Welcome to the Don't Be Rash Pediatric Dermatology Podcast, the owner's manual for your kid's
skin.
I'm your host, Dr. K, board certified pediatric dermatologist and father of two boys.
I'm here to chat with you to promote dermatological education and improve skin health in our children
everywhere.
Let's get started.
On today's episode, I'm joined by Dr. Alicia Walty, pediatrician and chief medical officer
of STAR Community Health.
We're going to be discussing some of the most common causes of lumps and bumps in kids,
including my favorite diagnosis that most sounds like a Harry Potter spell: "Molluscum
Contagiosum."
Welcome, Dr. Walty.
Thanks for joining us.
Where on the annoying list of things you have to deal with in kids does molluscum land for
you?
Pretty high up there.
Thank you very much for having me, Dr. Krakowski.
I look forward to it.
And yes, molluscum is one of the most frustrating things for pediatricians and for the parents
of the kids that bring them in.
What makes it so annoying?
Pediatricians like to fix, and molluscum is one of those things that is not always immediately
fixable and people love to have their kids looking perfect and really being as healthy
as possible.
And molluscum is a tough one because you can see it and you know it's not really doing
too much harm and you know it's not going to hurt them, but it just does not look good.
And there is a very small arsenal of things that we can do to make it better.
And yeah, we as Americans are not super patient and this one requires patience.
So speaking of what it looks like, let's paint the picture for the audience.
So we're talking about molluscum contagiosum.
That's the full name.
So for everybody who's a wordsmith out there, you should figure out that this is, in fact,
contagious.
Yes, it's an infection caused by a benign virus, a double-stranded DNA virus in the
poxviridae family, So it's a cousin to something like smallpox and the new thing we've heard
about the last couple of years, mpox, used to be called monkeypox, but it can't hurt
you like those can.
And like from a clinical perspective, we're talking about flesh to pink colored bumps.
They're usually small on the small side, maybe two, maybe five millimeters.
They're usually rounded.
They're sort of dome shape.
If you look really closely or you take a flashlight and you shine it from the side, you might
see what we call a little umbilication, a little sort of indentation or dell in the
center.
And you might see also like a little core that shadows when you shine the light.
But these things can be scattered all over.
They can be found in clusters.
And geez, you hit the nail on the head.
They don't look great.
And man, they can really drive some anxiety for both the kid who has them, the parent
of the kid who has them and anyone taking care of the child at school or daycare or
wrestling practice after school.
Yep, absolutely.
I think what you kind of looked at there in that first sense, so that central umbilication,
that's something that we really, really look at.
It's basically just a little bit of a hole in the middle.
You do have to pull out your microscope or it's kind of small.
You have to put your reading glasses on.
But it's something that for us as pediatricians really helps distinguish it from some of the
other things that look alike.
We do usually see molluscum and I know we're going to be talking about a couple other things,
but we see molluscum a lot in like you said clusters and in little lines.
And so it's very, very rare to see just one molluscum lesion.
So that's another clue that we look for as pediatricians.
The other thing is that we don't ever see molluscum on the palms or the soles.
And that's something that's really different from a lot of other rashes.
You're always going to see if you bring your kid in for a rash, we are always going to
look at the palms and soles.
You're going to think we're crazy, but we're always looking at the palms and soles.
That's a really big thing for us to kind of help us figure out which route to go down
for us.
So molluscum is one of those ones that steers clear of those areas.
And you mentioned that it sometimes can show up in a sort of streak or line.
That is not 100% unique to molluscum, but it's one of the few conditions that do what's
called "koebnerize."
And that's the technical term for where the virus will track along the line of trauma
basically from where the kid or adult, because adults can get this too, where they scratch
it, will sort of seed and track through that line.
And that can be a real good clue that you're dealing with something like molluscum and
not something more serious.
But we call that self-inoculation.
So yes, the virus is contagious to other people.
It's also contagious to the patient himself or herself.
They can spread it on themselves.
And it's one of the reasons we do, or at least in the United States, do try to try to treat.
Like you said, we like our fast food, unfortunately, and we like our molluscum gone quickly.
So we are a very impatient group when it comes to these kinds of things.
And we do tend to treat it a little bit more aggressively than maybe some countries.
So what sort of age group do you see molluscum popping up in?
Typically toddlers.
We don't see this as much.
We don't see molluscum as much in infants.
So we see it in toddlers.
Toddlers if you, I know you're a father, so they lick, they eat, they put everything in
their mouth.
Everything is around them.
So if they do have other kids in a child care center, if there's other kids in the family,
if there's a towel on the floor, if there's things like that, families and child care
centers, just everybody kind of gets them.
So we tend to see it a lot in the toddler age.
And to your point, kind of that auto-inoculation, kids have almost no self-restraint.
So if they have one, they're going to pick at it and they're going to get more.
The other area that we see it a lot is girls that are shaving their legs.
So if they have one on their legs and they're shaving, they tend to then have kind of that
nice long line and we'll see five or six in a row.
And that's kind of key for us to look at as well.
So we'll see that on their legs as well.
I have not seen it in boys shaving their faces.
I probably can come up with a good reason why not, but I just haven't.
But again, in most of the cases, it's really just that few clusters and these fairly small
lesions, unless there's something actually already medically wrong with the child.
So unless there's a reason for immunosuppression, so for example, if they're taking medicine
that makes them immunosuppressed or not able to actually mount that kind of response to
that virus, or if they're super young or if they have another condition that makes them
more susceptible, then yeah, for the most part, these are really kind of minor benign
things.
They just don't look good.
And that's really unpleasing to most people.
Yeah, I agree.
I'm seeing this mostly in kids around two to five years of age.
The sort of textbook answer is this is about supposed to be one of the most common skin
conditions that we see in kids.
About 1% of the world with a skin condition will be the result of this condition, molluscum
contagiosum.
I would say it's easily probably the third or fourth most common thing I see in clinic.
Now, it's kind of a referral bias, meaning people are sending their molluscum patients
to me because we have some treatments for it.
But I could easily fill up my entire clinic schedule with just molluscum patients, and
they would by far be mostly under 10 years of age.
I do know, and I see it every now and then in an older population, so teenagers, young
adults, you can get a little "blip" epidemiologically where you start to see a spike because it
is spread by physical contact, so sexual contact can spread it as well.
It's also - kind of to be a little bit gloom and doom -
...we do have to always think about if we're just seeing molluscum in the anogenital region,
so sort of in the diaper area in a young child, again, maybe four, five, six, seven years
of age, if it's just there for all the reasons you just talked about, the kids, they will
spread this.
They will take it from their arm.
They'll put it wherever their fingers go.
But if it's really just located in that underwear area, it does raise the concern for abuse.
We sometimes have to get involved and call that in and just have some extra questions
be asked to the families or the daycare team that's taking care of the kid just to make
sure that child's safe.
But yeah, by far, these kids are under 10 years of age.
I think one of the weirdest and hardest parts to explain to parents is why doesn't everybody
else have them in the family?
Molluscum is just these two kids.
Well, I think it's because we at some point learn how to kill the virus ourselves.
We get better at it.
So usually it's the older kids, the parents and adults who don't have the virus.
But certainly, if a six-year-old comes in and they have a two-year-old brother or sister,
I am counseling the family that there's a good chance that little baby is going to get
it too and try to eliminate sharing towels and bedding and everything else that you mentioned.
And I'll tell you, we see it so commonly that honestly it's something that doesn't even
really raise our eyebrows unless there's some kind of a complication.
They can get infected if the kids are really scratching at them or again, certain locations.
To your point, we will ask some questions.
So don't raise your eyebrows too much.
We're doing our jobs if we're asking some questions about them appearing kind of in
the diaper or private areas.
But for the most part, we will see these as kind of your hands on the door.
You're about to walk out.
The kids are there for their regular physical or sports physical or an ear infection.
And it's, "Hey, Doc, what's this thing?"
"I just noticed this thing."
"It keeps coming back".
Or, "I noticed it a couple months ago and it's just not going away."
And we give our regular spiel and we tell everyone not to be worried.
And we kind of go through it.
We see it several times a day, I would say.
The only time I would say as a pediatrician that we really generally will refer to dermatology
is if the parents are truly unsatisfied with the answer of it will go away, you just need
to give it time.
And unfortunately, in this case, time can be a year.
Time can be several, several months.
So people just generally aren't super pleased with that.
I know I personally will refer if it's an area that's super cosmetically unpleasing.
So if there's a cluster on the face, near the eyes, near the mouth, or again, if we
think that there is a sign of something else.
So now this is infected.
I think this needs more treatment or I really think this one needs to be kind of assessed
by the specialist for whatever reason.
Maybe I'm worried about immunosuppression.
Those are the ones that we're sending you.
For the most part, we generally give kind of the conservative "just wait and watch" approach
in our office.
And I think you're in at least close to the majority of what other health care professionals
are doing.
Someone did a survey back in a couple years ago, it was about 2,000 health care professionals.
And about 40% of them said, listen, we just tell you to "wait it out."
Now waiting it out, it can be, like you said, a couple months.
I think one study I saw recently was 1.3 years was the average while you wait this thing
out and it goes away on its own.
I quote two years to my family's mostly because I'm trying to create some realistic expectations.
And if it's faster than that, God bless everybody involved.
We did our job and made somebody happy.
But I don't think it's uncommon to have it last well more than a year.
And yeah, and that's a long time.
And there's the physical complications you mentioned that you can get infected if you
scratch.
The point is these things do itch.
I'm sure that's evolutionarily how they get passed.
They probably cause you to scratch them so you get the virus under your fingernails and
then spread it elsewhere.
But in addition to itching and getting potentially super infected with a bacteria like Staph
aureus. We know that these lesions can heal- even if they go away completely on their own -.
they can leave you with some pock scars.
They're permanent, "atrophic" - so flattened out scars - not heaped up scars like a keloid,
but sort of divoted out little pock scars similar to what a chicken pock scar would
look like.
And you mentioned a young woman's legs from shaving.
That's not necessarily ideal, right?
So that's kind of when I start thinking a little bit about where are the lesions?
Should I be treating more aggressively?
Also, if the kid is really just embarrassed and coming in, can't make eye contact with
me because they're already just beating themselves up that they have this or they can't.
We do have a pretty large wrestling population here in the Lehigh Valley where we are.
Big sports, big mixed martial arts.
If you have these lesions, if the virus is active and you can't cover them, a lot of
the sports say, "Hey, guess what?
You can't participate because you're going to put some other kids at risk."
So now you're talking not only not being able to play in that particular event, but you
might be at risk for losing a scholarship down the line or something to that effect.
So there's a lot of reasons that push me to get a little bit more aggressive.
But at the end of the day, yeah, if the family comes in and they don't care and I don't care,
especially if they live far away.
I mean, if you tell me you live two minutes from the office and I can come and have you
bring you back because the treatment that we most use, and we'll get into treatment
later, but it's not a once and done thing for any of this stuff.
And coming in every two or three or four weeks for four to six months, that's a burden by
itself.
So if the parents are fine with it and want to just do some at home stuff or nothing,
God bless them.
But we can ratchet it up if we need to.
I think the other thing to point out is that the lesions that are in areas where the kids
can't quite get to usually heal the fastest because they're not getting messed with.
They're not auto-inoculating.
They're not spreading it.
They're not getting infected.
The areas where the kids can either get to or where they have equipment.
So sports equipment, you know, they're wearing a jock, they have chest protectors for hockey
or they have something for baseball or football.
They're never going to heal.
They're always going to be irritated and they're always going to be kind of damp and sweaty
and the kids are going to be itching them and they're always going to be irritated.
So those tend to take a much longer time to heal.
So we definitely will refer some of those out depending on where they are.
To your point, it's really all about the location.
I think a really important point for listeners is you mentioned that super infection is possible,
but there's also this amazing thing called the B.O.T.E.sign.
And it's not "B-O-A-T," like a boat that you sail on the water.
It's the B-O-T-E sign.
Beginning Of The End.
I don't know if that's a thing that's made its way out to...
No, you're teaching me now.
I want to hear this.
This is exciting.
A lot of times what we see is when the immune system of the patient, the child, eventually
kicks in either because it just was time for that to happen or maybe one of our treatments
instigated that and accelerated that response, you get what clinically looks just like an
infection of each of the lesions.
So the molluscum themselves will turn red.
They'll get swollen.
They can be warm.
They can even start to sort of pus up, for lack of a better word.
It looks like they're going to be infected, but this is, in fact, probably the greatest
thing that you can ask for as a parent.
Yeah, it's just the immune response.
And so you don't need to necessarily put the kid on an antibiotic unless there's a fever
or other systemic symptoms.
We look at this and we just say, this is a great thing because it heralds that these
are going to go away on their own pretty soon.
So that's a very powerful measure of where you are in terms of if you can expect these
things to go away.
Another not so much awesome thing that can sometimes run with molluscum is an eczema-
like rash.
And in fact, it is just eczema, but it's not eczema in the sense that your child now has
a diagnosis of what's called "atopic dermatitis," which is separately discussed and more associated
with hay fever, allergies, asthma.
This is an eczema rash.
"Eczema" in dermatology is kind of a garbage catch-all bucket term.
It just means your skin is "boiled over."
And that's also probably in this case a consequence of the virus living in the skin.
Your immune system's probably just smart enough to know that there's a virus hanging out there
hidden.
Once that virus gets sort of acknowledged by your immune system, your immune system
rushes into that area and the skin does kind of bubble up, looks a little red, looks eczematous,
can be even more itchy.
So that's just something to know about.
The good news is we can treat that rash, that eczema, with some moisturizers.
And sometimes we'll use even some low-potency topical steroids to calm it down so you're
not scratching and itching and spreading the virus.
But kind of crazy that this little bump can do so much and look so many different ways.
It can be very confusing and very anxiety-inducing for the family.
I think another thing that's really interesting to point out is that you mentioned kind of
the technical and scientific and Latin name of all of this.
We're going to be talking about warts a little bit later.
And I think one of the things that we're going to really focus on with warts is that it's
a manifestation of this virus.
So even though we can kind of get rid of it, that virus is really in your system.
It's going to come back.
You're going to see it back again.
So molluscum's a little bit different.
There is a really nice immune response to it.
So you can get it again.
You know, if you rub up on someone else, you're still in daycare, you can get it in a different
area.
But generally, most times, and kids love to make liars out of me.
That's why I always say kids never read the book.
But for the most part, if the lesions are gone with molluscum, you're not going to see
it back again.
That virus is already kind of out of the area, out of the system.
And you're at least a little clear unless your kids are kind of back at it again with
the exact same triggers, which is different than with warts.
So I think it's really something to kind of remember that with molluscum, if you can by
that time and you can be patient, and you're not necessarily treating, again, you're going
to have that immunity to it.
So as a pediatrician, how do you approach treatment with the patients that you decide
you're going to treat?
So the kids that we do treat, again, the overwhelming majority, we really don't.
And the treatment that we're giving is we're observing it and we're watching it.
And I know that's highly dissatisfactory for most parents.
It's just as highly dissatisfactory for doctors.
We really love to fix things.
But sometimes NOT doing something is an option.
I think for the kids that we see that we will treat for it, generally, we will sometimes
do cryotherpay for it.
And I know we can kind of get into that a little bit.
Most general pediatricians will not do curettage.
And curettage is really just the fancy way for saying kind of "cutting it off."
And we're really just getting rid of the problem.
But really, those are the treatments that we're doing.
We're not prescribing anything.
If we think it's at that point that it needs to be treated, we're referring it out to Derm.
Family medicine doctors are sometimes a lot more aggressive.
They will do some curetting.
They've been trained in those procedures a lot more than general pediatricians have.
So a lot of times they will do some curette.
They will do some cautery.
They'll do the cryo, things like that.
It really just depends on how trained and what equipment is available in the office.
And that can vary from location to location and practice to practice.
So I would definitely say if you're interested in, you know, you've been seen, you know what
it is, you've been diagnosed with molluscum, and you're at that point and you want something
done, just make sure when you make the appointment with that provider that they are able to do
that and that it's not something that would require a referral.
Yeah, that's a great point.
It can really be frustrating to some parents when they're getting bounced around until
they find someone who either wants to do what they want to do or can offer some treatment.
For me, it comes down to, there's a lot of practical stuff to think about when you're
doing this.
And I think we should be a little bit more transparent with the audience in the sense
that there absolutely is a financial reason to treat molluscum when you are a physician
or a clinician.
There is a service that you bill for for that.
And it's separate from the visit of you coming in and having me tell you that you have molluscum.
So there is that.
But I can tell you, and I think I speak for most pediatric dermatologists, that, man,
if there was a way to do this much faster at home, safely and quickly, nobody would
be complaining about that because most of us have nine, 12-month waiting lists anyway.
So if we could actually open up some spots in our clinic to other kids with probably
more serious rashes, we would love that.
But each one of our molluscum patients really does take up an appointment slot about every
month for about four to six months.
And that's a lot.
That's a lot of people.
So I do kind of balance that when I'm trying to decide to treat.
For me, it really comes down to two branching points.
There's stuff that you can do at home, and then there's stuff that we can do in the office.
And the stuff that we can do at home is pretty good.
I mean, it's funny.
You mentioned the family medicine docs doing a lot of the procedural things and you guys
doing maybe some cryotherapy and some other stuff.
But man, if I could encourage you to feel free to prescribe something like a topical
retinoid.
It's like an over-the-counter medicine called adapalene gel.
It used to go by the brand name Differin, still does.
It used to be a $600 medicine if you couldn't get it.
And we loved it because it was sort of one of the most gentle of the topical retinoids
for acne.
That's what it was approved for.
Now it's over-the-counter.
You absolutely can prescribe this off label per se, but you're telling, you're asking
your patients to go home and put a pinhead sized amount of this medicine, which costs
now about $15 to $25 bucks a tube onto the molluscum.
You got to help counsel them in terms of which ones you want to treat.
I wouldn't, if there was one close to your eye, I don't think I'd be using a topical
retinoid up there.
It'll just be too irritating.
But you feel free as a parent to apply a pinhead size of this medicine every night for four
to six months.
You're going to do better than if you don't, as far as I'm concerned.
So that's a great treatment.
And for $15 to $25 bucks, absolutely worth it.
We also do hear of, and either we'll prescribe or we learn that the patients are using stuff
from Amazon or whatever they got it from, salicylic acid, podophyllin.
These can be heavy hitter medicines.
I don't think a non-trained parent or teenager should be doing this on their own without
probably the direct supervision of a doctor when you're talking about chemicals, because
you could absolutely hurt someone with that stuff.
Yeah.
We definitely don't recommend trying any of those for molluscum.
Other options for at home, I've prescribed and have the parent use it after I show them
how to do it.
This is 5-fluorouracil, that's a medicine that we actually use to treat skin cancers,
you can have some good success when...
This is now second or third line, meaning I've tried some other stuff.
I was going to say, this is all you, friend.
This is not me.
This is dermatology treatment, not pediatric/family med treatment.
This is deep into like, geez, this isn't working and the family can't get to us because they
live too far away or the kid's got six extracurricular activities.
What else are we going to do?
Then there's this other new medicine, I guess it's probably worth mentioning that was just
approved by the FDA.
We are not in any way sponsored except by St. Luke's, which is certainly there's no
conflict of interest here, but there's a new medicine that literally in the last couple
of months just got approved, berdazimer or berdesimer, I'm not even sure how to pronounce
it, 10.3% gel.
What it does is it releases nitric oxide, which both indirectly and directly probably
kills the virus and revs up the immune system to help kill the virus.
That's being touted as maybe an adjunct that you can use at home with some better success
that the families can do.
Remains to be seen, it's literally just been out.
I've never prescribed it for anyone yet myself.
I've never heard the word until today, so don't worry.
Berdazimer, if it's not pronounced that way, it should be because I think it sounds good.
In the office, man, how much time do we want to spend?
We have literally a dozen different ways that we could treat your molluscum in the office.
Again, it starts with the application of a medicine and it goes all the way up to some
procedural intervention.
Where I trained in San Diego, it was scary to hear about, but it happened a couple of
times both for molluscum and warts, which again, we'll talk about later.
There were people down in Mexico, you would cross the border and they were doing
full on surgeries.
Like you would cut out a skin cancer, they were cutting out molluscum and wart virus.
That's crazy.
Don't do that.
Don't allow that to be done to your child.
For us as pediatric dermatologists, I think most of us don't love the curetting, the scraping
with a blade or a needle.
It's done.
I've done it probably three times, I think, in 20 years of being a physician.
I can tell you that one time stood out, it was a child, unfortunately, that needed chemotherapy.
They had a child with cancer and they were getting, is it called intrathecal therapy?
Yep, through spinal cord.
Yep, they get their actual injections through spinal taps.
They get the chemotherapy that way.
This child just happened to have a collection of molluscum virus lesions right near the
area where they were going to be injecting.
The pediatric oncologist asked us, "Hey, can you help clear these things?"
It was like, yeah, sure.
This one trumps the norm.
We scraped them off and the child was asleep.
We did it right before the procedure that they were having and everything went fine.
That's so not even close to what the norm is for us.
What we typically are doing is, I think what you guys probably have heard we do is something
called "beetle juice," which is this amazing chemical called cantharone.
Literally, beetle juice.
It's literally beetle.
It's literally from a beetle in the area.
You can go out in the fields of Pennsylvania and a couple other states in the area.
It's actually pretty far reaching.
It's zoned.
You can find this beetle.
It's a shiny looking, almost metallic-looking beetle.
Pretty long.
They're a good one inch or maybe even longer than that.
Very distinct looking.
You can Google the cantharone beetle and man, in nature, if a bird eats one of these things,
that's it.
It never eats another one.
It gets this blistering reaction and it learns pretty quickly that shiny green or shiny blue
beetles are not to be eaten as a delicacy.
Someone smarter than me figured out that you could purify the - we call it a "vesicant."
It's a blistering agent.
You can purify that and dilute it, importantly, down to a certain strength and put that on
the skin.
It causes a very controlled little blister, very high up in the skin.
It's not a deep blister.
It's not really going to the level where you should be able to do any real damage, but
it will cause an irritation and can cause a blister.
It is called blistering beetle juice.
I think you just like saying that.
I do.
I think you like saying blistering beetle juice.
I think if you say it five times, beetle juice is supposed to come out.
That's the rumor.
I've actually never seen that movie.
I have to watch it.
We put this stuff on at least three, four times a day in our clinic.
For the most part, it works pretty well.
The nice thing about it from being a clinician side of things is it doesn't hurt when you're
putting it on.
It can in a day or two have a little bit of this irritated reaction area where the bumps
that you treat can get raw.
It's not pain free, but there's nothing that we're doing in the office except maybe scaring
the child by putting this stuff on.
How do we put it on?
We use a "cotton tipped applicator," basically a fancy term for a Q-tip with a little wooden
handle instead of the kind that you would use on your ear.
We use the wooden part, the sponge and soaks up way too much of this stuff and it would
be way too much to put on, but we just put a tiny little bit.
I've had a couple of moms call me out that I didn't put any on here or there, but it's
like, no, I promise you that's how much we need or how little we need.
It just requires a tiny little bit and you paint as many as you're comfortable with.
I usually am doing somewhere in the neighborhood of 18, 20.
I don't love to do more than that because it's just how much chemical do you want to
put on a kid and if, God forbid, they did have a problem, geez, you can't really reverse
that.
So you put it on in the clinic, you tell the mom or dad based on the anatomic location
of the bumps that you're treating, you're not going to leave this stuff on for more
than four hours and you set an alarm to make sure that they wash it off with soap and water.
Usually if it's like under the armpit or in the groin area, I'm usually doing an hour
to two hours max for leaving it on and then washing it off, but you kind of judge that
based on what you're treating.
And the kids, as long as they understand that the Q-tip doesn't hurt, they let you do it.
It's pretty straightforward and man, it does work.
On average, I'm seeing and I think my colleagues are seeing response rates and like I mentioned
earlier about four to six months with about a month in between treatments.
I think that's important to point out exactly what you just said, that it's not one treatment
and that's something that's for almost everything we're talking about today.
It's not one treatment.
This is repeated and even then it's several repetitions.
It's not like one or two.
This is several different visits.
So just definitely something to keep in mind in terms of setting expectations.
You don't want to think you're doing something wrong just because it didn't get fixed in
one or two visits.
No, and I know how annoying it is.
The family comes in and it's like the fourth visit, right?
And they still clearly have molluscum and they're looking at you going, you said, "Four
to six.!"
I'm like, yeah, exactly.
I said four to six.
You got to give me the other two because I've seen it a couple of times, like overnight,
boom, they just go away.
Just like a cold eventually goes away.
These things, your body figures it out.
That's what's clearing them.
It's not the medicine per se.
It's the immune response that we're instigating in the area that clears these things.
So it's really the kid's immune system.
And man, sometimes it's an average, right?
So sometimes it's two treatments, sometimes it's 10.
But most of the time, I think if you give them the education upfront, the families understand
that it's kind of out of your hands and we're doing the best that we can.
Is the application uncomfortable?
Because I've never actually applied it.
Does it sting?
Is it uncomfortable or is it really just getting them to sit still?
No, it's getting them to sit still.
And that's actually way more important than probably it'll come off at first listen.
So I don't bring the bottle to the child.
I keep it on a counter and I take the dipped stick and move it to the kid.
So there's a minimal amount of this canthrone floating around the room that I'm in.
Because I have absolutely seen and have had it happen to me where a kid will all of a
sudden look like they're doing great and just flail and they knock you and then the stuff
goes flying.
If it gets in your eye, it would be a big problem.
If it got in your mouth, it could cause the same blistering reaction that the bird had
from eating it.
So you don't want to do that.
But no, touching the lesion one time, one time I applied it in my office and by the
time the child got to the car, mom brought the child back in and said, he's complaining
that it's burning.
So we brought him into the bathroom and mom just washed them off right there.
And we considered that Treatment #1.
We'll see you again in four weeks.
That literally happened just one time.
And I guess you do always warn them.
It's four hours max, again, depending on that anatomical location, or as soon as the child
tells you it's starting to burn.
If they feel it tingling or hurting, hey, we've never lost a kid to molluscum contagiosum.
There's no reason to push this treatment any further.
Wash it off.
Be done with it.
And for the most part, I haven't had many problems.
There have been a couple of times.
One was particularly painful for me because I talked the family into doing the treatment.
They had kept coming back in.
They were watching these lesions spread.
They were kind of on the fence about what to do.
Mom, I vaguely remember, was a little bit more into sort of the naturopathic approach.
And they just spent probably more time than I would have as a dad, not as a doctor, but
as a dad coming in for this thing and not doing anything directly.
You know what I mean?
So I kind of talked them into it.
And wouldn't you know, like that next morning I got the phone call that the child had a
pretty exuberant blistering reaction.
And yeah, it just happens.
I mean, a lot of that stuff is just bad luck.
But there's some practical side of things.
The guy who trained me in pediatric dermatology used to say that it looks pretty simple to
put this stuff on, but it really does require some practice.
You have to understand all the bad things that could happen so that you eliminate them
and then it's the easiest thing ever.
But if you drip the stuff, if you're putting too much on the lesion, and if you don't allow
it to dry at the bedside there when you're putting it on and the kid puts the clothing
on or pulls the clothing off and brings it up to their face, now you spread the wet medicine.
So there's stuff like that that you can't really avoid unless you tell the parent and
the kid not to do that.
There's some other stuff in the background that I always found sort of interesting.
We don't really focus on it too much unless you make the point of talking about it.
And that is when you buy a fresh bottle of this stuff, it's at its mixed pharmaceutical
grade kind of concentration, if you will.
But as you spend a month at a time and this is being utilized, exposed to the atmosphere,
it's starting to dry out, you're getting closer to the bottom, you can see this stuff physically
thicken up.
I mean, it starts to look almost like rubber cement.
You remember playing with that when you were a kid?
And it had that consistency.
It'll get a little tackier.
And there's just, I mean, by definition, it's dehydrated.
So it's got to be more potent than it was when it started.
So you got to be careful.
You just throw that bottle out and start with a new one.
I think it's just, again, it all kind of goes towards the if you're able to be and are acceptable
to have kind of that weight and do that kind of cautious observation, that is an option.
And I think sometimes people think, again, not doing anything isn't really acceptable,
but sometimes it's actually the best option.
So definitely something to keep in the back of the mind.
Yeah.
I do use cantharone almost exclusively.
I mentioned a couple of times that I've done the curetting, but I've never used cryotherapy
in molluscum.
That's interesting that you're saying that pediatricians do that a little bit more.
For me, the risk of causing a light spot, I don't know if that's ever happened to you,
but that to me is probably greater than the success I would have using the liquid nitrogen
to cryotherapy.
Now, you guys also are using, I think, Freon for the most part, unless you're having the
liquid nitrogen filled, the big tank.
Nope.
It's the little tiny ones.
Yep.
So that's a little less aggressive.
If I remember my basic science, Freon's minus 50 degrees Celsius or thereabouts, liquid
nitrogen minus 176 degrees Celsius.
Now does it work any better?
Where did you pull that out of?
How do you know these things?
I can't sleep at night because I wake up thinking I have to take my board exam again for dermatology,
which is actually not a joke.
It's a thing I'm dealing with on my own.
Stuff like that.
Here's the important part.
No one's ever studied "does it work better?"
Just because it's colder doesn't mean it's going to work any better.
If you have to, there's a greater cost of storing the stuff.
It makes for a great magical trick when you dump it out on the floor and it poofs up and
the kids love that.
That's cool.
But short of that, I don't really use cryotherapy for molluscum.
I feel like it actually hurts and it really does tend to leave for me at least a lighter
or a darker spot there, especially in darker skinned patients, you can actually make a
darker spot.
I try to avoid that.
I guess it should also be mentioned, there is another - I guess this is "2024: molluscum
no more!"
This is the real year for new medicines coming out.
There's this other thing that I even hate to bring up that was approved.
It's being marketed under the name, Y-Canth, as in "Why can't we afford this?"
like it should be.
"Why can't we get rid of this?"
That's kind of what I would have said, but it's an old hat repackaged in a new look and
it's this sort of pen like applicator that the patient gets a prescription for and then
kind of procures for what looks like about $700 bucks.
These things are a one-time use deal.
You can, from what I understand, you can treat about 40 to 50 molluscum at one time with
one applicator.
If you have 40 to 50 molluscum at one time, you really, really need to be seeing a specialist
because that's not normal.
This is thankfully at least that it is prescribed by the specialist or at least a physician.
You can't just go buy this in Target, thankfully.
But there's a lot of stuff you can get on Amazon and maybe eventually at some day it'll
be on there.
But 40 to 50, I don't like putting more than about 20 applications on for molluscum for
my patients.
So now you've got a family that just spent $700 bucks for this pen like thing and maybe
you're going to see patients pushing the doctors to treat more because man, I paid for it.
So you better get my money out of that.
I don't know if that's the greatest way to go.
It is approved down to two years of age and older.
I think the good news about it is it does sort of justify and reconcile the historical
problem that we've had with the cantharone we use, which is we didn't have FDA approval
for it.
It was kind of like the FDA knew we were doing it.
They just looked the other way.
"Don't ask, don't tell."
You won't get in trouble because it's kind of accepted, but not really.
Okay, fine.
This one's been approved.
But now I'm worried that, geez, what's going to happen to the stuff that I would normally
use in my clinic if I'm not using this?
Are they going to start cracking down and making us go to the $700 option?
To the other one.
Yeah.
I just, I don't, and I don't see the value of it.
I mean, it's just, to me, it's, to me, the science wasn't there and the cost is just
too great for me to justify that to my patients at least, but I don't know.
Would you spend $700 bucks a pop to get rid of 40 to 50 molluscum?
It depends on where the molluscum are.
I'll say that before I answer the question, but I would go see the dermatologist significantly
sooner than that.
So I'll, I'll put that in.
I'll buck that back to you.
I'll put the referral in back to you.
Wow.
So that's, that's molluscum in a nutshell.
I never, ever thought I knew enough about molluscum to discuss it for 40 minutes.
So I'm, I'm very impressed with us, by the way.
Very impressed.
Well, it'll be great.
This episode will serve both to educate about molluscum and also to cure insomnia.
Absolutely.
All right.
Well that seems like a natural breaking point for us to drop molluscum and maybe shift gears
and talk about something just as much fun.
Wart's.
I wait all day for that.
I wait all day to talk about warts.
I'm very excited.
Probably the third or fourth most common thing I see in the pediatric dermatology clinic
today, that's wart virus and that's specifically the human papilloma virus or HPV, which can
affect mucosal surfaces or skin surfaces.
We call that cutaneous surfaces.
Today we're just going to be focused on the skin ones and there's like 150 different types
of strains or types of this HPV that's out there.
The common types that we're going to be sort of discussing today for the nerds out there
are types 1, 2, 3, 4, 10, 27, 29 and like 57.
Those are the strains particularly that'll get your hands, your feet and most commonly
are the ones that kids walk into the office with.
So, Dr. Walty,, how are warts the bane of your existence?
Maybe they're not.
I don't mind them that much.
It's okay.
It's very common and I think it's something that we can actually alleviate for the parents
fairly quickly.
It's something that we can actually kind of address and fix.
So I definitely don't mind them.
They will generally come in and look very standard.
But again, to your point, there's several different kinds of viruses that can cause
it.
And so you have kind of your classic, oh, that's obvious.
That's just a wart.
We know exactly what that is.
There are definitely sometimes when they're going to come in and they don't look necessarily
like your textbook classic standard wart.
And so sometimes we'll say, we're not really sure.
We want you to see the dermatologist.
We want to see this.
99% of the times we can fix it either in our office or with some other suggestions.
There's definitely a few that we will always refer to the specialist predominantly because
of either size or location.
So anything that is on the face, anything that is right around your nail bed, anything
that is in kind of an area that's going to be sensitive, we'll generally refer those
to dermatology to look at because the removal just needs to be a little bit more precise
than what we can offer in the offices.
But yeah, we see the same kids and we see the same families.
And generally it's really anxiety provoking for the parents, which is unnecessary.
Like I said, it's definitely something that we can fix.
It is anxiety provoking.
And there's a lot of reasons for that.
One we know, at least in the beginning of the infection, this is going to spread and
you're going to see more of it.
And it's kind of like we tell the parents to expect that, but that's a lot easier said
than done.
And asking them to wait either, it can be up to two years that these things go away
on their own tends to be a little too much for most families that I see at least to endure.
I think most people will give you about a window of maybe if you're lucky, six to eight
weeks to ask for something to resolve spontaneously and then you got to start doing something.
So what treatments do you use in the pediatrician's office for these?
So we use, it's actually a portable version of a chemical that's actually just really
cold, it's nitrous.
So it's super, super cold and you're essentially freezing the lesion.
And they had several different applicator types, they have several different size cones
and applicators to make sure that you're really predominantly hitting the affected skin and
not the healthy skin all around it.
It's mildly painful to the kids.
I'm not going to say it's not, but generally older kids tolerate it really, really well.
Younger kids just don't like to be held anyway.
And it's very, very quickly resolving.
So they're uncomfortable during the actual application, which maybe takes five to 10
seconds at the most.
I even think that's actually long.
And then after that, it's really not uncomfortable anymore.
So it's kind of like your vaccine.
So it's a very quick moment of being just uncomfortable.
And then it's better after that.
And again, if it's very, very large, it will require several treatments with that.
Or again, sometimes we'll actually refer it to your team to kind of look at, but we can
definitely do lots of small ones.
We can do one larger one, things like that we can do in the office.
I think to your point though, it's important to make sure that everybody knows that it's
not always going to go away the first time.
It's generally going to need, again, depending on the size, it's going to need repeated treatments.
So you're going to have to be able to kind of come back in, let us look at it.
It's very, very low risk.
The way that the applicators are produced now, I don't want to say it's hard to get
healthy skin, but it's very, very safe to apply just to that lesion.
And it's really, really well tolerated.
I think to the point of what you were saying before, where parents don't want to kind
of wait, it's also really hard to give that advice to a two-year-old.
So the don't scratch, don't move this, don't rub this, don't do that, don't pick at it.
It's really hard to do that with younger kids.
So parents are a little more impatient with the younger ones.
Well, it's an important point that you bring up too, is scratching is probably by design
that these things, much like the molluscum we talked about earlier, are itchy and the virus
can spread both, it can get under the person's fingernails after they've scratched it and
then get passed to another person through direct skin-to-skin contact, or it undergoes
the same process the molluscum can do where you auto-inoculate, where you can scratch
a part of the body and then transmit that virus right to the new part of the body.
And now, lo and behold, the virus has successfully spread.
So getting them under control in terms of not scratching is really paramount.
I try to make sure that the families know to keep those fingernails trimmed as low as
possible.
Make sure you're not picking your nose or picking anything else because wherever your
finger touches, the wart can show up and, man, that makes it a lot more complicated.
And your siblings, they like to scratch each other.
Oh, yeah.
That's true.
You don't scratch yourself, you scratch everyone else.
Yeah.
Now, one of the things that I feel like, man, I wish if I had about a half an hour for each
patient, I would be doing this so much more.
But they can do it at home, is paring the warts down.
Do you advocate that at all?
And if so, what's your sort of approach for that?
I don't.
I'd like to hear kind of what you recommend.
I imagine that that's going to be something that's kind of patient and parent dependent
on whether or not they're comfortable with it or capable of doing it with their particular
kids.
But generally, we will not know.
We do sometimes recommend the over-the-counter ones, specifically the larger, for larger
warts.
We'll recommend those, the over-the-counter formulations that you can get, which is just
salicylic acid to kind of help along whatever we're doing and reduce the size.
Or if they're really, really tiny and we actually don't think that we can freeze it without
getting healthy skin, so really, really new ones, tiny, tiny ones, we'll just tell them
to use the over-the-counter salicylic acid.
But no, tell me how to pare a wart.
Yeah, no, that's a great approach.
The process of paring is really, it can be pretty gross when you're in the clinic.
But what I'm saying for at home, it's really not that aggressive.
You start by getting a pumice stone or a file, just like a normal nail file.
The trick is it's got to be now dedicated just for this purpose.
You're probably going to throw it out when the warts are clear, or you have to sterilize
it so you can use it again.
But what I tell the families is, listen, wait till the child either comes out of the bath
or the shower.
You know how your fingers get that sort of pruney skin when you've been in there too
long?
It's macerated, so it's a little easier to, it's mushy.
There's fluid in there, so the skin's a little bit more flexible and juicy.
So then you take that pumice stone, you take that nail file, and you go over the wart gently.
You're not trying to do this, this is the key point, you're not trying to do this in
one event.
This is a marathon.
You are slowly removing the surface of this wart.
And you stop paring when you get to one of two things.
Either it starts to hurt the kid, great, stop, or you notice some pinpoint bleeding.
That means you're down to the right level.
You don't go farther than that, you stop.
Then I do totally advocate with what you were talking about.
You buy some of the over-the-counter salicylic acid, you apply that to the wart.
And then I like to put duct tape on.
Duct tape specifically, there have been some studies that-
Duct tape is really actually very well proven and studied, yeah.
Yeah, it's why, you know, probably mechanically de-breeds, probably macerates the area a little
bit better too.
But I have them put ideally duct tape over that area, and then don't touch it for 24
hours.
They come back, next day if it's bath time, you do the same thing.
You pull that duct tape off, some of that wart's going to come with it.
You're going to see it's going to be even a little bit more chewed up and macerated.
Take the bath, finish the bath, and repeat the process.
But gentle, gentle, gentle is the key.
Wait, we're supposed to take baths every day?
And if it gets too irritated from the salicylic acid, take a day, two, three days off.
Don't bother.
But if you do that, you could probably literally and figuratively shave off about one to two
visits from having to come in to see me to do what we do.
The key to it is really making sure, to your point, that it's actually 24 hours.
So all the studies that were done for duct tape, I tell people it's just as effective
as a lot of the other things, but you have to actually have that duct tape on for 24
hours at a time.
And kids tend to pick things off.
So we actually told them to cut a piece of the duct tape over the wart, and then put
a bandaid around it so that the little ones have a harder time getting it off.
I've found that if you put it on a kid, they'll play with it once or twice, and then after
that they kind of forget about it.
But for us, we do do freezing just like you guys do with what we call that cryotherapy.
We use liquid nitrogen.
It's minus 176 degrees Celsius.
That's really cold.
It's really no better or worse than the other main in the office treatment that we do, which
is called Candida antigen or immunotherapy.
They both take on average about four to six treatments about a month apart.
So four to six months long duration is what you're kind of waiting for as a parent or
a patient.
There's not much of one treatment approach over the other.
But what I've found is for me, at least in the young patient population that I'm treating,
which are really kind of school age kids is what we're talking about.
If I spend the time on that first visit and convince them to allow me to do this immunotherapy
approach, the Candida antigen, wow, there's some real benefits.
And let's go through that, what this is.
So back in the day when you used to check for tuberculosis, I don't know if you ever
had a PPD placed.
Technically I think you're supposed to always try on the other arm.
You have the nurse or whoever's placing the PPD also place a little Candida antigen.
Now this Candida is yeast.
It's commonly seen in our environment.
It's everywhere.
There's probably some sitting right here in front of me here.
I treat it all the time.
We treat kids with yeast in their diaper rashes and in their mouths and all that stuff all
the time.
So not always.
Nobody's really good at fighting it and killing it unless we don't have a working immune system.
And that was the point when they placed it with the PPD.
If you don't get a response to the Candida antigen, then you might not have a working
immune system.
So you could not trust the results from the PPD for the tuberculosis.
Well someone way smarter than me discovered that you could take that same Candida antigen,
which is not actual live yeast.
It's just - think of it as sort of the shell of the yeast that the body's immune system
reacts against -
You can take that Candida antigen and pump it directly into a wart.
Yes, that's using a needle, which sounds scary, but I'll give you some tips for how to do
this.
You can pump the Candida antigen into a wart and the body's immune system, again,
as long as it's a working immune system, which 99.9% of the time it is, the immune system
floods that area, goes into the wart, goes to fight the yeast.
And if you get lucky, if you get lucky, it figures out that there's a wart virus there
as well and then eventually turns on against it.
Now the benefits of this is that you only amazingly have to treat one or two of the
warts.
You do have to freeze each wart.
You just inject one or two and that saves the kid, as far as I'm concerned, a lot of
pain.
If I've had both done to me, I think freezing does hurt, like actually feels weird.
And the best part about the Candida antigen is you're right back in the mix.
You have that needle placed into the thick dead skin of the wart.
So you don't really feel much at all, as long as you don't move is what I tell the kids.
But you have that needle placed, the medicine goes in, and then five minutes later you can
play basketball, you can run a marathon.
You don't feel it afterwards.
Where the cryotherapy, I feel like at least for an hour or so, you get a tingling sensation.
So if you had some warts frozen on the bottom of your foot, you might not be able to walk
around without at least recognizing you had that treatment done.
And that's a really good point to go back to the cryotherapy.
If you are doing cryotherapy, you are going to see that it is going to get somewhat red,
somewhat swollen.
The wart itself is going to look like there's a problem.
We get a lot of calls back from patients the next couple days saying, is this normal?
Is it infected?
Do I need antibiotics?
It's not.
It's totally normal.
It's okay.
But then that top part usually will fall off.
And that's when you can kind of go back for your repeat treatment.
It can take a couple of weeks, depending on how aggressive it is.
I had two questions for you.
So is that the same reaction that you see if you do the Candida antigen injection?
Do you still see that kind of change in the appearance of the wart after?
So I do use the fact that a wart that might be flesh colored or maybe just kind of gray
will eventually form sort of a pink rim around it.
You'll notice that it's getting red.
That is inflammation.
And that's a sign to the families that I say, hey, listen, that's a good thing.
Your kid's immune system is now turned on in that area.
And yeah, they don't get as really as infected looking as the molluscum do.
But they'll start to dry out.
They'll kind of crust up and fall off.
For anyone listening at home, if you're wondering, geez, I have that appointment with Dr. Walty
or Dr. Krakowski coming up to get my wart treated again.
But geez, I think it might be clear.
A little trick that you can do is you get a magnifying glass and you look at the skin
in the area where the wart is.
If you can see what basically amounts to the skin lines, that's kind of like your fingerprints
on your hand.
But if you look closely at any of your skin, you'll see those little creases in the skin.
If you see those creases going through the area where the wart was, that's really a good
sign that there's no wart there anymore.
If there's something obstructing your view of those lines, the warts probably still there
and probably requires some additional treatment.
But if it's not there, you can cancel the appointment and save yourself a co-pay.
But we'd miss you.
We'd miss you if you didn't come in for your appointment.
There are a lot of kids who take the spot.
The second question that I had, I just wanted to make sure as well, you mentioned warts
on the bottom of your feet.
And those are a little bit different.
So I didn't know if you wanted to kind of touch on that or not.
Yeah, you know, plant our warts.
They can be painful.
That's one of the differences.
Yeah, they can really hurt depending on where they are.
My approach really is the same for ones on the hands or the elbows or the knees or the
feet.
Unbelievably, I do actually, I am able to convince a kid to let me put a needle into those plant
or warts and do the Candida antigen immunotherapy just as much as I'll do the freezing or anything
else.
I guess where sometimes I'll deviate and resort to what I would maybe refer to as a second
line treatment of using something called 5-fluorouracil or Effudex, which is a skin
cancer treatment, or imiquimod known as Aldara, which is an immunotherapy topical.
So it's a cream.
I'll do those treatments in that particular area of the soles of the feet, because sometimes,
and most of the time, I should say, those patients are doing some sort of extracurricular
activity where sports are important to them.
Maybe that's how they got the wart there in the first place.
So they don't want to give up the ability to perform at their at their best.
So those creams, although they take a lot longer, are gentle and usually pretty effective.
It's just more a matter of can you get them covered by the insurance company for something
they're not necessarily intended for.
And you do have to remember, a medicine like 5-fluorouracil should not be handled by
a pregnant woman.
And maybe mom is pregnant at the time that she's helping the child treat the warts.
So you got to be careful about that.
But otherwise, it works pretty well.
We also definitely do a whole "flip-flop and slide" lecture too, especially to my patients
that are going into colleges and they've got shared dorms and stuff like that.
So we do a whole lot of hygiene and again, reminding them they're supposed to take a
shower every day and they should really be careful with the flip flops and the slides
and stuff like that.
Just as a caveat, I would say if you are bringing your child in for any kind of a wart, I would
ask ahead of time when they call the office and you're telling us kind of where it is,
we can help guide you a little bit because pediatricians do not have the Candida antigen
that you were speaking of.
But that's really specifically what you're looking for, that's got to go to Derm.
And then there's a couple of other differences.
A lot of pediatricians aren't as comfortable treating the plantar warts just because of
the location and they're just, it's a little bit of a different skill.
But yeah, I would always say just check ahead of time.
You don't want to have a wasted visit coming in thinking that we're going to be able to
do something and then we're, we think it's better to be more comprehensively treated.
I would echo that as well.
Depending on anatomically where the wart is located, especially if it is around the nail
bed, anywhere around that, freezing done by whomever, could be a dermatologist doing it
30 years, doesn't matter.
It can really damage the nail.
So that in those cases, I would try to save yourself a visit by finding someone who can
do some of the other treatments.
And you know, that doesn't mean you have to see a dermatologist by any means.
It could be a pediatrician who's using the 5-fluorouracil method or the imiquimod.
There are salicylic acid options out there as well.
So in general, freezing in around where the nail forms, the nail matrix is a bad idea.
It can leave you with a permanently dystrophic nail and that's never good for something that's
going to go away on its own anyway.
Or a face.
We don't do face.
Face or genitals, we won't freeze.
That's all you.
Face is interesting.
That's a lot of times we'll see warts up in the face because someone was touching with
their finger and they auto-inoculated.
But many times we'll see flat warts or plain warts up on the face.
That's what we see a lot on there.
Yeah, they're tough.
Or on the legs of people shaving.
They can spread them through the razor.
For the face, that's a great option is your go-to topical retinoid, the same medicine
you would use for acne.
There is an option if the insurance company does not cover the topical retinoid because
this is not acne, it is warts.
Buying over-the-counter adapalene gel now, it's about $15 to $25 bucks, not expensive.
But a pinhead amount on each one of the flat warts every night before you go to bed will
work.
It just might take two, three, four months, but it will work.
And it does it without scarring.
It doesn't hurt.
So there really are some benefits to that approach.
I'm going to write that down because I didn't know that.
So I'm going to write that down.
Yeah, it's a good one.
We use it quite often.
Yeah, ever since that became available over-the-counter, it's been fabulous.
So we like that.
Well, thanks for joining us today, Dr. Walty.
It was wonderful speaking with you about molluscum and warts, two of our favorite things, and
look forward to the next episode.
That sounds great.
Thanks for having me.
Thanks for tuning in to this episode of the Don't Be Rash Pediatric Dermatology Podcast.
I'm your host, Dr. Andrew Krakowski.
Don't forget to subscribe to our show on your favorite podcast platform and check out dontberashed.org
for more information.
A special thank you to our nonprofit sponsor, the St. Luke's University Health Network,
for making this episode possible.
Until next time, remember: Keep calm and don't be rash!