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Photodynamic therapy for pediatric genital warts: A case report

Dear Editor, Genital warts (GWs) are the most common sexually transmitted infections (STIs), caused by the human papillomavirus. The most common way of infection in adults is sexual, but transmission in pediatric populations remains controversial. The increasing prevalence of GWs in children, ranged from 0% to 80%, has renewed the interest in understanding the social and legal impact in cases of sexual abuse. In addition to concerns regarding the potential abuse, treatment for GWs in pediatric populations also present a unique challenge. Many variables influence the treatment eligibility, such as the size, quantity, and location of the warts. Invasive treatments (surgical excision, cryotherapy, carbon dioxide laser, and electrocoagulation) are painful and often complicated by undesirable long-term effects like scars and hyper /hypopigmentation, potentially causing both functional and psychological impairment when used in particular areas of the body like the genital one. There is also a high risk of recurrence because these treatments only remove visible lesions but not occult ones. Topical drugs (imiquimod and podophyllotoxin) require prolonged use and may act as irritants with very low compliance in both children and parents. Conventional photodynamic therapy (C-PDT) relies on photosensitizer-mediated and light-induced cytotoxicity, which kills rapidly proliferating cells stimulating local immune response to pathogens, including bacteria, fungi, and viruses. Topical 5-aminulaevulinic acid (5-ALA) is the most widely used topical photosensitizer prodrug because it penetrates the stratum corneum easily. As regards warts, it promotes their regression through two mechanisms: the production of cytotoxic radicals that destroy keratinocytes by apoptosis and the stimulation of immune specific responses, with the release of various cytokines (interleukin-1β, interleukin-2, and tumor necrosis factor-α). In this study, we confirm the high efficacy and safety of C-PDT with 5-ALA in the pediatric setting. An otherwise healthy 5-year-old female was brought to our attention by her parents for a 30-months history of multiple skin-colored, verrucous papules in the perineal area (Figure 1A). She had been previously visited by many physicians (both pediatricians and dermatologists) with a diagnosis of GWs, and treated with imiquimod 5% cream and cryotherapy, which were ineffective, and poor tolerated by the patient. The patient has been screened previously for possible immunodeficiency but no evidence in this sense has been found. No signs of physical abuse were mentioned in the previous visits. At the time of our observation, multiple asymptomatic flesh-colored papules ranging from one to five millimeters in diameter were visible in the perineal area (Figure 1A). No erythema, lacerations, scars, or signs of sexual abuse in the above-mentioned areas were detected. As no physical abnormalities were detected on physical examination and given the possibility of non-sexual transmission of the GWs, the hypothesis of sexual abuse was not taken in consideration. Because of the previous failure of both medical and physical therapies, our therapeutic proposal was the administration of C-PDT with 5-ALA. Written informed consent was obtained from the parents of the child to proceed with the treatment and record images