Title: Giant condylomata acuminata of the vulva with florid warts all over the body in an adolescent girl treated with Nd: YAG laser
Authors: Mallika TewariMS, MRCS[1], Sanjay Singh  MD[2], and 	HS Shukla MS FRCSEd PhD [1]	
Affiliations: Department of Surgical Oncology[1] and  Dermatology[2], Institute of Medical Sciences, Banaras Hindu University, Varanasi, INDIA. mallika_vns@satyam.net.in
Citation: Dermatology Online Journal 11 (2): 35


Abstract:
Long-lasting cutaneous warts are a therapeutic challenge; this is especially true for widespread or symptomatic recalcitrant warts in children. We present a case of an 11-year-old girl with extensive cauliflower-like condylomata acuminata on vulva with warts all over her body, most exuberant on both her feet, since birth. The vulvar lesion was excised using neodymium: yttrium-aluminum-garnet (Nd: YAG)  laser. Warts on her limbs were also treated with Nd: YAG laser in two sessions. There was no recurrence in the treated regions in 3 months of followup. No new lesions appeared. A review of literature regarding warts in children and new treatment modalities are discussed.


Body:
I: Introduction
Human Papilloma Virus (HPV) infection is highly prevalent in adolescent girls and young women and is associated with substantial morbidity [1]. No antiviral treatment exists for HPV to date. The standard treatment options are cryotherapy, laser, trichloroacetic acid, salicylic acid, and podophyllotoxin [2]. We report a case of an 11-year-old girl with florid cutaneous warts and a giant vulvar condylomata acuminata.

I: Clinical synopsis
An 11-year-old unmarried girl presented to us with a history of warty growths all over her body, especially on lower limbs, present since birth. There was no pain, itching or discharge from the warts. She denied any history of contact or sexual assault. No such history could be obtained from her parents who appeared healthy. The patient's siblings were normal.
Examination surprisingly revealed a 8 x 2.5 cm fleshy mass arising from right  labia minora and majora entirely covering the vestibule (Fig. 1). Few warts were present on the mons pubis and thigh. Vaginal mucosa appeared normal with an intact hymen. In addition, numerous cutaneous warts were present on her entire body surface and especially clustered on her feet (Fig. 2). There was no associated bleeding or discharge. The Venereal Disease Research Laboratory (VDRL) and Human Immunodeficiency Virus (HIV) antibody tests were negative. Examination of both the parents was normal. A Pap smear performed on the patient's mother revealed no abnormality.
Figures 1 and 2: 1.jpg, 2.jpg
Figure 1. Giant condylomata acuminata of vulva is shown in an 11-year old girl. Warts can also be seen on mons-pubis (arrow).
Figure 2. Involvement of the foot


The patient was put under general anesthesia. The giant CA was fleshy and vascular with a broad base. Bloodless excision of CA was done using the neodymium: yttrium-aluminum-garnet (Nd: YAG)  laser. The warts on her limbs were treated with Nd-YAG laser in two sessions at 3-week intervals. Histopathology suggested presence of HPV with no malignant change in the lesion. Polymerase chain reaction showed the presence of HPV type 11 in the genital lesion.

I: Discussion
Warts result from infection with the double-stranded DNA virus, HPV, of which over 100 subtypes are now recognized [2, 3]. Different subtypes are responsible for several clinical variants viz., cutaneous, genital, respiratory and oral papillomatosis.
HPV infection is a sexually transmitted disease in adults. The modes of viral transmission in children remain controversial. These include perinatal transmission, autinoculation and heteroinoculation, sexual abuse, indirect transmission via fomites, etc. The newborn babies can be exposed to cervical HPV infection of the mother during delivery. In-utero transmission to the fetus may occur hematogenously, by semen fertilization, or as an ascending infection in the mother[3].  
The incubation period varies from 2-8 months. The virus multiplies in the connective tissue of the dermis followed by proliferation and keratinization of the epidermis. External anogenital condylomas are the clinical expression of HPV mucosal infection. Only a small portion of those infected with HPV express the disease [4]. The genital warts initially are usually small finely branched structures with a narrow stalk; they later may coalesce to form large cauliflower masses with broad-dermal attachments as was seen in our patient. Although the vulva (particularly the vestibule, and labial folds) and the perianal skin are the sites most frequently involved, lesions may occur within the vagina, cervix or mons pubis in females. In males, these are typically located around the coronal sulcus, on the glans and the frenulum, at the meatus and sometimes on the shaft and surrounding skin. The rectum, anal canal and perianal areas can also be involved, particularly in homosexual men (but heterosexual men can also be affected). Warts are rarely found on the scrotum and urethra. Only rarely do genital warts turn malignant. Genital warts are thought to be a co-factor in the development of cervical cancer, although this concept has been subject to much debate. 
Diagnosis is generally made on clinical grounds. Biopsy is required only rarely. Treatment may be prolonged and recurrences are common. Common cutaneous warts in children spontaneously regress within 2 years in two thirds of cases. These may be treated with wart paints containing salicylic acid. Spontaneous resolution of pediatric condyloma has also been reported and non-intervention is a reasonable initial approach [5].
Condyloma accuminata is a therapeutic challenge. Cryotherapy  with liquid nitrogen is the preferred treatment. Trichloroacetic acid, although widely used,  has unpleasant side effects. Patient-applied treatments including imiquimod and podophyllotoxin are the newer choices; these have good wart clearance and low recurrence rates. Other modalities in resistant cases include electrotherapy,   laser excision, and surgical excision [2, 6]. Various types of lasers viz. Nd: YAG [7], CO<small><sub>2</sub></small> [8], and pulsed dye [9] lasers have been used either alone or with surgery with good clearance rates. Vulvar edema, bleeding, and vulvodynia may occur following these treatments. One should never attempt to eradicate all warts in a single treatment. Therapy is best administered in several applications at weekly intervals. Our patient responded well to Nd: YAG laser ablation of the warts and had no postoperative complications. 

I: Conclusion
Anogenital warts in children have serious medical, social, and legal implications. They remain one of the most common STDs in adults. HPV infection may lead to cervical-intraepithelial neoplasia and cervical cancer. Treatment is difficult and recurrences common. New therapeutic strategies including vaccines are the need of the day. 

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