LAUSR

Dear Editor, Anogenital warts, especially on the penile region are rare in children. Treatment can be challenging due to their recurrent nature and destructive property of most treatment modalities. Here, we report a case of florid anogenital warts in a 7-month boy with dramatic response to imiquimod 5% cream. A 7-month-old boy presented with cauliflower-like growth on the penis, scrotum and perianal region for last 3.5 months. The baby was born by a term normal vaginal delivery at a hospital. The child was circumcised in a non-hospital setting 2 weeks before the onset of the lesions. No history of sexual abuse could be elicited. On examination, multiple skin colored verrucous papules coalescing to form plaques were seen on the glans penis, penile shaft and scrotum (Figures 1A, B). Single verrucous papule was prsent in the perianal region. The child's parents did not have any evidence of cutaneous or anogenital warts. Both parents' and child's venereal disease research laboratory (VDRL) and human immunodeficiency virus (HIV) serologies were negative. Histopathology from penile lesion showed basket weave hyperkeratosis, papillomatosis, prominent granular layer, koilocytes in the stratum granulosum and dilated blood vessels in the papillary dermis (Figures S1A and S1B). Tissue polymerase chain reaction (PCR) was positive for human papillomavirus (HPV) 11 (Figure S1C). After explaining the possibility of spontaneous resolution of the lesions and discussing the treatment options available, the parents insisted on active intervention. The child was started on imiquimod 5% cream to be applied once at bedtime on alternate days for 6 weeks. The parents could not bring the child for follow-up due to the ongoing COVID-19 pandemic. The lesions cleared completely after 6 weeks of imiquimod, with no side effects, according to the image provided by the parents (Figure 1C). There was no recurrence at 8 months of follow-up, as per telephonic consultation. Extensive anogenital warts are uncommon in children. Most of these are asymptomatic, but can be associated with ulceration, pain and bleeding, making treatment necessary. Large anogenital warts in children can be challenging to manage, with no specific treatment guidelines. Sexual abuse must be considered, especially if the child is more than 3 years of age. A study found that male circumcision decreased the acquisition and increased the clearance of high-risk HPV in adults. However, in our case the lesions started after circumcision, which may be attributed to the non-hospital setting in which it was done. Most modalities for the treatment of anogenital warts are destructive, with limited acceptability in children. Topical medications such as imiquimod 5%, podofilox 0.5%, sinecatechins ointment 15% and diphenylcyclopropenone have been used in children with encouraging results. Imiquimod is an immune stimulator that acts on the Toll-like receptors (TLRs)7 and 8 and enhances production of interferons, tumor necrosis factor-α and interleukins1, 6 and 8.