Journal of Dermatological Treatment (2001) 12, 215–217 © 2001 Journal of Dermatological Treatment. All rights reserved.

hts reserved. ISSN 0954–6634 215

Successful treatment of perianal warts in a child with

5% imiquimod cream

PC Gruber1 and J Wilkinson 2
1
Department of Dermatology, Stoke
Mandeville Hospital, Aylesbury,
Buckinghamshire, UK; 2Directorate of
Dermatology, Allergy and Plastic Surgery,
South Buckinghamshire NHS Trust,
Amersham Hospital, Amersham,
Buckinghamshire, UK
Treatment of anogenital warts in
children is difŽ cult. Commonly
used therapeutic regimes can be
painful, variably effective and
recurrence rates are high.
Imiquimod is a recently developed
imidazoquinolin heterocyclic
amine that is an immune response
modiŽ er. Topical imiquimod has
been used successfully to treat
anogenital warts in adults. This
case documents the effective use
of topical imiquimod in the treat-
ment of perianal warts in chil-
dren. (J Dermatol Treat (2001) 12:
215–217)

Received 11th June 2001

Revised 14th April 2001 Keywords: anogenital warts — children — imiquimod — perianal
Accepted 30th April 2001 warts

Introduction
Anogenital warts in children is an uncommon condition
but frequently presents a therapeutic dilemma. Treatment
options include cryotherapy, laser vaporization, electro-
cautery, excision and topical application of podophyllin,
which are often painful, frequently requiring the use of
general anaesthetics and recurrences are common. In
addition, repeated painful procedures in icted on a child’s
genitalia could have psychologic ramiŽ cations. We report
a case of perianal warts in a child that we successfully
treated with topical 5% imiquimod cream (AldaraÅ
cream).
Case summary
A 2-year-old boy presented with an 11-month history of
recalcitrant perianal warts. He had been initially treated
with podophyllin applied three times per week for 7
months with little beneŽ t. This treatment was com-
pounded by side effects of pain, bleeding and blistering at
the application site. He was otherwise Ž t and well. His
sister and mother had suffered from plantar warts for
Correspondence:
Pascale C Gruber, Department of Dermatology, Stoke Mandeville Hospital, Mandev-
ille Road, Aylesbury, Buckinghamshire HP21 8AL, UK. Tel +44 (0)1296 315551; Fax
+44 (0)1296 315796
many years and had been successfully treated with a sali-
cylic acid preparation 6 months previously. We thought
that it was likely that he had acquired his perianal warts
by direct innoculation from their plantar warts. There was
no suspicion of sexual abuse and his mother had no previ-
ous history of anogenital warts — ruling out any possibil-
ity of in utero transmission. When he was examined he
had evidence of con uent perianal warts with scattered
warts elsewhere on the perineum (Figure 1). Blood tests,
including a full blood count and immunoglobulin levels,
were normal.
He was subsequently started on 5% imiquimod cream
(AldaraÅ cream). This was applied topically twice a week
to the lesions and within 3 weeks there was already quite
a dramatic reduction in the number of perianal warts
visible and within 5 weeks complete clearance was
achieved. The only reported side effect was mild pruritis to
the application site. Follow up 15 months later has shown
no evidence of recurrence. As far as the authors know,
this is the Ž rst case documented in the literature reporting
the use of topical 5% imiquimod cream (AldaraÅ cream) to
treat perianal warts in a child.
Discussion
Warts may be caused by many different human papilloma
virus (HPV) types and are difŽ cult to treat. Anogenital
warts, in particular, are considered a more signiŽ cant
medical problem than other wart infections. First, because
216 PC Gruber and J Wilkinson
Figure 1
genital warts in adults are a sexually transmitted disease
and also because of the association between genital HPV
infection and cervical carcinoma.1 In children, the mode
of transmission of genital HPV is controversial. Possible
modes of transmission include sexual, from mother to
infant in utero, passing through an infected birth canal,
infection of a non-genital type virus to the genital area,
and non-sexual acquisition from fomite.
Although most small children acquire their anogenital
warts in innocuous ways, the possibility of sexual abuse
must be seriously considered. Studies have varied in
reporting the suspicion of sexual abuse in children with
condylomata acuminata from 0 to 90%.2 In particular,
genital types of HPV (6 or 11, 16 or 18) should alert the
physician to the possibility of sexual abuse. A careful
medical and social history must be taken to look for any
sign of neglect or abuse.3
Treatment of anogenital warts in children is difŽ cult –
mainly as a result to the painful nature of these proce-
dures as well as the high recurrence rate. The most
common methods for treating anogenital warts include
Treatment of perianal warts with 5% imiquimod cream
physical destruction with cryotherapy, electrocautery,
laser ablation, or surgical excision. Chemically destructive
measures include podophyllum resin or trichloroacetic
acid. However, none of these treatments eliminate the
wart virus itself and recurrence after treatments is
common.4
Imiquimod is a topically active immunomodulatory
agent.5 Imiquimod promotes the development of an innate
protective antiviral response by inducing keratinocytes to
produce interferon-alpha. SpeciŽ cally, imiquimod induces
(2’–5’)-oligoadenylate synthetase, which confers an
‘antiviral state’ and upregulates natural killer cell activity
in vivo and in vitro. Imiquimod also enhances cell-medi-
ated immunity.6 Pilot studies showing that topical
imiquimod was effective in the treatment of adult anogeni-
tal warts prompted larger, multicentre studies demon-
strating the efŽ cacy and safety of this agent in the
management of anogential warts. The dosing regime with
the best balance of efŽ cacy, side effects and practicality is
5% imiquimod cream (AldaraÅ cream) to be applied
overnight by the patient three times weekly until the
warts clear, for a maximum of 16 weeks. The largest
double-blind trial to examine this protocol involved 311
patients aged 18 and over with external anogenital warts
who were randomized to use 5% imiquimod cream, 1%
imiquimod cream or a vehicle cream. Evaluation of all
patients given medication at any time showed that 50% of
those who received 5% imiquimod cream experienced
clearing compared with 21% of those who used 1%
imiquimod and 11% of those treated with the vehicle. The
difference of the effectiveness of 5% imiquimod cream and
the vehicle was statistically signiŽ cant (p < 0.0001).
Overall, 5% imiquimod cream (AldaraÅ cream) is well
tolerated. The most common adverse reactions include
erythema, burning and itching – which occur in < 67% of
patients applying imiquimod three times a week. The tol-
erability proŽ le of imiquimod cream appears favourable
compared with that of podophyllotoxin.7 Less than 1% of
imiquimod applied topically is absorbed systemically and
therefore it is not surprising that no systemic adverse
effects have been reported.8
Despite the good efŽ cacy and safety proŽ le of
imiquimod, there is no one anogenital wart therapy that is
the therapy of choice for all anogential warts. Each treat-
ment has advantages and disadvantages. BeneŽ ts of
imiquimod include efŽ cacy superior to reports of chemode-
strucive therapies such as podophyllum resin or
trichloroacetic acid. Although immediate elimination of
warts occurs with laser, electrocautery and excision, and
these procedures are satisfactory in treating a small
number of lesions, they are painful and therefore often
poorly tolerated in children, sometimes even requiring
general anaesthesia. Other advantages of imiquimod
include less tissue damage, the ability for the patient to be
treated at home and the avoidance of multiple hospital
visits, and the ability of patients to begin therapy immedi-
ately on any new warts that appear rather than having to
PC Gruber and J Wilkinson
wait for a hospital appointment. The greatest advantage of
imiquimod is the apparent low recurrence rate when com-
pared with other therapies. Imiquimod has also been
shown to be cost-effective in comparison with other treat-
ment modalities. Disadvantages include the long duration
of therapy required to eliminate warts and the careful
application necessary to minimize local irritation.4
References
1. Tyring SK, Human papillomavirus infections: epidemiology
pathogenesis, and host immune response. J Am Acad Der-
matol (2000) 43 1(2): S18–26.
2. Handley J, Dinsmore W, Maw R, Corbett R, Anogenital
warts in prepubertal children: sexual abuse or not? Int J
STD AIDS (1997) 4(5): 271–9.
3. Stringel G, Mercer S, Coorshi L, Conyloma acuminata in
children. J Pediatr Surg (1985) 20(5): 499–501.
4. Edwards L, Imiquimod in clinical practice. J Am Acad Der-
matol (2000) 43 1(2): S12–17.
5. Dahl MV, Imiquimod: an immune response modiŽ er. J Am
Acad Dermatol (2000) 43 1(2): S1–5.
Treatment of perianal warts with 5% imiquimod cream 217
There have been no trials to date looking into the efŽ -
cacy and safety proŽ le of the use of 5% topical imiquimod
(AldaraÅ cream) in treating anogenital warts in children.
We report the Ž rst case of topically applied imiquimod
used successfully in the treatment of perianal warts in a
child. It was effective, well tolerated and showed no evid-
ence of recurrence at 15 months follow up.
6. Miller RL, Gerster JF, Owens ML, et al, Imiquimod applied
topically: a novel immune reponse modiŽ er and new class
of drug. Int J Immunopharmacol (1999) 21: 1–14.
7. Perry CM, Lamb HM, Topical imiquimod: a review of its use
in genital warts. Drugs (1999) 58(2): 375–90.
8. Owens ML, Tygum KI, Senta TA, et al, A safety assessment
of immunomodulator imiquimod 1997, Presented at 19th
World Congress of Dermatology, Sydney, Australia.
Abstract. 15–20 June 1997. Australas J Dermatol (1997)
38 Suppl 2: 3–313.
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