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Welcome to the Don't Be Rash Pediatric Dermatology Podcast, the owner's manual for your kid's

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skin.

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I'm your host, Dr. K, board certified pediatric dermatologist and father of two boys.

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I'm here to chat with you to promote dermatological education and improve skin health in our children

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everywhere.

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Let's get started.

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On today's episode, I'm joined by Dr. Alicia Walty, pediatrician and chief medical officer

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of STAR Community Health.

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We're going to be discussing some of the most common causes of lumps and bumps in kids,

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including my favorite diagnosis that most sounds like a Harry Potter spell: "Molluscum

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Contagiosum."

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Welcome, Dr. Walty.

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Thanks for joining us.

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Where on the annoying list of things you have to deal with in kids does molluscum land for

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you?

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Pretty high up there.

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Thank you very much for having me, Dr. Krakowski.

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I look forward to it.

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And yes, molluscum is one of the most frustrating things for pediatricians and for the parents

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of the kids that bring them in.

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What makes it so annoying?

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Pediatricians like to fix, and molluscum is one of those things that is not always immediately

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fixable and people love to have their kids looking perfect and really being as healthy

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as possible.

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And molluscum is a tough one because you can see it and you know it's not really doing

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too much harm and you know it's not going to hurt them, but it just does not look good.

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And there is a very small arsenal of things that we can do to make it better.

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And yeah, we as Americans are not super patient and this one requires patience.

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So speaking of what it looks like, let's paint the picture for the audience.

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So we're talking about molluscum contagiosum.

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That's the full name.

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So for everybody who's a wordsmith out there, you should figure out that this is, in fact,

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contagious.

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Yes, it's an infection caused by a benign virus, a double-stranded DNA virus in the

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poxviridae family,  So it's a cousin to something like smallpox and the new thing we've heard

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about the last couple of years, mpox, used to be called monkeypox, but it can't hurt

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you like those can.

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And like from a clinical perspective, we're talking about flesh to pink colored bumps.

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They're usually small on the small side, maybe two, maybe five millimeters.

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They're usually rounded.

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They're sort of dome shape.

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If you look really closely or you take a flashlight and you shine it from the side, you might

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see what we call a little umbilication, a little sort of indentation or dell in the

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center.

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And you might see also like a little core that shadows when you shine the light.

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But these things can be scattered all over.

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They can be found in clusters.

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And geez, you hit the nail on the head.

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They don't look great.

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And man, they can really drive some anxiety for both the kid who has them, the parent

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of the kid who has them and anyone taking care of the child at school or daycare or

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wrestling practice after school.

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Yep, absolutely.

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I think what you kind of looked at there in that first sense, so that central umbilication,

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that's something that we really, really look at.

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It's basically just a little bit of a hole in the middle.

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You do have to pull out your microscope or it's kind of small.

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You have to put your reading glasses on.

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But it's something that for us as pediatricians really helps distinguish it from some of the

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other things that look alike.

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We do usually see molluscum and I know we're going to be talking about a couple other things,

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but we see molluscum a lot in like you said clusters and in little lines.

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And so it's very, very rare to see just one molluscum lesion.

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So that's another clue that we look for as pediatricians.

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The other thing is that we don't ever see molluscum on the palms or the soles.

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And that's something that's really different from a lot of other rashes.

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You're always going to see if you bring your kid in for a rash, we are always going to

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look at the palms and soles.

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You're going to think we're crazy, but we're always looking at the palms and soles.

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That's a really big thing for us to kind of help us figure out which route to go down

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for us.

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So molluscum is one of those ones that steers clear of those areas.

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And you mentioned that it sometimes can show up in a sort of streak or line.

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That is not 100% unique to molluscum, but it's one of the few conditions that do what's

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called "koebnerize."

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And that's the technical term for where the virus will track along the line of trauma

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basically from where the kid or adult, because adults can get this too, where they scratch

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it, will sort of seed and track through that line.

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And that can be a real good clue that you're dealing with something like molluscum and

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not something more serious.

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But we call that self-inoculation.

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So yes, the virus is contagious to other people.

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It's also contagious to the patient himself or herself.

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They can spread it on themselves.

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And it's one of the reasons we do, or at least in the United States, do try to try to treat.

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Like you said, we like our fast food, unfortunately, and we like our molluscum gone quickly.

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So we are a very impatient group when it comes to these kinds of things.

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And we do tend to treat it a little bit more aggressively than maybe some countries.

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So what sort of age group do you see molluscum popping up in?

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Typically toddlers.

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We don't see this as much.

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We don't see molluscum as much in infants.

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So we see it in toddlers.

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Toddlers if you, I know you're a father, so they lick, they eat, they put everything in

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their mouth.

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Everything is around them.

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So if they do have other kids in a child care center, if there's other kids in the family,

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if there's a towel on the floor, if there's things like that, families and child care

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centers, just everybody kind of gets them.

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So we tend to see it a lot in the toddler age.

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And to your point, kind of that auto-inoculation, kids have almost no self-restraint.

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So if they have one, they're going to pick at it and they're going to get more.

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The other area that we see it a lot is girls that are shaving their legs.

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So if they have one on their legs and they're shaving, they tend to then have kind of that

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nice long line and we'll see five or six in a row.

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And that's kind of key for us to look at as well.

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So we'll see that on their legs as well.

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I have not seen it in boys shaving their faces.

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I probably can come up with a good reason why not, but I just haven't.

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But again, in most of the cases, it's really just that few clusters and these fairly small

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lesions, unless there's something actually already medically wrong with the child.

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So unless there's a reason for immunosuppression, so for example, if they're taking medicine

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that makes them immunosuppressed or not able to actually mount that kind of response to

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that virus, or if they're super young or if they have another condition that makes them

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more susceptible, then yeah, for the most part, these are really kind of minor benign

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things.

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They just don't look good.

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And that's really unpleasing to most people.

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Yeah, I agree.

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I'm seeing this mostly in kids around two to five years of age.

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The sort of textbook answer is this is about supposed to be one of the most common skin

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conditions that we see in kids.

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About 1% of the world with a skin condition will be the result of this condition, molluscum

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contagiosum.

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I would say it's easily probably the third or fourth most common thing I see in clinic.

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Now, it's kind of a referral bias, meaning people are sending their molluscum patients

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to me because we have some treatments for it.

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But I could easily fill up my entire clinic schedule with just molluscum patients, and

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they would by far be mostly under 10 years of age.

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I do know, and I see it every now and then in an older population, so teenagers, young

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adults, you can get a little "blip" epidemiologically where you start to see a spike because it

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is spread by physical contact, so sexual contact can spread it as well.

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It's also - kind of to be a little bit gloom and doom -

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...we do have to always think about if we're just seeing molluscum in the anogenital region,

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so sort of in the diaper area in a young child, again, maybe four, five, six, seven years

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of age, if it's just there for all the reasons you just talked about, the kids, they will

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spread this.

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They will take it from their arm.

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They'll put it wherever their fingers go.

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But if it's really just located in that underwear area, it does raise the concern for abuse.

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We sometimes have to get involved and call that in and just have some extra questions

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be asked to the families or the daycare team that's taking care of the kid just to make

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sure that child's safe.

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But yeah, by far, these kids are under 10 years of age.

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I think one of the weirdest and hardest parts to explain to parents is why doesn't everybody

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else have them in the family?

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Molluscum is just these two kids.

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Well, I think it's because we at some point learn how to kill the virus ourselves.

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We get better at it.

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So usually it's the older kids, the parents and adults who don't have the virus.

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But certainly, if a six-year-old comes in and they have a two-year-old brother or sister,

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I am counseling the family that there's a good chance that little baby is going to get

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it too and try to eliminate sharing towels and bedding and everything else that you mentioned.

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And I'll tell you, we see it so commonly that honestly it's something that doesn't even

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really raise our eyebrows unless there's some kind of a complication.

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They can get infected if the kids are really scratching at them or again, certain locations.

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To your point, we will ask some questions.

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So don't raise your eyebrows too much.

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We're doing our jobs if we're asking some questions about them appearing kind of in

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the diaper or private areas.

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But for the most part, we will see these as kind of your hands on the door.

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You're about to walk out.

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The kids are there for their regular physical or sports physical or an ear infection.

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And it's, "Hey, Doc, what's this thing?"

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"I just noticed this thing."

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"It keeps coming back".

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Or, "I noticed it a couple months ago and it's just not going away."

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And we give our regular spiel and we tell everyone not to be worried.

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And we kind of go through it.

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We see it several times a day, I would say.

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The only time I would say as a pediatrician that we really generally will refer to dermatology

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is if the parents are truly unsatisfied with the answer of it will go away, you just need

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to give it time.

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And unfortunately, in this case, time can be a year.

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Time can be several, several months.

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So people just generally aren't super pleased with that.

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I know I personally will refer if it's an area that's super cosmetically unpleasing.

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So if there's a cluster on the face, near the eyes, near the mouth, or again, if we

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think that there is a sign of something else.

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So now this is infected.

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I think this needs more treatment or I really think this one needs to be kind of assessed

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by the specialist for whatever reason.

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Maybe I'm worried about immunosuppression.

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Those are the ones that we're sending you.

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For the most part, we generally give kind of the conservative "just wait and watch" approach

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in our office.

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And I think you're in at least close to the majority of what other health care professionals

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are doing.

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Someone did a survey back in a couple years ago, it was about 2,000 health care professionals.

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And about 40% of them said, listen, we just tell you to "wait it out."

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Now waiting it out, it can be, like you said, a couple months.

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I think one study I saw recently was 1.3 years was the average while you wait this thing

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out and it goes away on its own.

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I quote two years to my family's mostly because I'm trying to create some realistic expectations.

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And if it's faster than that, God bless everybody involved.

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We did our job and made somebody happy.

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But I don't think it's uncommon to have it last well more than a year.

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And yeah, and that's a long time.

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And there's the physical complications you mentioned that you can get infected if you

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scratch.

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The point is these things do itch.

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I'm sure that's evolutionarily how they get passed.

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They probably cause you to scratch them so you get the virus under your fingernails and

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then spread it elsewhere.

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But in addition to itching and getting potentially super infected with a bacteria like Staph

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aureus.  We know that these lesions can heal- even if they go away completely on their own -.

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they can leave you with some pock scars.

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They're permanent, "atrophic" - so flattened out scars - not heaped up scars like a keloid,

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but sort of divoted out little pock scars similar to what a chicken pock scar would

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look like.

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And you mentioned a young woman's legs from shaving.

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That's not necessarily ideal, right?

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So that's kind of when I start thinking a little bit about where are the lesions?

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Should I be treating more aggressively?

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Also, if the kid is really just embarrassed and coming in, can't make eye contact with

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me because they're already just beating themselves up that they have this or they can't.

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We do have a pretty large wrestling population here in the Lehigh Valley where we are.

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Big sports, big mixed martial arts.

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If you have these lesions, if the virus is active and you can't cover them, a lot of

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the sports say, "Hey, guess what?

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You can't participate because you're going to put some other kids at risk."

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So now you're talking not only not being able to play in that particular event, but you

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might be at risk for losing a scholarship down the line or something to that effect.

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So there's a lot of reasons that push me to get a little bit more aggressive.

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But at the end of the day, yeah, if the family comes in and they don't care and I don't care,

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especially if they live far away.

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I mean, if you tell me you live two minutes from the office and I can come and have you

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bring you back because the treatment that we most use, and we'll get into treatment

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later, but it's not a once and done thing for any of this stuff.

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And coming in every two or three or four weeks for four to six months, that's a burden by

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itself.

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So if the parents are fine with it and want to just do some at home stuff or nothing,

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God bless them.

234
00:13:20,240 --> 00:13:22,800
But we can ratchet it up if we need to.

235
00:13:22,800 --> 00:13:27,320
I think the other thing to point out is that the lesions that are in areas where the kids

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00:13:27,320 --> 00:13:31,320
can't quite get to usually heal the fastest because they're not getting messed with.

237
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They're not auto-inoculating.

238
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They're not spreading it.

239
00:13:33,600 --> 00:13:35,960
They're not getting infected.

240
00:13:35,960 --> 00:13:39,680
The areas where the kids can either get to or where they have equipment.

241
00:13:39,680 --> 00:13:45,140
So sports equipment, you know, they're wearing a jock, they have chest protectors for hockey

242
00:13:45,140 --> 00:13:48,260
or they have something for baseball or football.

243
00:13:48,260 --> 00:13:49,260
They're never going to heal.

244
00:13:49,260 --> 00:13:52,520
They're always going to be irritated and they're always going to be kind of damp and sweaty

245
00:13:52,520 --> 00:13:55,800
and the kids are going to be itching them and they're always going to be irritated.

246
00:13:55,800 --> 00:13:59,480
So those tend to take a much longer time to heal.

247
00:13:59,480 --> 00:14:02,400
So we definitely will refer some of those out depending on where they are.

248
00:14:02,400 --> 00:14:04,440
To your point, it's really all about the location.

249
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I think a really important point for listeners is you mentioned that super infection is possible,

250
00:14:10,320 --> 00:14:13,600
but there's also this amazing thing called the B.O.T.E.sign.

251
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And it's not "B-O-A-T," like a boat that you sail on the water.

252
00:14:17,080 --> 00:14:20,080
It's the B-O-T-E sign.

253
00:14:20,080 --> 00:14:21,080
Beginning Of The End.

254
00:14:21,080 --> 00:14:24,040
I don't know if that's a thing that's made its way out to...

255
00:14:24,040 --> 00:14:25,560
No, you're teaching me now.

256
00:14:25,560 --> 00:14:26,560
I want to hear this.

257
00:14:26,560 --> 00:14:27,560
This is exciting.

258
00:14:27,560 --> 00:14:34,440
A lot of times what we see is when the immune system of the patient, the child, eventually

259
00:14:34,440 --> 00:14:39,320
kicks in either because it just was time for that to happen or maybe one of our treatments

260
00:14:39,320 --> 00:14:46,980
instigated that and accelerated that response, you get what clinically looks just like an

261
00:14:46,980 --> 00:14:49,940
infection of each of the lesions.

262
00:14:49,940 --> 00:14:54,200
So the molluscum themselves will turn red.

263
00:14:54,200 --> 00:14:55,680
They'll get swollen.

264
00:14:55,680 --> 00:14:57,000
They can be warm.

265
00:14:57,000 --> 00:15:00,600
They can even start to sort of pus up, for lack of a better word.

266
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It looks like they're going to be infected, but this is, in fact, probably the greatest

267
00:15:06,120 --> 00:15:08,920
thing that you can ask for as a parent.

268
00:15:08,920 --> 00:15:10,860
Yeah, it's just the immune response.

269
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And so you don't need to necessarily put the kid on an antibiotic unless there's a fever

270
00:15:15,200 --> 00:15:18,920
or other systemic symptoms.

271
00:15:18,920 --> 00:15:23,800
We look at this and we just say, this is a great thing because it heralds that these

272
00:15:23,800 --> 00:15:26,320
are going to go away on their own pretty soon.

273
00:15:26,320 --> 00:15:33,320
So that's a very powerful measure of where you are in terms of if you can expect these

274
00:15:33,320 --> 00:15:35,060
things to go away.

275
00:15:35,060 --> 00:15:41,440
Another not so much awesome thing that can sometimes run with molluscum is an eczema-

276
00:15:41,440 --> 00:15:42,440
like rash.

277
00:15:42,440 --> 00:15:47,520
And in fact, it is just eczema, but it's not eczema in the sense that your child now has

278
00:15:47,520 --> 00:15:54,600
a diagnosis of what's called "atopic dermatitis," which is separately discussed and more associated

279
00:15:54,600 --> 00:15:56,560
with hay fever, allergies, asthma.

280
00:15:56,560 --> 00:15:58,840
This is an eczema rash.

281
00:15:58,840 --> 00:16:02,680
"Eczema" in dermatology is kind of a garbage catch-all bucket term.

282
00:16:02,680 --> 00:16:05,380
It just means your skin is "boiled over."

283
00:16:05,380 --> 00:16:10,880
And that's also probably in this case a consequence of the virus living in the skin.

284
00:16:10,880 --> 00:16:15,280
Your immune system's probably just smart enough to know that there's a virus hanging out there

285
00:16:15,280 --> 00:16:19,560
hidden.

286
00:16:19,560 --> 00:16:24,680
Once that virus gets sort of acknowledged by your immune system, your immune system

287
00:16:24,680 --> 00:16:29,600
rushes into that area and the skin does kind of bubble up, looks a little red, looks eczematous,

288
00:16:29,600 --> 00:16:30,640
can be even more itchy.

289
00:16:30,640 --> 00:16:33,200
So that's just something to know about.

290
00:16:33,200 --> 00:16:37,980
The good news is we can treat that rash, that eczema, with some moisturizers.

291
00:16:37,980 --> 00:16:42,520
And sometimes we'll use even some low-potency topical steroids to calm it down so you're

292
00:16:42,520 --> 00:16:45,640
not scratching and itching and spreading the virus.

293
00:16:45,640 --> 00:16:51,120
But kind of crazy that this little bump can do so much and look so many different ways.

294
00:16:51,120 --> 00:16:55,800
It can be very confusing and very anxiety-inducing for the family.

295
00:16:55,800 --> 00:17:00,320
I think another thing that's really interesting to point out is that you mentioned kind of

296
00:17:00,320 --> 00:17:04,160
the technical and scientific and Latin name of all of this.

297
00:17:04,160 --> 00:17:06,280
We're going to be talking about warts a little bit later.

298
00:17:06,280 --> 00:17:09,880
And I think one of the things that we're going to really focus on with warts is that it's

299
00:17:09,880 --> 00:17:11,740
a manifestation of this virus.

300
00:17:11,740 --> 00:17:15,240
So even though we can kind of get rid of it, that virus is really in your system.

301
00:17:15,240 --> 00:17:16,240
It's going to come back.

302
00:17:16,240 --> 00:17:17,620
You're going to see it back again.

303
00:17:17,620 --> 00:17:19,120
So molluscum's a little bit different.

304
00:17:19,120 --> 00:17:21,440
There is a really nice immune response to it.

305
00:17:21,440 --> 00:17:22,600
So you can get it again.

306
00:17:22,600 --> 00:17:25,960
You know, if you rub up on someone else, you're still in daycare, you can get it in a different

307
00:17:25,960 --> 00:17:26,960
area.

308
00:17:26,960 --> 00:17:30,760
But generally, most times, and kids love to make liars out of me.

309
00:17:30,760 --> 00:17:32,800
That's why I always say kids never read the book.

310
00:17:32,800 --> 00:17:37,560
But for the most part, if the lesions are gone with molluscum, you're not going to see

311
00:17:37,560 --> 00:17:38,560
it back again.

312
00:17:38,560 --> 00:17:40,920
That virus is already kind of out of the area, out of the system.

313
00:17:40,920 --> 00:17:44,600
And you're at least a little clear unless your kids are kind of back at it again with

314
00:17:44,600 --> 00:17:48,200
the exact same triggers, which is different than with warts.

315
00:17:48,200 --> 00:17:51,840
So I think it's really something to kind of remember that with molluscum, if you can by

316
00:17:51,840 --> 00:17:57,120
that time and you can be patient, and you're not necessarily treating, again, you're going

317
00:17:57,120 --> 00:17:58,660
to have that immunity to it.

318
00:17:58,660 --> 00:18:01,880
So as a pediatrician, how do you approach treatment with the patients that you decide

319
00:18:01,880 --> 00:18:02,880
you're going to treat?

320
00:18:02,880 --> 00:18:07,040
So the kids that we do treat, again, the overwhelming majority, we really don't.

321
00:18:07,040 --> 00:18:11,160
And the treatment that we're giving is we're observing it and we're watching it.

322
00:18:11,160 --> 00:18:14,520
And I know that's highly dissatisfactory for most parents.

323
00:18:14,520 --> 00:18:16,760
It's just as highly dissatisfactory for doctors.

324
00:18:16,760 --> 00:18:19,280
We really love to fix things.

325
00:18:19,280 --> 00:18:22,920
But sometimes NOT doing something is an option.

326
00:18:22,920 --> 00:18:29,240
I think for the kids that we see that we will treat for it, generally, we will sometimes

327
00:18:29,240 --> 00:18:30,240
do cryotherpay for it.

328
00:18:30,240 --> 00:18:33,000
And I know we can kind of get into that a little bit.

329
00:18:33,000 --> 00:18:35,240
Most general pediatricians will not do curettage.

330
00:18:35,240 --> 00:18:39,400
And curettage is really just the fancy way for saying kind of "cutting it off."

331
00:18:39,400 --> 00:18:41,560
And we're really just getting rid of the problem.

332
00:18:41,560 --> 00:18:43,520
But really, those are the treatments that we're doing.

333
00:18:43,520 --> 00:18:45,300
We're not prescribing anything.

334
00:18:45,300 --> 00:18:49,800
If we think it's at that point that it needs to be treated, we're referring it out to Derm.

335
00:18:49,800 --> 00:18:52,520
Family medicine doctors are sometimes a lot more aggressive.

336
00:18:52,520 --> 00:18:54,800
They will do some curetting.

337
00:18:54,800 --> 00:18:58,960
They've been trained in those procedures a lot more than general pediatricians have.

338
00:18:58,960 --> 00:19:01,000
So a lot of times they will do some curette.

339
00:19:01,000 --> 00:19:02,000
They will do some cautery.

340
00:19:02,000 --> 00:19:04,880
They'll do the cryo, things like that.

341
00:19:04,880 --> 00:19:10,240
It really just depends on how trained and what equipment is available in the office.

342
00:19:10,240 --> 00:19:13,400
And that can vary from location to location and practice to practice.

343
00:19:13,400 --> 00:19:17,600
So I would definitely say if you're interested in, you know, you've been seen, you know what

344
00:19:17,600 --> 00:19:22,000
it is, you've been diagnosed with molluscum, and you're at that point and you want something

345
00:19:22,000 --> 00:19:26,600
done, just make sure when you make the appointment with that provider that they are able to do

346
00:19:26,600 --> 00:19:29,160
that and that it's not something that would require a referral.

347
00:19:29,160 --> 00:19:31,360
Yeah, that's a great point.

348
00:19:31,360 --> 00:19:35,240
It can really be frustrating to some parents when they're getting bounced around until

349
00:19:35,240 --> 00:19:41,340
they find someone who either wants to do what they want to do or can offer some treatment.

350
00:19:41,340 --> 00:19:45,660
For me, it comes down to, there's a lot of practical stuff to think about when you're

351
00:19:45,660 --> 00:19:46,660
doing this.

352
00:19:46,660 --> 00:19:50,340
And I think we should be a little bit more transparent with the audience in the sense

353
00:19:50,340 --> 00:19:57,140
that there absolutely is a financial reason to treat molluscum when you are a physician

354
00:19:57,140 --> 00:19:59,080
or a clinician.

355
00:19:59,080 --> 00:20:03,360
There is a service that you bill for for that.

356
00:20:03,360 --> 00:20:08,880
And it's separate from the visit of you coming in and having me tell you that you have molluscum.

357
00:20:08,880 --> 00:20:10,760
So there is that.

358
00:20:10,760 --> 00:20:16,280
But I can tell you, and I think I speak for most pediatric dermatologists, that, man,

359
00:20:16,280 --> 00:20:25,760
if there was a way to do this much faster at home, safely and quickly, nobody would

360
00:20:25,760 --> 00:20:31,400
be complaining about that because most of us have nine, 12-month waiting lists anyway.

361
00:20:31,400 --> 00:20:39,320
So if we could actually open up some spots in our clinic to other kids with probably

362
00:20:39,320 --> 00:20:42,080
more serious rashes, we would love that.

363
00:20:42,080 --> 00:20:47,200
But each one of our molluscum patients really does take up an appointment slot about every

364
00:20:47,200 --> 00:20:49,240
month for about four to six months.

365
00:20:49,240 --> 00:20:50,240
And that's a lot.

366
00:20:50,240 --> 00:20:51,400
That's a lot of people.

367
00:20:51,400 --> 00:20:55,240
So I do kind of balance that when I'm trying to decide to treat.

368
00:20:55,240 --> 00:20:58,760
For me, it really comes down to two branching points.

369
00:20:58,760 --> 00:21:02,920
There's stuff that you can do at home, and then there's stuff that we can do in the office.

370
00:21:02,920 --> 00:21:05,720
And the stuff that we can do at home is pretty good.

371
00:21:05,720 --> 00:21:07,200
I mean, it's funny.

372
00:21:07,200 --> 00:21:11,480
You mentioned the family medicine docs doing a lot of the procedural things and you guys

373
00:21:11,480 --> 00:21:14,080
doing maybe some cryotherapy and some other stuff.

374
00:21:14,080 --> 00:21:21,400
But man, if I could encourage you to feel free to prescribe something like a topical

375
00:21:21,400 --> 00:21:22,400
retinoid.

376
00:21:22,400 --> 00:21:28,240
It's like an over-the-counter medicine called adapalene gel.

377
00:21:28,240 --> 00:21:31,120
It used to go by the brand name Differin, still does.

378
00:21:31,120 --> 00:21:35,240
It used to be a $600 medicine if you couldn't get it.

379
00:21:35,240 --> 00:21:39,440
And we loved it because it was sort of one of the most gentle of the topical retinoids

380
00:21:39,440 --> 00:21:40,440
for acne.

381
00:21:40,440 --> 00:21:42,440
That's what it was approved for.

382
00:21:42,440 --> 00:21:44,480
Now it's over-the-counter.

383
00:21:44,480 --> 00:21:51,360
You absolutely can prescribe this off label per se, but you're telling, you're asking

384
00:21:51,360 --> 00:21:56,800
your patients to go home and put a pinhead sized amount of this medicine, which costs

385
00:21:56,800 --> 00:22:01,400
now about $15 to $25 bucks a tube onto the molluscum.

386
00:22:01,400 --> 00:22:05,000
You got to help counsel them in terms of which ones you want to treat.

387
00:22:05,000 --> 00:22:09,280
I wouldn't, if there was one close to your eye, I don't think I'd be using a topical

388
00:22:09,280 --> 00:22:10,280
retinoid up there.

389
00:22:10,280 --> 00:22:11,720
It'll just be too irritating.

390
00:22:11,720 --> 00:22:18,000
But you feel free as a parent to apply a pinhead size of this medicine every night for four

391
00:22:18,000 --> 00:22:19,000
to six months.

392
00:22:19,000 --> 00:22:22,320
You're going to do better than if you don't, as far as I'm concerned.

393
00:22:22,320 --> 00:22:24,000
So that's a great treatment.

394
00:22:24,000 --> 00:22:27,640
And for $15 to $25 bucks, absolutely worth it.

395
00:22:27,640 --> 00:22:33,720
We also do hear of, and either we'll prescribe or we learn that the patients are using stuff

396
00:22:33,720 --> 00:22:39,280
from Amazon or whatever they got it from, salicylic acid, podophyllin.

397
00:22:39,280 --> 00:22:41,960
These can be heavy hitter medicines.

398
00:22:41,960 --> 00:22:50,680
I don't think a non-trained parent or teenager should be doing this on their own without

399
00:22:50,680 --> 00:22:55,600
probably the direct supervision of a doctor when you're talking about chemicals, because

400
00:22:55,600 --> 00:22:57,440
you could absolutely hurt someone with that stuff.

401
00:22:57,440 --> 00:22:58,440
Yeah.

402
00:22:58,440 --> 00:23:01,440
We definitely don't recommend trying any of those for molluscum.

403
00:23:01,440 --> 00:23:05,640
Other options for at home, I've prescribed and have the parent use it after I show them

404
00:23:05,640 --> 00:23:06,640
how to do it.

405
00:23:06,640 --> 00:23:12,120
This is 5-fluorouracil, that's a medicine that we actually use to treat skin cancers,

406
00:23:12,120 --> 00:23:14,840
you can have some good success when...

407
00:23:14,840 --> 00:23:16,800
This is now second or third line, meaning I've tried some other stuff.

408
00:23:16,800 --> 00:23:18,520
I was going to say, this is all you, friend.

409
00:23:18,520 --> 00:23:19,520
This is not me.

410
00:23:19,520 --> 00:23:23,760
This is dermatology treatment, not pediatric/family med treatment.

411
00:23:23,760 --> 00:23:28,180
This is deep into like, geez, this isn't working and the family can't get to us because they

412
00:23:28,180 --> 00:23:32,260
live too far away or the kid's got six extracurricular activities.

413
00:23:32,260 --> 00:23:33,760
What else are we going to do?

414
00:23:33,760 --> 00:23:37,120
Then there's this other new medicine, I guess it's probably worth mentioning that was just

415
00:23:37,120 --> 00:23:38,700
approved by the FDA.

416
00:23:38,700 --> 00:23:43,720
We are not in any way sponsored except by St. Luke's, which is certainly there's no

417
00:23:43,720 --> 00:23:48,120
conflict of interest here, but there's a new medicine that literally in the last couple

418
00:23:48,120 --> 00:23:53,440
of months just got approved, berdazimer or berdesimer, I'm not even sure how to pronounce

419
00:23:53,440 --> 00:23:55,440
it, 10.3% gel.

420
00:23:55,440 --> 00:23:59,720
What it does is it releases nitric oxide, which both indirectly and directly probably

421
00:23:59,720 --> 00:24:04,360
kills the virus and revs up the immune system to help kill the virus.

422
00:24:04,360 --> 00:24:10,720
That's being touted as maybe an adjunct that you can use at home with some better success

423
00:24:10,720 --> 00:24:12,640
that the families can do.

424
00:24:12,640 --> 00:24:14,920
Remains to be seen, it's literally just been out.

425
00:24:14,920 --> 00:24:17,880
I've never prescribed it for anyone yet myself.

426
00:24:17,880 --> 00:24:20,960
I've never heard the word until today, so don't worry.

427
00:24:20,960 --> 00:24:26,540
Berdazimer, if it's not pronounced that way, it should be because I think it sounds good.

428
00:24:26,540 --> 00:24:30,720
In the office, man, how much time do we want to spend?

429
00:24:30,720 --> 00:24:36,600
We have literally a dozen different ways that we could treat your molluscum in the office.

430
00:24:36,600 --> 00:24:41,840
Again, it starts with the application of a medicine and it goes all the way up to some

431
00:24:41,840 --> 00:24:44,040
procedural intervention.

432
00:24:44,040 --> 00:24:48,080
Where I trained in San Diego, it was scary to hear about, but it happened a couple of

433
00:24:48,080 --> 00:24:52,520
times both for molluscum and warts, which again, we'll talk about later.

434
00:24:52,520 --> 00:24:56,400
There were people down in Mexico, you would cross the border and they were doing

435
00:24:56,400 --> 00:24:58,560
full on surgeries.

436
00:24:58,560 --> 00:25:03,560
Like you would cut out a skin cancer, they were cutting out molluscum and wart virus.

437
00:25:03,560 --> 00:25:04,840
That's crazy.

438
00:25:04,840 --> 00:25:05,840
Don't do that.

439
00:25:05,840 --> 00:25:07,640
Don't allow that to be done to your child.

440
00:25:07,640 --> 00:25:14,340
For us as pediatric dermatologists, I think most of us don't love the curetting, the scraping

441
00:25:14,340 --> 00:25:16,500
with a blade or a needle.

442
00:25:16,500 --> 00:25:17,500
It's done.

443
00:25:17,500 --> 00:25:23,960
I've done it probably three times, I think, in 20 years of being a physician.

444
00:25:23,960 --> 00:25:29,080
I can tell you that one time stood out, it was a child, unfortunately, that needed chemotherapy.

445
00:25:29,080 --> 00:25:34,120
They had a child with cancer and they were getting, is it called intrathecal therapy?

446
00:25:34,120 --> 00:25:36,160
Yep, through spinal cord.

447
00:25:36,160 --> 00:25:39,440
Yep, they get their actual injections through spinal taps.

448
00:25:39,440 --> 00:25:42,040
They get the chemotherapy that way.

449
00:25:42,040 --> 00:25:48,160
This child just happened to have a collection of molluscum virus lesions right near the

450
00:25:48,160 --> 00:25:50,640
area where they were going to be injecting.

451
00:25:50,640 --> 00:25:55,480
The pediatric oncologist asked us, "Hey, can you help clear these things?"

452
00:25:55,480 --> 00:25:57,360
It was like, yeah, sure.

453
00:25:57,360 --> 00:26:00,180
This one trumps the norm.

454
00:26:00,180 --> 00:26:03,220
We scraped them off and the child was asleep.

455
00:26:03,220 --> 00:26:07,880
We did it right before the procedure that they were having and everything went fine.

456
00:26:07,880 --> 00:26:12,400
That's so not even close to what the norm is for us.

457
00:26:12,400 --> 00:26:16,180
What we typically are doing is, I think what you guys probably have heard we do is something

458
00:26:16,180 --> 00:26:20,560
called "beetle juice," which is this amazing chemical called cantharone.

459
00:26:20,560 --> 00:26:21,560
Literally, beetle juice.

460
00:26:21,560 --> 00:26:23,240
It's literally beetle.

461
00:26:23,240 --> 00:26:25,280
It's literally from a beetle in the area.

462
00:26:25,280 --> 00:26:29,800
You can go out in the fields of Pennsylvania and a couple other states in the area.

463
00:26:29,800 --> 00:26:32,680
It's actually pretty far reaching.

464
00:26:32,680 --> 00:26:34,000
It's zoned.

465
00:26:34,000 --> 00:26:35,480
You can find this beetle.

466
00:26:35,480 --> 00:26:39,520
It's a shiny looking, almost metallic-looking beetle.

467
00:26:39,520 --> 00:26:40,520
Pretty long.

468
00:26:40,520 --> 00:26:45,240
They're a good one inch or maybe even longer than that.

469
00:26:45,240 --> 00:26:46,240
Very distinct looking.

470
00:26:46,240 --> 00:26:54,680
You can Google the cantharone beetle and man, in nature, if a bird eats one of these things,

471
00:26:54,680 --> 00:26:55,680
that's it.

472
00:26:55,680 --> 00:26:56,680
It never eats another one.

473
00:26:56,680 --> 00:27:01,480
It gets this blistering reaction and it learns pretty quickly that shiny green or shiny blue

474
00:27:01,480 --> 00:27:05,920
beetles are not to be eaten as a delicacy.

475
00:27:05,920 --> 00:27:11,640
Someone smarter than me figured out that you could purify the - we call it a "vesicant."

476
00:27:11,640 --> 00:27:13,060
It's a blistering agent.

477
00:27:13,060 --> 00:27:20,680
You can purify that and dilute it, importantly, down to a certain strength and put that on

478
00:27:20,680 --> 00:27:21,680
the skin.

479
00:27:21,680 --> 00:27:26,040
It causes a very controlled little blister, very high up in the skin.

480
00:27:26,040 --> 00:27:27,680
It's not a deep blister.

481
00:27:27,680 --> 00:27:32,360
It's not really going to the level where you should be able to do any real damage, but

482
00:27:32,360 --> 00:27:35,440
it will cause an irritation and can cause a blister.

483
00:27:35,440 --> 00:27:37,520
It is called blistering beetle juice.

484
00:27:37,520 --> 00:27:39,000
I think you just like saying that.

485
00:27:39,000 --> 00:27:40,000
I do.

486
00:27:40,000 --> 00:27:41,560
I think you like saying blistering beetle juice.

487
00:27:41,560 --> 00:27:46,880
I think if you say it five times, beetle juice is supposed to come out.

488
00:27:46,880 --> 00:27:47,880
That's the rumor.

489
00:27:47,880 --> 00:27:48,880
I've actually never seen that movie.

490
00:27:48,880 --> 00:27:50,640
I have to watch it.

491
00:27:50,640 --> 00:27:56,720
We put this stuff on at least three, four times a day in our clinic.

492
00:27:56,720 --> 00:27:58,620
For the most part, it works pretty well.

493
00:27:58,620 --> 00:28:03,320
The nice thing about it from being a clinician side of things is it doesn't hurt when you're

494
00:28:03,320 --> 00:28:04,480
putting it on.

495
00:28:04,480 --> 00:28:10,960
It can in a day or two have a little bit of this irritated reaction area where the bumps

496
00:28:10,960 --> 00:28:13,640
that you treat can get raw.

497
00:28:13,640 --> 00:28:18,720
It's not pain free, but there's nothing that we're doing in the office except maybe scaring

498
00:28:18,720 --> 00:28:20,660
the child by putting this stuff on.

499
00:28:20,660 --> 00:28:21,660
How do we put it on?

500
00:28:21,660 --> 00:28:27,000
We use a "cotton tipped applicator," basically a fancy term for a Q-tip with a little wooden

501
00:28:27,000 --> 00:28:29,680
handle instead of the kind that you would use on your ear.

502
00:28:29,680 --> 00:28:34,560
We use the wooden part, the sponge and soaks up way too much of this stuff and it would

503
00:28:34,560 --> 00:28:38,160
be way too much to put on, but we just put a tiny little bit.

504
00:28:38,160 --> 00:28:42,160
I've had a couple of moms call me out that I didn't put any on here or there, but it's

505
00:28:42,160 --> 00:28:46,320
like, no, I promise you that's how much we need or how little we need.

506
00:28:46,320 --> 00:28:51,560
It just requires a tiny little bit and you paint as many as you're comfortable with.

507
00:28:51,560 --> 00:28:55,600
I usually am doing somewhere in the neighborhood of 18, 20.

508
00:28:55,600 --> 00:28:59,400
I don't love to do more than that because it's just how much chemical do you want to

509
00:28:59,400 --> 00:29:04,400
put on a kid and if, God forbid, they did have a problem, geez, you can't really reverse

510
00:29:04,400 --> 00:29:05,400
that.

511
00:29:05,400 --> 00:29:11,840
So you put it on in the clinic, you tell the mom or dad based on the anatomic location

512
00:29:11,840 --> 00:29:15,400
of the bumps that you're treating, you're not going to leave this stuff on for more

513
00:29:15,400 --> 00:29:20,700
than four hours and you set an alarm to make sure that they wash it off with soap and water.

514
00:29:20,700 --> 00:29:24,240
Usually if it's like under the armpit or in the groin area, I'm usually doing an hour

515
00:29:24,240 --> 00:29:28,540
to two hours max for leaving it on and then washing it off, but you kind of judge that

516
00:29:28,540 --> 00:29:30,520
based on what you're treating.

517
00:29:30,520 --> 00:29:34,760
And the kids, as long as they understand that the Q-tip doesn't hurt, they let you do it.

518
00:29:34,760 --> 00:29:39,640
It's pretty straightforward and man, it does work.

519
00:29:39,640 --> 00:29:45,960
On average, I'm seeing and I think my colleagues are seeing response rates and like I mentioned

520
00:29:45,960 --> 00:29:50,040
earlier about four to six months with about a month in between treatments.

521
00:29:50,040 --> 00:29:54,920
I think that's important to point out exactly what you just said, that it's not one treatment

522
00:29:54,920 --> 00:29:58,280
and that's something that's for almost everything we're talking about today.

523
00:29:58,280 --> 00:29:59,500
It's not one treatment.

524
00:29:59,500 --> 00:30:03,520
This is repeated and even then it's several repetitions.

525
00:30:03,520 --> 00:30:04,760
It's not like one or two.

526
00:30:04,760 --> 00:30:06,360
This is several different visits.

527
00:30:06,360 --> 00:30:10,560
So just definitely something to keep in mind in terms of setting expectations.

528
00:30:10,560 --> 00:30:14,160
You don't want to think you're doing something wrong just because it didn't get fixed in

529
00:30:14,160 --> 00:30:15,160
one or two visits.

530
00:30:15,160 --> 00:30:17,440
No, and I know how annoying it is.

531
00:30:17,440 --> 00:30:20,880
The family comes in and it's like the fourth visit, right?

532
00:30:20,880 --> 00:30:24,340
And they still clearly have molluscum and they're looking at you going, you said, "Four

533
00:30:24,340 --> 00:30:25,340
to six.!"

534
00:30:25,340 --> 00:30:26,340
I'm like, yeah, exactly.

535
00:30:26,340 --> 00:30:27,340
I said four to six.

536
00:30:27,340 --> 00:30:31,240
You got to give me the other two because I've seen it a couple of times, like overnight,

537
00:30:31,240 --> 00:30:33,120
boom, they just go away.

538
00:30:33,120 --> 00:30:35,660
Just like a cold eventually goes away.

539
00:30:35,660 --> 00:30:38,160
These things, your body figures it out.

540
00:30:38,160 --> 00:30:39,160
That's what's clearing them.

541
00:30:39,160 --> 00:30:41,400
It's not the medicine per se.

542
00:30:41,400 --> 00:30:45,520
It's the immune response that we're instigating in the area that clears these things.

543
00:30:45,520 --> 00:30:47,640
So it's really the kid's immune system.

544
00:30:47,640 --> 00:30:50,500
And man, sometimes it's an average, right?

545
00:30:50,500 --> 00:30:52,920
So sometimes it's two treatments, sometimes it's 10.

546
00:30:52,920 --> 00:30:58,120
But most of the time, I think if you give them the education upfront, the families understand

547
00:30:58,120 --> 00:31:02,780
that it's kind of out of your hands and we're doing the best that we can.

548
00:31:02,780 --> 00:31:05,120
Is the application uncomfortable?

549
00:31:05,120 --> 00:31:07,440
Because I've never actually applied it.

550
00:31:07,440 --> 00:31:08,440
Does it sting?

551
00:31:08,440 --> 00:31:12,480
Is it uncomfortable or is it really just getting them to sit still?

552
00:31:12,480 --> 00:31:14,480
No, it's getting them to sit still.

553
00:31:14,480 --> 00:31:20,620
And that's actually way more important than probably it'll come off at first listen.

554
00:31:20,620 --> 00:31:23,520
So I don't bring the bottle to the child.

555
00:31:23,520 --> 00:31:29,540
I keep it on a counter and I take the dipped stick and move it to the kid.

556
00:31:29,540 --> 00:31:35,960
So there's a minimal amount of this canthrone floating around the room that I'm in.

557
00:31:35,960 --> 00:31:40,600
Because I have absolutely seen and have had it happen to me where a kid will all of a

558
00:31:40,600 --> 00:31:45,200
sudden look like they're doing great and just flail and they knock you and then the stuff

559
00:31:45,200 --> 00:31:46,200
goes flying.

560
00:31:46,200 --> 00:31:49,080
If it gets in your eye, it would be a big problem.

561
00:31:49,080 --> 00:31:52,880
If it got in your mouth, it could cause the same blistering reaction that the bird had

562
00:31:52,880 --> 00:31:53,880
from eating it.

563
00:31:53,880 --> 00:31:55,600
So you don't want to do that.

564
00:31:55,600 --> 00:32:03,160
But no, touching the lesion one time, one time I applied it in my office and by the

565
00:32:03,160 --> 00:32:08,080
time the child got to the car, mom brought the child back in and said, he's complaining

566
00:32:08,080 --> 00:32:09,080
that it's burning.

567
00:32:09,080 --> 00:32:12,340
So we brought him into the bathroom and mom just washed them off right there.

568
00:32:12,340 --> 00:32:13,720
And we considered that Treatment #1.

569
00:32:13,720 --> 00:32:15,240
We'll see you again in four weeks.

570
00:32:15,240 --> 00:32:18,040
That literally happened just one time.

571
00:32:18,040 --> 00:32:20,760
And I guess you do always warn them.

572
00:32:20,760 --> 00:32:26,640
It's four hours max, again, depending on that anatomical location, or as soon as the child

573
00:32:26,640 --> 00:32:28,160
tells you it's starting to burn.

574
00:32:28,160 --> 00:32:35,600
If they feel it tingling or hurting, hey, we've never lost a kid to molluscum contagiosum.

575
00:32:35,600 --> 00:32:38,320
There's no reason to push this treatment any further.

576
00:32:38,320 --> 00:32:39,320
Wash it off.

577
00:32:39,320 --> 00:32:40,320
Be done with it.

578
00:32:40,320 --> 00:32:43,960
And for the most part, I haven't had many problems.

579
00:32:43,960 --> 00:32:45,280
There have been a couple of times.

580
00:32:45,280 --> 00:32:53,440
One was particularly painful for me because I talked the family into doing the treatment.

581
00:32:53,440 --> 00:32:55,040
They had kept coming back in.

582
00:32:55,040 --> 00:32:58,920
They were watching these lesions spread.

583
00:32:58,920 --> 00:33:01,880
They were kind of on the fence about what to do.

584
00:33:01,880 --> 00:33:08,920
Mom, I vaguely remember, was a little bit more into sort of the naturopathic approach.

585
00:33:08,920 --> 00:33:14,840
And they just spent probably more time than I would have as a dad, not as a doctor, but

586
00:33:14,840 --> 00:33:18,600
as a dad coming in for this thing and not doing anything directly.

587
00:33:18,600 --> 00:33:20,120
You know what I mean?

588
00:33:20,120 --> 00:33:22,200
So I kind of talked them into it.

589
00:33:22,200 --> 00:33:28,800
And wouldn't you know, like that next morning I got the phone call that the child had a

590
00:33:28,800 --> 00:33:31,800
pretty exuberant blistering reaction.

591
00:33:31,800 --> 00:33:33,520
And yeah, it just happens.

592
00:33:33,520 --> 00:33:37,900
I mean, a lot of that stuff is just bad luck.

593
00:33:37,900 --> 00:33:39,520
But there's some practical side of things.

594
00:33:39,520 --> 00:33:45,240
The guy who trained me in pediatric dermatology used to say that it looks pretty simple to

595
00:33:45,240 --> 00:33:50,280
put this stuff on, but it really does require some practice.

596
00:33:50,280 --> 00:33:54,160
You have to understand all the bad things that could happen so that you eliminate them

597
00:33:54,160 --> 00:33:56,960
and then it's the easiest thing ever.

598
00:33:56,960 --> 00:34:01,580
But if you drip the stuff, if you're putting too much on the lesion, and if you don't allow

599
00:34:01,580 --> 00:34:06,200
it to dry at the bedside there when you're putting it on and the kid puts the clothing

600
00:34:06,200 --> 00:34:12,920
on or pulls the clothing off and brings it up to their face, now you spread the wet medicine.

601
00:34:12,920 --> 00:34:19,080
So there's stuff like that that you can't really avoid unless you tell the parent and

602
00:34:19,080 --> 00:34:20,560
the kid not to do that.

603
00:34:20,560 --> 00:34:23,760
There's some other stuff in the background that I always found sort of interesting.

604
00:34:23,760 --> 00:34:28,000
We don't really focus on it too much unless you make the point of talking about it.

605
00:34:28,000 --> 00:34:34,760
And that is when you buy a fresh bottle of this stuff, it's at its mixed pharmaceutical

606
00:34:34,760 --> 00:34:37,480
grade kind of concentration, if you will.

607
00:34:37,480 --> 00:34:44,440
But as you spend a month at a time and this is being utilized, exposed to the atmosphere,

608
00:34:44,440 --> 00:34:48,400
it's starting to dry out, you're getting closer to the bottom, you can see this stuff physically

609
00:34:48,400 --> 00:34:49,400
thicken up.

610
00:34:49,400 --> 00:34:52,480
I mean, it starts to look almost like rubber cement.

611
00:34:52,480 --> 00:34:54,720
You remember playing with that when you were a kid?

612
00:34:54,720 --> 00:34:56,280
And it had that consistency.

613
00:34:56,280 --> 00:34:58,280
It'll get a little tackier.

614
00:34:58,280 --> 00:35:01,360
And there's just, I mean, by definition, it's dehydrated.

615
00:35:01,360 --> 00:35:04,200
So it's got to be more potent than it was when it started.

616
00:35:04,200 --> 00:35:05,200
So you got to be careful.

617
00:35:05,200 --> 00:35:08,120
You just throw that bottle out and start with a new one.

618
00:35:08,120 --> 00:35:14,280
I think it's just, again, it all kind of goes towards the if you're able to be and are acceptable

619
00:35:14,280 --> 00:35:20,740
to have kind of that weight and do that kind of cautious observation, that is an option.

620
00:35:20,740 --> 00:35:24,880
And I think sometimes people think, again, not doing anything isn't really acceptable,

621
00:35:24,880 --> 00:35:26,560
but sometimes it's actually the best option.

622
00:35:26,560 --> 00:35:29,400
So definitely something to keep in the back of the mind.

623
00:35:29,400 --> 00:35:30,400
Yeah.

624
00:35:30,400 --> 00:35:33,080
I do use cantharone almost exclusively.

625
00:35:33,080 --> 00:35:39,200
I mentioned a couple of times that I've done the curetting, but I've never used cryotherapy

626
00:35:39,200 --> 00:35:40,200
in molluscum.

627
00:35:40,200 --> 00:35:44,920
That's interesting that you're saying that pediatricians do that a little bit more.

628
00:35:44,920 --> 00:35:50,160
For me, the risk of causing a light spot, I don't know if that's ever happened to you,

629
00:35:50,160 --> 00:35:56,880
but that to me is probably greater than the success I would have using the liquid nitrogen

630
00:35:56,880 --> 00:35:57,880
to cryotherapy.

631
00:35:57,880 --> 00:36:02,040
Now, you guys also are using, I think, Freon for the most part, unless you're having the

632
00:36:02,040 --> 00:36:04,120
liquid nitrogen filled, the big tank.

633
00:36:04,120 --> 00:36:05,120
Nope.

634
00:36:05,120 --> 00:36:06,120
It's the little tiny ones.

635
00:36:06,120 --> 00:36:07,120
Yep.

636
00:36:07,120 --> 00:36:08,840
So that's a little less aggressive.

637
00:36:08,840 --> 00:36:13,640
If I remember my basic science, Freon's minus 50 degrees Celsius or thereabouts, liquid

638
00:36:13,640 --> 00:36:16,600
nitrogen minus 176 degrees Celsius.

639
00:36:16,600 --> 00:36:18,240
Now does it work any better?

640
00:36:18,240 --> 00:36:19,240
Where did you pull that out of?

641
00:36:19,240 --> 00:36:23,760
How do you know these things?

642
00:36:23,760 --> 00:36:29,520
I can't sleep at night because I wake up thinking I have to take my board exam again for dermatology,

643
00:36:29,520 --> 00:36:32,440
which is actually not a joke.

644
00:36:32,440 --> 00:36:36,760
It's a thing I'm dealing with on my own.

645
00:36:36,760 --> 00:36:37,760
Stuff like that.

646
00:36:37,760 --> 00:36:38,760
Here's the important part.

647
00:36:38,760 --> 00:36:41,320
No one's ever studied "does it work better?"

648
00:36:41,320 --> 00:36:44,000
Just because it's colder doesn't mean it's going to work any better.

649
00:36:44,000 --> 00:36:48,080
If you have to, there's a greater cost of storing the stuff.

650
00:36:48,080 --> 00:36:51,840
It makes for a great magical trick when you dump it out on the floor and it poofs up and

651
00:36:51,840 --> 00:36:52,840
the kids love that.

652
00:36:52,840 --> 00:36:53,840
That's cool.

653
00:36:53,840 --> 00:36:58,200
But short of that, I don't really use cryotherapy for molluscum.

654
00:36:58,200 --> 00:37:02,920
I feel like it actually hurts and it really does tend to leave for me at least a lighter

655
00:37:02,920 --> 00:37:06,800
or a darker spot there, especially in darker skinned patients, you can actually make a

656
00:37:06,800 --> 00:37:07,800
darker spot.

657
00:37:07,800 --> 00:37:10,000
I try to avoid that.

658
00:37:10,000 --> 00:37:16,000
I guess it should also be mentioned, there is another -  I guess this is "2024:  molluscum

659
00:37:16,000 --> 00:37:17,000
no more!"

660
00:37:17,000 --> 00:37:20,960
This is the real year for new medicines coming out.

661
00:37:20,960 --> 00:37:25,080
There's this other thing that I even hate to bring up that was approved.

662
00:37:25,080 --> 00:37:31,880
It's being marketed under the name, Y-Canth, as in "Why can't we afford this?"

663
00:37:31,880 --> 00:37:32,880
like it should be.

664
00:37:32,880 --> 00:37:34,720
"Why can't we get rid of this?"

665
00:37:34,720 --> 00:37:41,680
That's kind of what I would have said, but it's an old hat repackaged in a new look and

666
00:37:41,680 --> 00:37:47,600
it's this sort of pen like applicator that the patient gets a prescription for and then

667
00:37:47,600 --> 00:37:53,040
kind of procures for what looks like about $700 bucks.

668
00:37:53,040 --> 00:37:55,600
These things are a one-time use deal.

669
00:37:55,600 --> 00:38:00,720
You can, from what I understand, you can treat about 40 to 50 molluscum at one time with

670
00:38:00,720 --> 00:38:01,720
one applicator.

671
00:38:01,720 --> 00:38:06,840
If you have 40 to 50 molluscum at one time, you really, really need to be seeing a specialist

672
00:38:06,840 --> 00:38:08,960
because that's not normal.

673
00:38:08,960 --> 00:38:14,200
This is thankfully at least that it is prescribed by the specialist or at least a physician.

674
00:38:14,200 --> 00:38:17,320
You can't just go buy this in Target, thankfully.

675
00:38:17,320 --> 00:38:21,360
But there's a lot of stuff you can get on Amazon and maybe eventually at some day it'll

676
00:38:21,360 --> 00:38:22,520
be on there.

677
00:38:22,520 --> 00:38:28,160
But 40 to 50, I don't like putting more than about 20 applications on for molluscum for

678
00:38:28,160 --> 00:38:29,160
my patients.

679
00:38:29,160 --> 00:38:33,760
So now you've got a family that just spent $700 bucks for this pen like thing and maybe

680
00:38:33,760 --> 00:38:39,920
you're going to see patients pushing the doctors to treat more because man, I paid for it.

681
00:38:39,920 --> 00:38:42,560
So you better get my money out of that.

682
00:38:42,560 --> 00:38:45,440
I don't know if that's the greatest way to go.

683
00:38:45,440 --> 00:38:47,920
It is approved down to two years of age and older.

684
00:38:47,920 --> 00:38:57,760
I think the good news about it is it does sort of justify and reconcile the historical

685
00:38:57,760 --> 00:39:01,720
problem that we've had with the cantharone we use, which is we didn't have FDA approval

686
00:39:01,720 --> 00:39:02,720
for it.

687
00:39:02,720 --> 00:39:04,080
It was kind of like the FDA knew we were doing it.

688
00:39:04,080 --> 00:39:06,360
They just looked the other way.

689
00:39:06,360 --> 00:39:07,360
"Don't ask, don't tell."

690
00:39:07,360 --> 00:39:10,520
You won't get in trouble because it's kind of accepted, but not really.

691
00:39:10,520 --> 00:39:11,520
Okay, fine.

692
00:39:11,520 --> 00:39:12,520
This one's been approved.

693
00:39:12,520 --> 00:39:17,520
But now I'm worried that, geez, what's going to happen to the stuff that I would normally

694
00:39:17,520 --> 00:39:20,120
use in my clinic if I'm not using this?

695
00:39:20,120 --> 00:39:23,280
Are they going to start cracking down and making us go to the $700 option?

696
00:39:23,280 --> 00:39:24,280
To the other one.

697
00:39:24,280 --> 00:39:25,280
Yeah.

698
00:39:25,280 --> 00:39:27,120
I just, I don't, and I don't see the value of it.

699
00:39:27,120 --> 00:39:34,440
I mean, it's just, to me, it's, to me, the science wasn't there and the cost is just

700
00:39:34,440 --> 00:39:38,640
too great for me to justify that to my patients at least, but I don't know.

701
00:39:38,640 --> 00:39:44,200
Would you spend $700 bucks a pop to get rid of 40 to 50 molluscum?

702
00:39:44,200 --> 00:39:45,760
It depends on where the molluscum are.

703
00:39:45,760 --> 00:39:51,280
I'll say that before I answer the question, but I would go see the dermatologist significantly

704
00:39:51,280 --> 00:39:52,440
sooner than that.

705
00:39:52,440 --> 00:39:53,720
So I'll, I'll put that in.

706
00:39:53,720 --> 00:39:55,160
I'll buck that back to you.

707
00:39:55,160 --> 00:39:57,400
I'll put the referral in back to you.

708
00:39:57,400 --> 00:39:58,400
Wow.

709
00:39:58,400 --> 00:39:59,880
So that's, that's molluscum in a nutshell.

710
00:39:59,880 --> 00:40:03,360
I never, ever thought I knew enough about molluscum to discuss it for 40 minutes.

711
00:40:03,360 --> 00:40:05,640
So I'm, I'm very impressed with us, by the way.

712
00:40:05,640 --> 00:40:06,640
Very impressed.

713
00:40:06,640 --> 00:40:08,760
Well, it'll be great.

714
00:40:08,760 --> 00:40:13,920
This episode will serve both to educate about molluscum and also to cure insomnia.

715
00:40:13,920 --> 00:40:15,920
Absolutely.

716
00:40:15,920 --> 00:40:17,720
All right.

717
00:40:17,720 --> 00:40:23,360
Well that seems like a natural breaking point for us to drop molluscum and maybe shift gears

718
00:40:23,360 --> 00:40:25,880
and talk about something just as much fun.

719
00:40:25,880 --> 00:40:26,880
Wart's.

720
00:40:26,880 --> 00:40:28,640
I wait all day for that.

721
00:40:28,640 --> 00:40:30,320
I wait all day to talk about warts.

722
00:40:30,320 --> 00:40:31,720
I'm very excited.

723
00:40:31,720 --> 00:40:35,600
Probably the third or fourth most common thing I see in the pediatric dermatology clinic

724
00:40:35,600 --> 00:40:42,640
today, that's wart virus and that's specifically the human papilloma virus or HPV, which can

725
00:40:42,640 --> 00:40:45,680
affect mucosal surfaces or skin surfaces.

726
00:40:45,680 --> 00:40:46,920
We call that cutaneous surfaces.

727
00:40:46,920 --> 00:40:51,360
Today we're just going to be focused on the skin ones and there's like 150 different types

728
00:40:51,360 --> 00:40:55,560
of strains or types of this HPV that's out there.

729
00:40:55,560 --> 00:41:00,720
The common types that we're going to be sort of discussing today for the nerds out there

730
00:41:00,720 --> 00:41:08,180
are types 1, 2, 3, 4, 10, 27, 29 and like 57.

731
00:41:08,180 --> 00:41:13,280
Those are the strains particularly that'll get your hands, your feet and most commonly

732
00:41:13,280 --> 00:41:15,600
are the ones that kids walk into the office with.

733
00:41:15,600 --> 00:41:19,240
So, Dr. Walty,, how are warts the bane of your existence?

734
00:41:19,240 --> 00:41:20,240
Maybe they're not.

735
00:41:20,240 --> 00:41:21,840
I don't mind them that much.

736
00:41:21,840 --> 00:41:22,840
It's okay.

737
00:41:22,840 --> 00:41:25,680
It's very common and I think it's something that we can actually alleviate for the parents

738
00:41:25,680 --> 00:41:26,680
fairly quickly.

739
00:41:26,680 --> 00:41:28,800
It's something that we can actually kind of address and fix.

740
00:41:28,800 --> 00:41:31,180
So I definitely don't mind them.

741
00:41:31,180 --> 00:41:35,440
They will generally come in and look very standard.

742
00:41:35,440 --> 00:41:39,000
But again, to your point, there's several different kinds of viruses that can cause

743
00:41:39,000 --> 00:41:40,000
it.

744
00:41:40,000 --> 00:41:42,120
And so you have kind of your classic, oh, that's obvious.

745
00:41:42,120 --> 00:41:43,120
That's just a wart.

746
00:41:43,120 --> 00:41:44,120
We know exactly what that is.

747
00:41:44,120 --> 00:41:47,360
There are definitely sometimes when they're going to come in and they don't look necessarily

748
00:41:47,360 --> 00:41:50,620
like your textbook classic standard wart.

749
00:41:50,620 --> 00:41:52,380
And so sometimes we'll say, we're not really sure.

750
00:41:52,380 --> 00:41:54,040
We want you to see the dermatologist.

751
00:41:54,040 --> 00:41:55,280
We want to see this.

752
00:41:55,280 --> 00:42:00,960
99% of the times we can fix it either in our office or with some other suggestions.

753
00:42:00,960 --> 00:42:04,920
There's definitely a few that we will always refer to the specialist predominantly because

754
00:42:04,920 --> 00:42:07,340
of either size or location.

755
00:42:07,340 --> 00:42:12,280
So anything that is on the face, anything that is right around your nail bed, anything

756
00:42:12,280 --> 00:42:16,040
that is in kind of an area that's going to be sensitive, we'll generally refer those

757
00:42:16,040 --> 00:42:19,960
to dermatology to look at because the removal just needs to be a little bit more precise

758
00:42:19,960 --> 00:42:22,840
than what we can offer in the offices.

759
00:42:22,840 --> 00:42:25,760
But yeah, we see the same kids and we see the same families.

760
00:42:25,760 --> 00:42:30,000
And generally it's really anxiety provoking for the parents, which is unnecessary.

761
00:42:30,000 --> 00:42:32,080
Like I said, it's definitely something that we can fix.

762
00:42:32,080 --> 00:42:33,880
It is anxiety provoking.

763
00:42:33,880 --> 00:42:35,440
And there's a lot of reasons for that.

764
00:42:35,440 --> 00:42:41,000
One we know, at least in the beginning of the infection, this is going to spread and

765
00:42:41,000 --> 00:42:42,320
you're going to see more of it.

766
00:42:42,320 --> 00:42:46,560
And it's kind of like we tell the parents to expect that, but that's a lot easier said

767
00:42:46,560 --> 00:42:48,080
than done.

768
00:42:48,080 --> 00:42:53,400
And asking them to wait either, it can be up to two years that these things go away

769
00:42:53,400 --> 00:42:59,760
on their own tends to be a little too much for most families that I see at least to endure.

770
00:42:59,760 --> 00:43:04,240
I think most people will give you about a window of maybe if you're lucky, six to eight

771
00:43:04,240 --> 00:43:08,960
weeks to ask for something to resolve spontaneously and then you got to start doing something.

772
00:43:08,960 --> 00:43:12,880
So what treatments do you use in the pediatrician's office for these?

773
00:43:12,880 --> 00:43:18,120
So we use, it's actually a portable version of a chemical that's actually just really

774
00:43:18,120 --> 00:43:19,120
cold, it's nitrous.

775
00:43:19,120 --> 00:43:23,680
So it's super, super cold and you're essentially freezing the lesion.

776
00:43:23,680 --> 00:43:28,320
And they had several different applicator types, they have several different size cones

777
00:43:28,320 --> 00:43:32,720
and applicators to make sure that you're really predominantly hitting the affected skin and

778
00:43:32,720 --> 00:43:35,560
not the healthy skin all around it.

779
00:43:35,560 --> 00:43:37,480
It's mildly painful to the kids.

780
00:43:37,480 --> 00:43:42,600
I'm not going to say it's not, but generally older kids tolerate it really, really well.

781
00:43:42,600 --> 00:43:45,840
Younger kids just don't like to be held anyway.

782
00:43:45,840 --> 00:43:47,640
And it's very, very quickly resolving.

783
00:43:47,640 --> 00:43:53,760
So they're uncomfortable during the actual application, which maybe takes five to 10

784
00:43:53,760 --> 00:43:54,760
seconds at the most.

785
00:43:54,760 --> 00:43:56,840
I even think that's actually long.

786
00:43:56,840 --> 00:43:59,280
And then after that, it's really not uncomfortable anymore.

787
00:43:59,280 --> 00:44:00,540
So it's kind of like your vaccine.

788
00:44:00,540 --> 00:44:03,880
So it's a very quick moment of being just uncomfortable.

789
00:44:03,880 --> 00:44:05,460
And then it's better after that.

790
00:44:05,460 --> 00:44:10,280
And again, if it's very, very large, it will require several treatments with that.

791
00:44:10,280 --> 00:44:14,040
Or again, sometimes we'll actually refer it to your team to kind of look at, but we can

792
00:44:14,040 --> 00:44:16,000
definitely do lots of small ones.

793
00:44:16,000 --> 00:44:19,400
We can do one larger one, things like that we can do in the office.

794
00:44:19,400 --> 00:44:22,920
I think to your point though, it's important to make sure that everybody knows that it's

795
00:44:22,920 --> 00:44:25,520
not always going to go away the first time.

796
00:44:25,520 --> 00:44:30,600
It's generally going to need, again, depending on the size, it's going to need repeated treatments.

797
00:44:30,600 --> 00:44:33,920
So you're going to have to be able to kind of come back in, let us look at it.

798
00:44:33,920 --> 00:44:35,680
It's very, very low risk.

799
00:44:35,680 --> 00:44:39,880
The way that the applicators are produced now, I don't want to say it's hard to get

800
00:44:39,880 --> 00:44:45,000
healthy skin, but it's very, very safe to apply just to that lesion.

801
00:44:45,000 --> 00:44:47,280
And it's really, really well tolerated.

802
00:44:47,280 --> 00:44:50,960
I think to the point of what you were saying before, where parents don't want to kind

803
00:44:50,960 --> 00:44:55,200
of wait, it's also really hard to give that advice to a two-year-old.

804
00:44:55,200 --> 00:45:00,440
So the don't scratch, don't move this, don't rub this, don't do that, don't pick at it.

805
00:45:00,440 --> 00:45:02,120
It's really hard to do that with younger kids.

806
00:45:02,120 --> 00:45:04,240
So parents are a little more impatient with the younger ones.

807
00:45:04,240 --> 00:45:08,200
Well, it's an important point that you bring up too, is scratching is probably by design

808
00:45:08,200 --> 00:45:13,480
that these things, much like the molluscum we talked about earlier, are itchy and the virus

809
00:45:13,480 --> 00:45:18,240
can spread both, it can get under the person's fingernails after they've scratched it and

810
00:45:18,240 --> 00:45:23,680
then get passed to another person through direct skin-to-skin contact, or it undergoes

811
00:45:23,680 --> 00:45:27,140
the same process the molluscum can do where you auto-inoculate, where you can scratch

812
00:45:27,140 --> 00:45:32,640
a part of the body and then transmit that virus right to the new part of the body.

813
00:45:32,640 --> 00:45:35,700
And now, lo and behold, the virus has successfully spread.

814
00:45:35,700 --> 00:45:40,400
So getting them under control in terms of not scratching is really paramount.

815
00:45:40,400 --> 00:45:45,240
I try to make sure that the families know to keep those fingernails trimmed as low as

816
00:45:45,240 --> 00:45:46,320
possible.

817
00:45:46,320 --> 00:45:50,040
Make sure you're not picking your nose or picking anything else because wherever your

818
00:45:50,040 --> 00:45:54,520
finger touches, the wart can show up and, man, that makes it a lot more complicated.

819
00:45:54,520 --> 00:45:56,560
And your siblings, they like to scratch each other.

820
00:45:56,560 --> 00:45:57,560
Oh, yeah.

821
00:45:57,560 --> 00:45:58,560
That's true.

822
00:45:58,560 --> 00:46:01,080
You don't scratch yourself, you scratch everyone else.

823
00:46:01,080 --> 00:46:02,080
Yeah.

824
00:46:02,080 --> 00:46:06,200
Now, one of the things that I feel like, man, I wish if I had about a half an hour for each

825
00:46:06,200 --> 00:46:08,560
patient, I would be doing this so much more.

826
00:46:08,560 --> 00:46:12,760
But they can do it at home, is paring the warts down.

827
00:46:12,760 --> 00:46:14,360
Do you advocate that at all?

828
00:46:14,360 --> 00:46:15,920
And if so, what's your sort of approach for that?

829
00:46:15,920 --> 00:46:16,920
I don't.

830
00:46:16,920 --> 00:46:19,280
I'd like to hear kind of what you recommend.

831
00:46:19,280 --> 00:46:23,080
I imagine that that's going to be something that's kind of patient and parent dependent

832
00:46:23,080 --> 00:46:27,240
on whether or not they're comfortable with it or capable of doing it with their particular

833
00:46:27,240 --> 00:46:28,240
kids.

834
00:46:28,240 --> 00:46:29,540
But generally, we will not know.

835
00:46:29,540 --> 00:46:34,320
We do sometimes recommend the over-the-counter ones, specifically the larger, for larger

836
00:46:34,320 --> 00:46:35,320
warts.

837
00:46:35,320 --> 00:46:38,240
We'll recommend those, the over-the-counter formulations that you can get, which is just

838
00:46:38,240 --> 00:46:43,360
salicylic acid to kind of help along whatever we're doing and reduce the size.

839
00:46:43,360 --> 00:46:48,720
Or if they're really, really tiny and we actually don't think that we can freeze it without

840
00:46:48,720 --> 00:46:53,120
getting healthy skin, so really, really new ones, tiny, tiny ones, we'll just tell them

841
00:46:53,120 --> 00:46:55,280
to use the over-the-counter salicylic acid.

842
00:46:55,280 --> 00:46:57,160
But no, tell me how to pare a wart.

843
00:46:57,160 --> 00:46:59,460
Yeah, no, that's a great approach.

844
00:46:59,460 --> 00:47:04,640
The process of paring is really, it can be pretty gross when you're in the clinic.

845
00:47:04,640 --> 00:47:08,960
But what I'm saying for at home, it's really not that aggressive.

846
00:47:08,960 --> 00:47:13,700
You start by getting a pumice stone or a file, just like a normal nail file.

847
00:47:13,700 --> 00:47:16,840
The trick is it's got to be now dedicated just for this purpose.

848
00:47:16,840 --> 00:47:20,180
You're probably going to throw it out when the warts are clear, or you have to sterilize

849
00:47:20,180 --> 00:47:21,400
it so you can use it again.

850
00:47:21,400 --> 00:47:26,080
But what I tell the families is, listen, wait till the child either comes out of the bath

851
00:47:26,080 --> 00:47:27,080
or the shower.

852
00:47:27,080 --> 00:47:30,240
You know how your fingers get that sort of pruney skin when you've been in there too

853
00:47:30,240 --> 00:47:31,240
long?

854
00:47:31,240 --> 00:47:34,440
It's macerated, so it's a little easier to, it's mushy.

855
00:47:34,440 --> 00:47:39,640
There's fluid in there, so the skin's a little bit more flexible and juicy.

856
00:47:39,640 --> 00:47:45,720
So then you take that pumice stone, you take that nail file, and you go over the wart gently.

857
00:47:45,720 --> 00:47:50,120
You're not trying to do this, this is the key point, you're not trying to do this in

858
00:47:50,120 --> 00:47:51,580
one event.

859
00:47:51,580 --> 00:47:52,940
This is a marathon.

860
00:47:52,940 --> 00:47:55,960
You are slowly removing the surface of this wart.

861
00:47:55,960 --> 00:48:00,120
And you stop paring when you get to one of two things.

862
00:48:00,120 --> 00:48:05,000
Either it starts to hurt the kid, great, stop, or you notice some pinpoint bleeding.

863
00:48:05,000 --> 00:48:06,640
That means you're down to the right level.

864
00:48:06,640 --> 00:48:09,240
You don't go farther than that, you stop.

865
00:48:09,240 --> 00:48:11,980
Then I do totally advocate with what you were talking about.

866
00:48:11,980 --> 00:48:17,780
You buy some of the over-the-counter salicylic acid, you apply that to the wart.

867
00:48:17,780 --> 00:48:19,480
And then I like to put duct tape on.

868
00:48:19,480 --> 00:48:21,280
Duct tape specifically, there have been some studies that-

869
00:48:21,280 --> 00:48:25,160
Duct tape is really actually very well proven and studied, yeah.

870
00:48:25,160 --> 00:48:30,120
Yeah, it's why, you know, probably mechanically de-breeds, probably macerates the area a little

871
00:48:30,120 --> 00:48:31,460
bit better too.

872
00:48:31,460 --> 00:48:36,960
But I have them put ideally duct tape over that area, and then don't touch it for 24

873
00:48:36,960 --> 00:48:37,960
hours.

874
00:48:37,960 --> 00:48:40,800
They come back, next day if it's bath time, you do the same thing.

875
00:48:40,800 --> 00:48:44,080
You pull that duct tape off, some of that wart's going to come with it.

876
00:48:44,080 --> 00:48:48,280
You're going to see it's going to be even a little bit more chewed up and macerated.

877
00:48:48,280 --> 00:48:50,800
Take the bath, finish the bath, and repeat the process.

878
00:48:50,800 --> 00:48:52,760
But gentle, gentle, gentle is the key.

879
00:48:52,760 --> 00:48:53,760
Wait, we're supposed to take baths every day?

880
00:48:53,760 --> 00:48:58,080
And if it gets too irritated from the salicylic acid, take a day, two, three days off.

881
00:48:58,080 --> 00:48:59,080
Don't bother.

882
00:48:59,080 --> 00:49:04,480
But if you do that, you could probably literally and figuratively shave off about one to two

883
00:49:04,480 --> 00:49:08,600
visits from having to come in to see me to do what we do.

884
00:49:08,600 --> 00:49:13,320
The key to it is really making sure, to your point, that it's actually 24 hours.

885
00:49:13,320 --> 00:49:16,960
So all the studies that were done for duct tape, I tell people it's just as effective

886
00:49:16,960 --> 00:49:20,800
as a lot of the other things, but you have to actually have that duct tape on for 24

887
00:49:20,800 --> 00:49:21,800
hours at a time.

888
00:49:21,800 --> 00:49:22,920
And kids tend to pick things off.

889
00:49:22,920 --> 00:49:26,520
So we actually told them to cut a piece of the duct tape over the wart, and then put

890
00:49:26,520 --> 00:49:30,040
a bandaid around it so that the little ones have a harder time getting it off.

891
00:49:30,040 --> 00:49:33,720
I've found that if you put it on a kid, they'll play with it once or twice, and then after

892
00:49:33,720 --> 00:49:35,140
that they kind of forget about it.

893
00:49:35,140 --> 00:49:41,000
But for us, we do do freezing just like you guys do with what we call that cryotherapy.

894
00:49:41,000 --> 00:49:42,000
We use liquid nitrogen.

895
00:49:42,000 --> 00:49:44,800
It's minus 176 degrees Celsius.

896
00:49:44,800 --> 00:49:46,080
That's really cold.

897
00:49:46,080 --> 00:49:52,380
It's really no better or worse than the other main in the office treatment that we do, which

898
00:49:52,380 --> 00:49:55,060
is called Candida antigen or immunotherapy.

899
00:49:55,060 --> 00:49:59,120
They both take on average about four to six treatments about a month apart.

900
00:49:59,120 --> 00:50:03,320
So four to six months long duration is what you're kind of waiting for as a parent or

901
00:50:03,320 --> 00:50:04,320
a patient.

902
00:50:04,320 --> 00:50:09,240
There's not much of one treatment approach over the other.

903
00:50:09,240 --> 00:50:13,880
But what I've found is for me, at least in the young patient population that I'm treating,

904
00:50:13,880 --> 00:50:16,340
which are really kind of school age kids is what we're talking about.

905
00:50:16,340 --> 00:50:21,800
If I spend the time on that first visit and convince them to allow me to do this immunotherapy

906
00:50:21,800 --> 00:50:25,720
approach, the Candida antigen, wow, there's some real benefits.

907
00:50:25,720 --> 00:50:27,560
And let's go through that, what this is.

908
00:50:27,560 --> 00:50:32,440
So back in the day when you used to check for tuberculosis, I don't know if you ever

909
00:50:32,440 --> 00:50:34,480
had a PPD placed.

910
00:50:34,480 --> 00:50:38,680
Technically I think you're supposed to always try on the other arm.

911
00:50:38,680 --> 00:50:44,280
You have the nurse or whoever's placing the PPD also place a little Candida antigen.

912
00:50:44,280 --> 00:50:46,600
Now this Candida is yeast.

913
00:50:46,600 --> 00:50:48,800
It's commonly seen in our environment.

914
00:50:48,800 --> 00:50:49,800
It's everywhere.

915
00:50:49,800 --> 00:50:52,640
There's probably some sitting right here in front of me here.

916
00:50:52,640 --> 00:50:53,920
I treat it all the time.

917
00:50:53,920 --> 00:50:57,320
We treat kids with yeast in their diaper rashes and in their mouths and all that stuff all

918
00:50:57,320 --> 00:50:58,320
the time.

919
00:50:58,320 --> 00:50:59,320
So not always.

920
00:50:59,320 --> 00:51:03,480
Nobody's really good at fighting it and killing it unless we don't have a working immune system.

921
00:51:03,480 --> 00:51:07,000
And that was the point when they placed it with the PPD.

922
00:51:07,000 --> 00:51:11,400
If you don't get a response to the Candida antigen, then you might not have a working

923
00:51:11,400 --> 00:51:12,400
immune system.

924
00:51:12,400 --> 00:51:16,240
So you could not trust the results from the PPD for the tuberculosis.

925
00:51:16,240 --> 00:51:20,680
Well someone way smarter than me discovered that you could take that same Candida antigen,

926
00:51:20,680 --> 00:51:22,680
which is not actual live yeast.

927
00:51:22,680 --> 00:51:26,400
It's just - think of it as sort of the shell of the yeast that the body's immune system

928
00:51:26,400 --> 00:51:27,720
reacts against -

929
00:51:27,720 --> 00:51:31,880
You can take that Candida antigen and pump it directly into a wart.

930
00:51:31,880 --> 00:51:36,320
Yes, that's using a needle, which sounds scary, but I'll give you some tips for how to do

931
00:51:36,320 --> 00:51:37,320
this.

932
00:51:37,320 --> 00:51:41,400
You can pump the Candida antigen into a wart and the body's immune system, again,

933
00:51:41,400 --> 00:51:46,520
as long as it's a working immune system, which 99.9% of the time it is, the immune system

934
00:51:46,520 --> 00:51:51,060
floods that area, goes into the wart, goes to fight the yeast.

935
00:51:51,060 --> 00:51:55,200
And if you get lucky, if you get lucky, it figures out that there's a wart virus there

936
00:51:55,200 --> 00:51:57,920
as well and then eventually turns on against it.

937
00:51:57,920 --> 00:52:04,280
Now the benefits of this is that you only amazingly have to treat one or two of the

938
00:52:04,280 --> 00:52:05,280
warts.

939
00:52:05,280 --> 00:52:06,720
You do have to freeze each wart.

940
00:52:06,720 --> 00:52:11,840
You just inject one or two and that saves the kid, as far as I'm concerned, a lot of

941
00:52:11,840 --> 00:52:12,840
pain.

942
00:52:12,840 --> 00:52:19,020
If I've had both done to me, I think freezing does hurt, like actually feels weird.

943
00:52:19,020 --> 00:52:23,360
And the best part about the Candida antigen is you're right back in the mix.

944
00:52:23,360 --> 00:52:27,480
You have that needle placed into the thick dead skin of the wart.

945
00:52:27,480 --> 00:52:31,240
So you don't really feel much at all, as long as you don't move is what I tell the kids.

946
00:52:31,240 --> 00:52:36,200
But you have that needle placed, the medicine goes in, and then five minutes later you can

947
00:52:36,200 --> 00:52:39,280
play basketball, you can run a marathon.

948
00:52:39,280 --> 00:52:40,280
You don't feel it afterwards.

949
00:52:40,280 --> 00:52:45,000
Where the cryotherapy, I feel like at least for an hour or so, you get a tingling sensation.

950
00:52:45,000 --> 00:52:49,440
So if you had some warts frozen on the bottom of your foot, you might not be able to walk

951
00:52:49,440 --> 00:52:53,480
around without at least recognizing you had that treatment done.

952
00:52:53,480 --> 00:52:58,040
And that's a really good point to go back to the cryotherapy.

953
00:52:58,040 --> 00:53:02,160
If you are doing cryotherapy, you are going to see that it is going to get somewhat red,

954
00:53:02,160 --> 00:53:03,160
somewhat swollen.

955
00:53:03,160 --> 00:53:04,760
The wart itself is going to look like there's a problem.

956
00:53:04,760 --> 00:53:08,920
We get a lot of calls back from patients the next couple days saying, is this normal?

957
00:53:08,920 --> 00:53:09,920
Is it infected?

958
00:53:09,920 --> 00:53:11,200
Do I need antibiotics?

959
00:53:11,200 --> 00:53:12,200
It's not.

960
00:53:12,200 --> 00:53:13,200
It's totally normal.

961
00:53:13,200 --> 00:53:14,200
It's okay.

962
00:53:14,200 --> 00:53:16,280
But then that top part usually will fall off.

963
00:53:16,280 --> 00:53:18,520
And that's when you can kind of go back for your repeat treatment.

964
00:53:18,520 --> 00:53:21,880
It can take a couple of weeks, depending on how aggressive it is.

965
00:53:21,880 --> 00:53:23,240
I had two questions for you.

966
00:53:23,240 --> 00:53:27,640
So is that the same reaction that you see if you do the Candida antigen injection?

967
00:53:27,640 --> 00:53:31,620
Do you still see that kind of change in the appearance of the wart after?

968
00:53:31,620 --> 00:53:38,840
So I do use the fact that a wart that might be flesh colored or maybe just kind of gray

969
00:53:38,840 --> 00:53:42,000
will eventually form sort of a pink rim around it.

970
00:53:42,000 --> 00:53:43,960
You'll notice that it's getting red.

971
00:53:43,960 --> 00:53:44,960
That is inflammation.

972
00:53:44,960 --> 00:53:49,760
And that's a sign to the families that I say, hey, listen, that's a good thing.

973
00:53:49,760 --> 00:53:53,200
Your kid's immune system is now turned on in that area.

974
00:53:53,200 --> 00:53:57,900
And yeah, they don't get as really as infected looking as the molluscum do.

975
00:53:57,900 --> 00:53:59,880
But they'll start to dry out.

976
00:53:59,880 --> 00:54:02,040
They'll kind of crust up and fall off.

977
00:54:02,040 --> 00:54:07,340
For anyone listening at home, if you're wondering, geez, I have that appointment with Dr. Walty

978
00:54:07,340 --> 00:54:11,400
or Dr. Krakowski coming up to get my wart treated again.

979
00:54:11,400 --> 00:54:13,400
But geez, I think it might be clear.

980
00:54:13,400 --> 00:54:17,540
A little trick that you can do is you get a magnifying glass and you look at the skin

981
00:54:17,540 --> 00:54:19,740
in the area where the wart is.

982
00:54:19,740 --> 00:54:24,800
If you can see what basically amounts to the skin lines, that's kind of like your fingerprints

983
00:54:24,800 --> 00:54:25,800
on your hand.

984
00:54:25,800 --> 00:54:30,080
But if you look closely at any of your skin, you'll see those little creases in the skin.

985
00:54:30,080 --> 00:54:34,720
If you see those creases going through the area where the wart was, that's really a good

986
00:54:34,720 --> 00:54:36,880
sign that there's no wart there anymore.

987
00:54:36,880 --> 00:54:41,480
If there's something obstructing your view of those lines, the warts probably still there

988
00:54:41,480 --> 00:54:44,640
and probably requires some additional treatment.

989
00:54:44,640 --> 00:54:49,000
But if it's not there, you can cancel the appointment and save yourself a co-pay.

990
00:54:49,000 --> 00:54:50,000
But we'd miss you.

991
00:54:50,000 --> 00:54:52,400
We'd miss you if you didn't come in for your appointment.

992
00:54:52,400 --> 00:54:55,320
There are a lot of kids who take the spot.

993
00:54:55,320 --> 00:54:58,560
The second question that I had, I just wanted to make sure as well, you mentioned warts

994
00:54:58,560 --> 00:54:59,560
on the bottom of your feet.

995
00:54:59,560 --> 00:55:00,920
And those are a little bit different.

996
00:55:00,920 --> 00:55:03,400
So I didn't know if you wanted to kind of touch on that or not.

997
00:55:03,400 --> 00:55:05,000
Yeah, you know, plant our warts.

998
00:55:05,000 --> 00:55:06,280
They can be painful.

999
00:55:06,280 --> 00:55:07,600
That's one of the differences.

1000
00:55:07,600 --> 00:55:10,520
Yeah, they can really hurt depending on where they are.

1001
00:55:10,520 --> 00:55:16,360
My approach really is the same for ones on the hands or the elbows or the knees or the

1002
00:55:16,360 --> 00:55:17,360
feet.

1003
00:55:17,360 --> 00:55:23,200
Unbelievably, I do actually, I am able to convince a kid to let me put a needle into those plant

1004
00:55:23,200 --> 00:55:28,720
or warts and do the Candida antigen immunotherapy just as much as I'll do the freezing or anything

1005
00:55:28,720 --> 00:55:29,720
else.

1006
00:55:29,720 --> 00:55:34,800
I guess where sometimes I'll deviate and resort to what I would maybe refer to as a second

1007
00:55:34,800 --> 00:55:39,700
line treatment of using something called 5-fluorouracil  or Effudex, which is a skin

1008
00:55:39,700 --> 00:55:46,540
cancer treatment, or imiquimod known as Aldara, which is an immunotherapy topical.

1009
00:55:46,540 --> 00:55:48,000
So it's a cream.

1010
00:55:48,000 --> 00:55:54,480
I'll do those treatments in that particular area of the soles of the feet, because sometimes,

1011
00:55:54,480 --> 00:55:58,800
and most of the time, I should say, those patients are doing some sort of extracurricular

1012
00:55:58,800 --> 00:56:02,080
activity where sports are important to them.

1013
00:56:02,080 --> 00:56:04,360
Maybe that's how they got the wart there in the first place.

1014
00:56:04,360 --> 00:56:08,580
So they don't want to give up the ability to perform at their at their best.

1015
00:56:08,580 --> 00:56:13,560
So those creams, although they take a lot longer, are gentle and usually pretty effective.

1016
00:56:13,560 --> 00:56:17,880
It's just more a matter of can you get them covered by the insurance company for something

1017
00:56:17,880 --> 00:56:20,120
they're not necessarily intended for.

1018
00:56:20,120 --> 00:56:24,720
And you do have to remember, a medicine like 5-fluorouracil should not be handled by

1019
00:56:24,720 --> 00:56:26,400
a pregnant woman.

1020
00:56:26,400 --> 00:56:30,680
And maybe mom is pregnant at the time that she's helping the child treat the warts.

1021
00:56:30,680 --> 00:56:31,920
So you got to be careful about that.

1022
00:56:31,920 --> 00:56:33,200
But otherwise, it works pretty well.

1023
00:56:33,200 --> 00:56:38,080
We also definitely do a whole "flip-flop and slide" lecture too, especially to my patients

1024
00:56:38,080 --> 00:56:40,920
that are going into colleges and they've got shared dorms and stuff like that.

1025
00:56:40,920 --> 00:56:44,480
So we do a whole lot of hygiene and again, reminding them they're supposed to take a

1026
00:56:44,480 --> 00:56:47,640
shower every day and they should really be careful with the flip flops and the slides

1027
00:56:47,640 --> 00:56:48,840
and stuff like that.

1028
00:56:48,840 --> 00:56:55,320
Just as a caveat, I would say if you are bringing your child in for any kind of a wart, I would

1029
00:56:55,320 --> 00:56:59,920
ask ahead of time when they call the office and you're telling us kind of where it is,

1030
00:56:59,920 --> 00:57:04,400
we can help guide you a little bit because pediatricians do not have the Candida antigen

1031
00:57:04,400 --> 00:57:05,400
that you were speaking of.

1032
00:57:05,400 --> 00:57:09,640
But that's really specifically what you're looking for, that's got to go to Derm.

1033
00:57:09,640 --> 00:57:11,120
And then there's a couple of other differences.

1034
00:57:11,120 --> 00:57:16,320
A lot of pediatricians aren't as comfortable treating the plantar warts just because of

1035
00:57:16,320 --> 00:57:19,520
the location and they're just, it's a little bit of a different skill.

1036
00:57:19,520 --> 00:57:21,840
But yeah, I would always say just check ahead of time.

1037
00:57:21,840 --> 00:57:24,560
You don't want to have a wasted visit coming in thinking that we're going to be able to

1038
00:57:24,560 --> 00:57:29,200
do something and then we're, we think it's better to be more comprehensively treated.

1039
00:57:29,200 --> 00:57:31,200
I would echo that as well.

1040
00:57:31,200 --> 00:57:37,320
Depending on anatomically where the wart is located, especially if it is around the nail

1041
00:57:37,320 --> 00:57:43,120
bed, anywhere around that, freezing done by whomever, could be a dermatologist doing it

1042
00:57:43,120 --> 00:57:44,560
30 years, doesn't matter.

1043
00:57:44,560 --> 00:57:46,240
It can really damage the nail.

1044
00:57:46,240 --> 00:57:51,360
So that in those cases, I would try to save yourself a visit by finding someone who can

1045
00:57:51,360 --> 00:57:52,960
do some of the other treatments.

1046
00:57:52,960 --> 00:57:56,320
And you know, that doesn't mean you have to see a dermatologist by any means.

1047
00:57:56,320 --> 00:58:02,600
It could be a pediatrician who's using the 5-fluorouracil method or the imiquimod.

1048
00:58:02,600 --> 00:58:06,040
There are salicylic acid options out there as well.

1049
00:58:06,040 --> 00:58:11,760
So in general, freezing in around where the nail forms, the nail matrix is a bad idea.

1050
00:58:11,760 --> 00:58:17,320
It can leave you with a permanently dystrophic nail and that's never good for something that's

1051
00:58:17,320 --> 00:58:18,840
going to go away on its own anyway.

1052
00:58:18,840 --> 00:58:19,840
Or a face.

1053
00:58:19,840 --> 00:58:20,840
We don't do face.

1054
00:58:20,840 --> 00:58:22,800
Face or genitals, we won't freeze.

1055
00:58:22,800 --> 00:58:23,800
That's all you.

1056
00:58:23,800 --> 00:58:24,800
Face is interesting.

1057
00:58:24,800 --> 00:58:28,560
That's a lot of times we'll see warts up in the face because someone was touching with

1058
00:58:28,560 --> 00:58:30,780
their finger and they auto-inoculated.

1059
00:58:30,780 --> 00:58:34,440
But many times we'll see flat warts or plain warts up on the face.

1060
00:58:34,440 --> 00:58:36,000
That's what we see a lot on there.

1061
00:58:36,000 --> 00:58:37,360
Yeah, they're tough.

1062
00:58:37,360 --> 00:58:40,400
Or on the legs of people shaving.

1063
00:58:40,400 --> 00:58:42,760
They can spread them through the razor.

1064
00:58:42,760 --> 00:58:47,360
For the face, that's a great option is your go-to topical retinoid, the same medicine

1065
00:58:47,360 --> 00:58:49,520
you would use for acne.

1066
00:58:49,520 --> 00:58:55,840
There is an option if the insurance company does not cover the topical retinoid because

1067
00:58:55,840 --> 00:58:59,080
this is not acne, it is warts.

1068
00:58:59,080 --> 00:59:04,820
Buying over-the-counter adapalene gel now, it's about $15 to $25 bucks, not expensive.

1069
00:59:04,820 --> 00:59:10,200
But a pinhead amount on each one of the flat warts every night before you go to bed will

1070
00:59:10,200 --> 00:59:11,200
work.

1071
00:59:11,200 --> 00:59:13,600
It just might take two, three, four months, but it will work.

1072
00:59:13,600 --> 00:59:15,400
And it does it without scarring.

1073
00:59:15,400 --> 00:59:16,400
It doesn't hurt.

1074
00:59:16,400 --> 00:59:18,640
So there really are some benefits to that approach.

1075
00:59:18,640 --> 00:59:20,400
I'm going to write that down because I didn't know that.

1076
00:59:20,400 --> 00:59:21,400
So I'm going to write that down.

1077
00:59:21,400 --> 00:59:22,400
Yeah, it's a good one.

1078
00:59:22,400 --> 00:59:23,400
We use it quite often.

1079
00:59:23,400 --> 00:59:27,000
Yeah, ever since that became available over-the-counter, it's been fabulous.

1080
00:59:27,000 --> 00:59:28,800
So we like that.

1081
00:59:28,800 --> 00:59:31,240
Well, thanks for joining us today, Dr. Walty.

1082
00:59:31,240 --> 00:59:36,000
It was wonderful speaking with you about molluscum and warts, two of our favorite things, and

1083
00:59:36,000 --> 00:59:37,680
look forward to the next episode.

1084
00:59:37,680 --> 00:59:38,680
That sounds great.

1085
00:59:38,680 --> 00:59:43,680
Thanks for having me.

1086
00:59:43,680 --> 00:59:48,120
Thanks for tuning in to this episode of the Don't Be Rash Pediatric Dermatology Podcast.

1087
00:59:48,120 --> 00:59:50,120
I'm your host, Dr. Andrew Krakowski.

1088
00:59:50,120 --> 00:59:56,160
Don't forget to subscribe to our show on your favorite podcast platform and check out dontberashed.org

1089
00:59:56,160 --> 00:59:57,160
for more information.

1090
00:59:57,160 --> 01:00:02,000
A special thank you to our nonprofit sponsor, the St. Luke's University Health Network,

1091
01:00:02,000 --> 01:00:03,800
for making this episode possible.

1092
01:00:03,800 --> 01:00:19,240
Until next time, remember:  Keep calm and don't be rash!