Genital Wart Treatment in an 18-Month-Old Child: Experience with Imiquimod

Dear Editor, There are limited therapeutic options, that are safe and efficacious, for the management of pediatric genital warts, especially in the younger age group (<2 years). An 18-month-old male child presented with an asymptomatic skin growth on the genitalia for past 7 months. There was an irregular, erythematous, warty growth present in a circumferential pattern on the penile tip, a similar lesion below the penile shaft, and 2–3 discrete warty lesions present on the scrotum. No other sites were involved [Figures 1 and 2]. The child’s mother denied any history of sexual abuse. She confirmed absence of similar lesions in her. The child’s father had warty lesions that resolved spontaneously. There was a history of topical application of podophyllin for 4–5 weeks, without any improvement. Podophyllin application was associated with side effects in the form of irritation and erosions/ulcerations. All routine biochemical investigations were within normal limits. The child’s and his parents’ non-treponemal test (venereal disease research laboratory, VDRL) and treponemal test (treponema pallidum hemagglutination assay, TPHA) for syphilis, hepatitis B and C, and HIV were non-reactive.Figure 1: Well-defined erythematous warty lesions on the distal end of the penile shaft in a circumferential distributionFigure 2: Well-defined erythematous warty lesions on the median raphe of the scrotum and base of the penile shaftDiagnosis of genital warts was made, and he was treated with the application of trichloroacetic acid (TCA) 80% weekly, along with oral zinc suspension (10 mg) daily. After eight weekly applications of TCA, there was minimal improvement (25%). Since the parents were not satisfied with treatment response, further application was stopped. Imiquimod 5% was started as short-contact therapy for 5–6 hours on alternate days. Later, a regimen of 12-hour applications, three times a week, was advised. After 2–3 applications, the child developed erosions and macerations due to the improper application technique. The imiquimod application was temporarily withheld, and topical 2% mupirocin was prescribed. Imiquimod application was restarted after the erosions healed. The child’s parents were advised about precautions to be observed. The patient had total clearance of all warts without any residual pigmentary changes and scarring after 5–6 weeks [Figure 3]. The child continued to be under supervision till reporting, without any relapse. We referred the child to the “one stop center”, at our institute for further evaluation in view of the provisions of the Protection of Children from Sexual Offences Act, 2012 (POSCO).Figure 3: Complete resolution of all warty growthsGenital warts are caused mostly by low-risk types of human papilloma virus (HPV) types 6 and 11. The modes of transmission of HPV virus in children are both sexual and non-sexual. Non sexual modes are - vertical transmission from mother to child, auto inoculation, or direct contact from a caretaker infected with either genital or common warts. The genital warts may resolve spontaneously, or they may grow in size and number. Both the type of HPV and the site of infection are responsible for the clinical appearance of the warts. Various therapeutic options include topical applications of preparations like podophyllin, TCA, physical removal of wart by cryotherapy, electrocautery, photodynamic therapy, and laser. Treatment of genital warts in pediatric populations may be challenging in comparison to adults. Therapeutic options depend on various factors like the age of the child, the site and extent of lesions, and social and family factors.[1,2] Treatment options for the pediatric population, such as chemical cauterization, cryotherapy, electrocautery, laser vaporization, and surgical excision, are often painful, and may result in scarring, and require frequent visits.[2] Imiquimod is a topical synthetic immunomodulator, which enhances both innate and acquired immunity by stimulating toll-like receptors and stimulates the production of interferon alpha, tumor necrosis factors, and other cytokines to inhibit viral replication. Imiquimod 5% is approved for external warts in children aged 12 years and older[3] and is a first-line treatment for anogenital warts in this age group.[4] There are several reports in the literature showing the efficacy of its use in the pediatric population, with cure rates of up to 75%.[5] Only a few case reports have demonstrated the safety and effectiveness of imiquimod in the treatment of genital warts in children [Table 1].[6-17] Imiquimod is generally well tolerated. Side effects like local pain, erythema, pruritus, irritation and erosion are generally mild and limited to the site of application. Flu- like symptoms occur rarely. Our case had genital warts that caused disfigurement and pain while retracting the prepuce. The child failed to respond to conventional treatments. He had a dramatic improvement with the application of imiquimod 5%, resulting in a total cure without any recurrence till the time of reporting.Table 1: Previous publications reporting use of imiquimod in infants and young children with anogenital wartsDeclaration of patient consent The authors certify that they have obtained all appropriate parent consent forms. In the form a parent has given their consent for his images and other clinical information to be reported in the journal. The parent understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.