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Saturday, December 02, 2006

Anogenital Warts in Children: Does HPV Typing Show Transmission Mode?

— Mary Wu Chang, MD

Published in Journal Watch Dermatology August 18, 2006

Careful examination and history taking are more valuable than serotyping for identifying sexual abuse in children with HPV.

The rate of anogenital warts in children is on the rise, due to increased prevalence and recognition of human papillomavirus (HPV). How common are anogenital warts in young children, and can we identify which of these children have been sexually abused? Investigators in Montreal delineated clinical characteristics, identified HPV types, and assessed the value of HPV typing for identifying abuse in 72 prepubertal children seen at one clinic for anogenital warts (age, <12> in their patient population, 1.7/1000).

Age-of-onset data were available for 68 patients (mean age at onset, 3 years, 9 months). In two children, the warts had been transmitted prenatally or during birth. Onset of infection occurred before age 2 years in 28%, and between 2 and 6 years of age in 62%. Only 10% were older than 6 years at onset. Sexual abuse was confirmed in 6 children and suspected in another 12; onset in these children occurred at a mean age of 4 years, 8 months. Twenty-six percent of patients ages 2 to 6 years at onset had suspected or confirmed sexual abuse, compared with 85% of patients older than 6.

HPV serotypes 2A, 3, 6, 7, 11, 16, and 57 were noted (7 and 57 are unusual types). The mode of transmission could not be identified by HPV typing, age of onset, or clinical appearance of the lesions. The authors conclude that the best way to identify possible sexual abuse remains history taking, careful assessment of the socioclinical context, and physical examination.

Comment: Children may become infected with HPV at any time and via various modes of transmission. Given these realities and possible viral latency, evaluation of the mode of transmission is extremely challenging. In this study, all infants under age 1 year had innocent transmission. In this small sample, children older than 6 had a high rate of suspected or proven sexual abuse, and most abused children were girls. However, there are no reliable rules. There is no substitute for careful examination and interview. Clinicians must use their judgment, not necessarily to establish sexual abuse, but to determine whether referral to child protective services is indicated.

The 25% rate of suspected or proven sexual abuse is sobering. In any case of suspected abuse, clinicians should document all findings and refer to child protective services (ideally, a multidisciplinary child abuse team) as soon as possible. In addition, it may be best to defer the questioning of the young child to the abuse team. Repeated questioning of young children can contaminate the evidence, as children may change their answers to please adults. Lastly, long-term follow-up of girls with anogenital warts is indicated, as malignancy can follow pediatric infection.


Marcoux D et al. Pediatric anogenital warts: A 7-year review of children referred to a tertiary-care hospital in Montreal, Canada. Pediatr Dermatol 2006 May/Jun; 23:199-207.
[Medline abstract]