Successful treatment with carbon dioxide laser
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Increasing reports of its prevalence in recent years have demonstrated that Anogenital Condyloma Acuminata (CA) in the pediatric population is not so rare a condition (1)(2)(3). However, Periurethral CA is an unusual location for this virally transmitted disease, and reported cases in medical literature are highly uncommon.
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Human Papilloma Viruses (HPV) is the etiological cause for all types of warts, and various forms of transmission, both sexual and non-sexual, have been registered in the pediatric age group (1)(3). Current treatments for Anogenital CA in children are challenging due to several factors, such as young age, anatomic location, and high recurrence rates (1)(4). Multiple therapeutic approaches include various measures ranging from topical treatments to more aggressive procedures and, ultimately, surgery (5)(6).
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We hereby report the case of a healthy 2-year-old girl referred to our Department of Dermatology with a 2-month history of progressively increasing asymptomatic lesions in the diaper area. Physical examination showed multiple flesh-colored and brownish papules 1-2mm in diameter located in the vestibular and vulvar region in a symmetrical V-shaped distribution and the perianal region. (Fig. 1 (a)) Additionally, careful periurethral examination revealed an exophytic, reddish, and papillomatous lesion of 1,2cm in diameter (Fig.2) which showed rich vascularity under a dermoscopy.
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A clinical diagnosis of CA stage IV was established due to the extension of the lesions (2), after which PCR testing was performed for the vulvar, perianal, and periurethral areas, confirming the diagnosis of CA for HPV subtype 6. Subsequently, the patient was screened for other sexually transmitted diseases and reported to social services for possible child abuse. The father presented genital warts; however, PCR testing results were not conclusive on the detection and typification of HPV. No relevant information was retrieved from the mother, and the exact source of infection could not be determined. Most importantly, no signs of sexual abuse were identified.
CO2 laser surgery was proposed as the most efficient solution to remove the large periurethral wart within the extensive lesions in the anogenital area, an approach better suited due to the size of the lesion and the young patient's lack of sphincter control which would interfere with topical treatments.
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The procedure was carried out through an in-patient regimen under general anesthesia and prophylactic systemic doses of the antibiotic Cefazolin. Under gynecological examination, urethral catheterization was indicated. The surgeons were required to use masks to prevent inhalation of HPV in the vapor plume emitted by the CO2 laser. Vaporization with CO2 laser was performed with parameters of 5 Watts, continuous mode, and repeated pulse in two consecutive passes. After vaporization and using the same laser parameters, the periurethral wart was coagulated from the base and sent for histopathological analysis.
The treated area was covered with Mupirocin ointment and a non-adherent dressing, both of which were changed on a daily basis until complete healing was achieved.
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The laser surgery lasted approximately 30 minutes with no postoperative complications. Histopathological study results revealed acanthosis and parakeratosis with elongation of rete ridges and the presence of koilocytes; all features consistent with CA. Complete epithelialization was accomplished within nine days; only one session was required to achieve clearance. The extensive periurethral and anogenital CA did not recur, and the 7-month follow-up showed complete remission and no signs of scarring (Fig. 1(b), 3).
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As we have stated above, even if Anogenital CA in the pediatric population is not as infrequent in daily practice as is supposed (1)(2)(3), abnormally large periurethral condyloma occurs in exceptional cases, often associated with extensive dissemination of CA (5)(6). Extensive HPV infections in this particular age group pose a tremendous therapeutic challenge. Among the several treatment recommendations for CA are podophyllin or imiquimod (2), trichloroacetic acid, 5-fluorouracil(3), cryotherapy, CO2 laser (4), electrocautery and surgery, (6)(7)(8) all of which present variable cure and recurrence rates.
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The multiple approaches and varying responses suggest that there is no gold standard for the treatment of CA in children (7)(8)(9). While topical therapies are indicated as a first-line approach, there is no consensus regarding their pediatric management (8)(9)(10). In this particular case, topical therapy was not a choice both because we were dealing with a giant periurethral CA and the fact that we were dealing with an infant under diaper care, in which case occlusion and constant diaper changes could lead to a possible lack of therapeutic effectiveness and unwanted adherence. However, one of the most significant concerns was the periurethral wart, which required a surgical procedure due to size and location (6)(10).
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CO2 laser surgery is an effective technique, with rapid healing and lower recurrence rates being its main advantages (1)(5). In our patient's case, after nine days and only one session, complete epithelialization was achieved, and no recurrence was observed in the 7-month follow-up (Fig.3). To our knowledge, this is the first pediatric case showing a periurethral CA successfully treated with CO2 laser to appear in the medical literature.
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We conclude by reporting the outstanding results achieved with a CO2 laser for treating a periurethral and disseminated CA in a pediatric patient and, therefore, recommend this surgical procedure in cases where a large CA in association with disseminated infection is observed.