A total of 77 children were invited to take part in the study. Two children meeting the inclusion criteria declined to take part in the study and four were excluded after review of their medical records showed that their conditions did not meet the inclusion criteria (autoimmune thyroid disease, widespread musculoskeletal pain, undiagnosed condition, (non-inflammatory) pain syndrome).
The study included 71 children, ages ranged from four to 17 years old (mean = 11yrs; SD = 3.5 yrs). Seventy three percent of children had a diagnosis of Juvenile Idiopathic Arthritis. The conditions included and disease-modifying medications taken are shown in Table 1.
Table 1
Disease subtype and medication
Disease type (n) | Medication |
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Juvenile Idiopathic Arthritis • Systemic (5) • Oligo (13) • Extended Oligo (11) • Poly (17) • Enthesitis Related Arthritis (5) • Psoriatic (3) • Mono (1) • Unclassified (2) | MTX (2); Biologic only (2); MTX + Biologic (1) MTX (7); MTX + Biologic (2); no meds (4) MTX (6); MTX + Biologic (4); no meds (1) MTX (10); MTX + Biologic (5); Biologic only (1); no meds (1) MTX (1); MTX + Biologic (1); no meds (2); sulfasalazine (1) MTX (2); Sulfasalazine (1) No meds (1) MTX (1); MTX + Biologics (1) |
Juvenile Dermatomyositis JDM overlap (1) | MTX + Prednisolone (1) |
Vasculitides (2) | Azothiaprine (1); no meds (1) |
Fever Syndromes (5) | Colchicine (2); Prednisolone (1); No meds (2) |
Immunopathies (2) | Immunoglobulins (1); No meds (1) |
Connective tissue disease (1) | No meds (1) |
Uveitis (2) | MTX (1); MMF (1) |
Other (1) | MTX + Biologic (1) |
Of the group, 55 children had no VPs present, 16 children had one or more VPs. The prevalence of VPs in the whole group was 22.5%. Table 2 shows the prevalence of VPs by disease and by disease subgroup for the JIA group.
Table 2
Prevalence of VPs by disease type
Disease type | Percentage of specific group with VPs |
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Juvenile Idiopathic Arthritis | 22.9% |
• Systemic • Oligo • Extended Oligo • Poly • Enthesitis Related Arthritis • Psoriatic • Mono • unclassified | • 0% • 1.8% • 12.3% • 8.8% • 0% • 0% • 0% • 0% |
Total Non-JIA Subjects | 21.4% |
Methotrexate was the most frequently prescribed medication. The chance of having a VP was greater when taking methotrexate plus a biologic rather than methotrexate alone (OR = 4.3, 95%CI 1.26 to 14.9, p = 0.026). But overall, there appeared to be no greater chance of having VPs if taking immunosuppressive medication than compared to having no medication (OR = 1.1, 95%CI 0.26 to 4.48, p = 0.46). Table 3 shows the presence / absence of VPs by medication taken.
Table 3
VP presence in relation to medication prescribed.
Medication prescribed | VP present | VP absent |
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None | 3 | 11 |
MTX | 4 | 26 |
MTX + biologic | 6 | 9 |
MTX + prednisolone | 0 | 1 |
Biological only | 1 | 2 |
Prednisolone | 1 | 0 |
Sulfasalazine | 0 | 2 |
Azathioprine | 1 | 0 |
MMF | 0 | 1 |
Immunoglobulins | 0 | 1 |
Colchicine | 0 | 2 |
Only one subject associated the onset of their verrucae with the start of taking medication (Tocalizamab being added to MTX) and one subject associated their VPs with the start of a swimming programme. None of the other subjects identified a triggering factor.
Children with VPs tended to be 9 years old or older and most children had 1–3 VPs. Fewer children in the older age range (13–17 yrs) had VPs suggesting, most VPs do resolve by their teenage years. Of those teenagers with VPs, very few had recent lesions but had VPs that were several years old suggestive of these being invisible to the skin’s immune system and thus being more persistent. In total, 37.5% of the young people had their VPs for 24 months or more. Table 4 demonstrates these figures.
Table 4
Subject age range and duration of VPs when present
Age range | Number without VP | Number with VPs | VP duration | No of VPs present per subject 1–3 +4 |
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4–8 years | 16 | 2 | < 6m 6m 6-12m 12m 18m 24m > 24m | 1 1 | 2 | |
9–12 years | 16 | 9 | < 6m 6m 6-12m 12m 18m 24m > 24m | 2 1 3 1 1 1 | 7 | 2 |
13–17 years | 23 | 5 | < 6m 6m 6-12m 12m 18m 24m > 24m | 2 3 | 4 | 1 |
|
All verrucae occurred on the plantar surface with none seen on the dorsum of the digits or in the interdigital spaces. The deep plantar wart (HPV 1) was the most frequently seen VP type, being present in 12 of the 26 individually counted verrucae. When this type was identified only one or two lesions were present per foot in 75% of the cases. Endophytic VPs (HPV 4) were counted in seven VPs and one case where there were multiple endophytic VPs present; five identifiable mosaic VPs (HPV 2) were seen with one further case having multiple plaques.
When asking whether any other family member in the household had verrucae, there were three cases (18.75%) of the children with VPs reporting someone else in the household having with verrucae, compared to three children without verrucae (7%) but this was non-significant (OR = 2.62, 95%CI 0.48 to 14.38, p = 0.13).
Less than half the subjects with a VP knew that it was a wart (n = 7), of the remaining nine subjects, three had no idea what a verruca was, three recognized it was a type of infection (virus / germ / contagious spot) and three subjects thought it was hard skin or dirt. Despite not being entirely clear on what the lesions were, the majority of subjects (81%) had sought treatment for the VPs. This consisted of over the counter (OTC) remedies in 10 cases (typically Bazuka gel which contains 12 to 26% salicylic acid), one was advised by pharmacist to watch & wait, one by a GP to “rub it with a stone”, and one had tried laser treatment. Of the 13 subjects trying treatment, only the laser treatment was considered, by the subject, to be successful although that subject still had VPs present on observation. All but two subjects expressed a wish for further information about verrucae and their treatment to be available in the clinic.
When seeking their feelings about having a verruca, two-thirds of the subjects were not concerned about VPs being present, four said they “did not like them” being present, one subject said they were “embarrassed” by them and one subject said it “made their feet look dirty and not looked after properly”.