City and Hackney Paediatric Viral Wart and Molluscum Contagiosum pathway

Patient presents with Viral Wart or Molluscum Contagiosum

Clinical certainty of Molluscum Contagiosum Clinical certainty Refer to No that the lesion(s) dermatology is a viral wart? Reassure parents/ guardians; explain can take 18 months to resolve. Offer Patient Information leaflet http://www.bad.org.uk/shared/get- Yes file.ashx?id=220&itemtype=document Reassure Parents that majority of warts will resolve within 18 months without Cosmetically sensitive area any treatment and without scars. OR duration more than 18 months Click here for patient information OR highly symptomatic (eg itchy, bleeding) leaflet via www.Dermnetnz.org

Parents requesting treatment Prescribe Molludab (5% Potassium hydroxide) to be applied twice daily on Molluscum for maximum of 2 weeks. Warn parents/ guardians that it will cause irritation and redness.  Anogenital Warts on the hands and or feet Facial/Torso/Limbs Molluscum should resolve around 4 (verrucas)  Can be vertical transmission  Explain that no single weeks after redness first appeared. up to age of 36 months.  Explain treatment is often treatment will definitely work. Molludab is non-formulary so get OTC. laborious, not guaranteed to work Treatments to consider include:  Consider auto-inoculation if and that there is limited evidence history of warts on fingers on each modality.  Referral to local Cryotherapy of the child or on carers clinic however warn of risk hands.  Advise against cryotherapy, laser of permanent and surgery due to pain, blistering hypopigmentation  Usual advice is no treatment and permanent scarring. as risk of pigment changes  Topical retinoid such as and irritation outweigh  An alternate night “soak-pare- Adapalene once daily for benefits. paint” regime is often sufficient: 6-12 weeks*  In older children (>36  Soak wart in warm soapy water;  Imiquimod cream 3 times months) or if you have any pare/ file down with emery per week for 6-12 weeks*. safeguarding concerns it is board-avoid bleeding; paint wart Prescribe Aldara reasonable to consider with any salicylic containing Sexual Abuse. solution (can be bought OTC);  Facial warts are not apply duct tape or a plaster to routinely treated by GPs and  Discuss safeguarding wart; leave on for 24 hours treat only if confident and concerns with named GP for consider referring to Safeguarding; child may  Repeat alternate evenings/ secondary care. require STI screen and nights for 12 weeks** referral to appropriate *Adapalene is teratogenic and may services. For more aggressive treatment cause local irritation and is consider: unlicensed.

 Morning: soak wart in warm soapy ** Imiquimod can cause water, file down with emery board, permanent hypopigmentation, flu- apply Adapalene* cream or gel like symptoms and local irritation. followed by duct tape Prescribe Aldara.  Evening: Soak wart in warm soapy water, gently file down, apply Verracur gel then duct tape/plaster Notes  Continue treatment daily for 12 Cryotherapy clearance rates; weeks** 50% - hands 10% - feet *Adapalene is teratogenic and may cause local irritation and is unlicensed. ** If no resolution after 3 months, reassure parents that repeated treatment unlikely to benefit child or speed up resolution of the wart.

Authors: Hannah Waddingham (GP Clinical Lead), Rhiannon England (GP Clinical Lead), Mary Sommerlad, (Locum Consultant Dermatologist, Meena Patel (Consultant Paediatric Emergency Medicine Named Doctor for Children's Safeguarding), Tammy Rothenberg (Consultant Paediatrician with an Interest in Allergy, Clinical Tutor), July 2017 Review date: July 2019