July 1996
WASHINGTON, D.C. — Anogenital warts in a young child may signal sexual abuse, but then again, they may not, said Bernard Cohen, MD.
This does not mean that abuse should not be considered, but a careful evaluation needs to be done before any accusations are made, Cohen suggested at the American Academy of Dermatology meeting here.
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Cohen has been involved in studies that looked at anogenital warts in children, and found that many of the infections were not a result of sexual abuse. "The bottom line is that the majority of these patients had no evidence of sexual abuse and by extensive Social Service and medical evaluation were not felt to be at high risk for sexual abuse," said Cohen, who is director of pediatric dermatology at Johns Hopkins Childrens Center in Baltimore.
Paul Honig and colleagues in Philadelphia have looked at 73 children; Cohen has looked at 50 children in Pittsburgh and has studied another cohort in Baltimore. Most of the children were younger than 3 years old; more than half were younger than 2. Many of the children had been referred by the local child protection agency as potential abuse victims. "We identified children with anogenital warts as having true [common] warts in the diaper area," Cohen said.
The children were given a careful examination. "In many cases where there was some difficulty in identifying the extent of the disease, we used acetic acid wash to identify lesions." The investigators did a careful social service evaluation, photo documentation, and when possible sampled lesions for testing. The children also were screened for other sexually transmitted diseases (STDs).
"Basically what we found was that only rarely were these children, after extensive evaluation, thought to be in a situation that was a high risk for sexual abuse," he said.
Many of the warts that were typed were human papillomavirus types 1 and 2, the most frequent cause of common warts. Many of the adult caregivers had common warts on their hands and feet, he said. This implies that the children may have been infected during routine care, such as changing diapers or bathing, not from sexual abuse.
"I recommend to both dermatologist and pediatricians that careful, routine examinations of the anogenital area are important, and this is particularly important for pediatricians who are doing regular health checks. It [sexual abuse] is something that needs to be considered if lesions are present," he said.
"There certainly are patients who have acquired these in a venereal fashion, so the issue of child abuse needs to be raised. These children need a careful examination of the skin to make sure that there are no other signs of child abuse."
Any physician who is uncomfortable dealing with this issue, should refer these patients to "someone in your community who routinely evaluates these patients," he added.
Another issue about anogenital warts that pediatricians face is the increasing number of cases among sexually active teenagers. HPV is "probably the most common cause for a consultation when it comes to STDs [in adults], far outpacing herpes simplex," Cohen said. "The issue for those of us who take care of children is that there has been an incredible explosion of these cases in adolescents and even preadolescents and young adults, and these are the patients who have the children who we deal with who present with anogenital lesions."
Most people will develop clinical lesions within three months of direct exposure. Early in the epidemic, the warts were associated with HPV types 6 and 11, but now types 16, 18, 32, 42 through 45 are all associated with genital warts. This may be important later, because types 16, 18, 42 through 45 have been associated with an increased risk of genital skin malignancy. A question that remains about treating children for these lesions is the long-term follow-up. "How do we follow these children, and in fact what is the risk? No one knows that long-term risk," Cohen said.
Presented at the American Academy of Dermatology 54th annual meeting, Feb. 10-15, Washington, D.C.
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