Wart and Molluscum Management Made Easy

Squaric acid, a topical immunotherapy, is a fairly painless wart treatment, and the recurrence rate is fairly low among patients who respond, Dr. Mancini said. Allergic contact dermatitis can occur with this treatment, but it is not usually limiting.

Imiquimod is approved for genital warts with a recommended application frequency of 3 times per week, but it can be effective as an off-label treatment for common warts in children when applied once or twice daily, Dr. Mancini said.

Chemotherapy, in the form of 5% 5-fluorouracil (5-FU), also can be used off-label for warts in children, and is particularly useful for flat warts. Dr. Mancini recommends an application of 5-FU to the wart 3 nights each week, with the caveat that this treatment can result in severe dermatitis.

The injection of fungal antigens into the warts has been shown to be effective in some patients, possibly by inducing a host immune response directed at the human papillomavirus-infected tissue. Candida antigen injections have demonstrated some effectiveness, and are injected into 1–3 warts at each of two or three visits. As with other forms of topical or injection immunotherapy, untreated lesions often resolve on a parallel time frame to the involution of treated lesions.

Finally, laser therapy can be used to treat warts. Laser therapy, which is usually done with a pulsed dye laser, probably works by targeting the blood supply to the wart.

Dr. Mancini generally reserves this mode of therapy as a last resort, and it often requires several treatment sessions.

Molluscum Contagiosum

Mollusca have become more common than warts in many practices, Dr. Mancini noted. The condition is spread by skin-to-skin contact and possibly via fomites. Public swimming pools frequently are cited as a potential source of infection transmission.

Mollusca present as dome-shaped waxy papules, and often occur in conjunction with an associated dermatitis (“molluscum dermatitis”). The spontaneous resolution rate is nearly 100%, he said, although it may take 12–18 months, or longer. Remind parents that when the molluscum lesions suddenly and synchronously turn red, it is a good sign; it usually signals that the host immune response has kicked in, Dr. Mancini noted.

Despite a physician's efforts at reassurance of their self-limiting nature, many families want to treat mollusca. Treatment options have some overlap with those used for warts, and include chemovesicants, curettage, cryotherapy, imiquimod, cidofovir, tretinoin cream (especially for the face), and laser treatments.

Cantharidin, made from the extract of the Chinese blister beetle (Cantharis vesicatoris) is clearly the most effective treatment for mollusca in children. When used correctly, it has been demonstrated as safe and effective in the treatment of mollusca.

Dr. Mancini cited a study from his practice in which 90% of 300 molluscum patients cleared after cantharidin treatment, and another 8% improved. “It was very well-tolerated, and about 95% of parents said that they would choose this therapy again for their child.”

Cantharidin is not approved by the Food and Drug Administration, but was nominated for inclusion on a list of bulk drug substances that may be used in compounding and applied by the physician in the professional office setting.

Cryotherapy is safe when performed by an experienced physician, but it is important not to overfreeze the area. DR. MANCINI

Common warts are shown prior to treatment by Candida antigen injection therapy.

The warts have resolved following two injections into the lesions.

A host immune response (erythema, edema) is shown in two molluscum contagiosum lesions. Photos courtesy Dr. Anthony J. Mancini