated
cases of impetigo and deeper nonpurulent SSTIs.
Noncomplicated purulent SSTIs can be treated with
I&D alone, but more systemic involvement should
include systemic antibiotics that cover S. aureus
species, especially CA-MRSA, in severe cases. For
viral infections including molluscum contagiosum
and warts in immune-competent children, no treat-
ment may be a sufficient option in regard to either
disease. Cantharidin has a high-satisfaction rate
among patients and providers. KOH is a potentially
effective and inexpensive form of therapy for mol-
luscum contagiosum. Imiquimod is running out of
favor as a form of molluscum contagiosum therapy
because of limited efficacy and unfavorable safety
profile. For warts, high-risk HPV types have been
detected in cutaneous warts, the HPV vaccine may
play a role in treating cutaneous warts in the future,
and topical SADBE may effectively treat recalcitrant
warts.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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