Changing morbidity of cutaneous diseases in patients with HIV after the introduction of highly active antiretroviral therapy including a protease inhibitor

Dermatological Opportunistic Infections in HIV Seropositive Patients: An Observational Study

Background and objective

In developing countries, the dermatological manifestation of the human immunodeficiency virus (HIV) has a high prevalence. Apart from the systemic infection that ensues HIV, skin manifestations form a major part of the disease burden. They can present with atypical forms, and necessary tools for diagnosis may not be available in rural and remote parts of the country. Hence, they can stay misdiagnosed or undiagnosed, contributing to the morbidity of the patients. We attempted to enumerate the dermatologic opportunistic infections (OIs) in Rajkot city, Gujarat, India, in order to disseminate knowledge regarding the same. 

Material and methods

It is a retrospective observational study. A total of 253 patients under treatment for HIV/acquired immunodeficiency syndrome (AIDS) at the ART Center (anti-retroviral therapy center) from 2011 to 2019 were included. The data recorded in the registry during the above-mentioned period were utilized in the study. The diagnoses of OIs were made clinically by multiple health care providers experienced in the field.

Result

Two hundred twenty-seven (227) of 253 (89.72%) of the patients had some form of dermatologic OI during the course of their treatment. Overall, fungal infections (33.03%) were most common, followed by bacterial infections (28.18%) and viral (14.55%) infections. Among the non-infectious causes, cheilitis/angular stomatitis topped the list. Among the STDs, herpes was the most common skin manifestation seen with a 10.57% prevalence. The CD4+ cell count for fungal infection ranged from 353-467 and was seen in stage 2 of the disease course. Bacterial infections were seen mainly during the early and middle stages of the disease while viral infections were most prevalent in stage 2 of the disease.

Conclusion

Skin manifestations can be useful clinical predictors of the disease stage, especially in resource-limited settings and in developing countries. They can present with unusual and atypical forms. Hence, knowledge about the prevalence of these OIs in a particular geographical area can be very useful for physicians in treating them and decreasing the disease burden.

HIV medicine for dermatologists and venereologists

Broad administration of combined antiretroviral therapy (ART) has dramatically reduced the morbidity and mortality of the HIV-infection and substantially improved the life expectancy of people living with HIV (PLWH). PLWH, who are effectively treated with an ART, are considered to be unable to transmit HIV. The standard of care is usually an antiretroviral single tablet regimen. Since 2015 the Robert Koch Institute has reported a slight decrease in the rate of recently diagnosed HIV-infections in Germany, but the proportion of late presenters (initial diagnosis in advanced stages of infection) has remained consistently high at around 32 % since 2005. HIV-infections have not been diagnosed in 10,800 PLWH so far. In comparison to the general population PLWH suffer more frequently from skin diseases. Depending on the stage of immunodeficiency, untreated PLWH develop HIV indicator diseases of the skin and the mucocutaneous membranes. Knowledge of these diseases facilitates the selection of individuals who should be offered HIV testing. Early diagnosis of HIV-infections allows early introduction of the ART, prevents the spread of HIV and reduces the mortality rates and treatment costs associated with late diagnosis. HIV is a predominantly sexually transmitted infection. Through focused sexual anamnesis and the diagnosis of HIV indicator diseases and other sexually transmitted infections, dermatovenereologists in particular may be able to identify previously undiagnosed PLWH and persons with an increased risk of HIV infection, enabling initiation of ART in the former and pre-exposure prophylaxis counseling in the latter.

The prevalence and spectrum of mucocutaneous disease in South African people living with HIV and accessing care at a district-level hospital

Background

Although the association between human immunodeficiency virus (HIV) and mucocutaneous diseases has been well studied within South African specialist centres, there is limited data from district-level hospitals. Available data may, therefore, fail to reflect the prevalence and full spectrum of dermatoses seen in people living with HIV (PLWH).

Objectives

To determine the prevalence and spectrum of dermatoses seen in PLWH.

Method

We conducted a cross-sectional, descriptive study of 970 PLWH (men and women, ≥ 18 years old) accessing care at Karl Bremer Hospital, a district-level hospital located in the Western Cape province, South Africa, between 01 September 2016 and 28 February 2017.

Results

The prevalence of mucocutaneous disease in this sample was 12.7% (95% confidence interval [CI] 0.11–0.15). Non-infectious dermatoses comprised 71.0% of the disorders. Pruritic papular eruption (20.0%) and seborrheic dermatitis (6.0%) were the most common non-infectious dermatoses. Tinea corporis (8.0%) and oral candidiasis (6.0%) were the most prevalent infectious dermatoses. There was no significant association between skin disease category (infectious or non-infectious dermatoses) and patient demographics (gender and ethnicity) or HIV-disease characteristics (CD4+ cell count, viral load and duration of antiretroviral therapy [ART]).

Conclusion

This study provides valuable scientific data on the prevalence and spectrum of mucocutaneous disease in PLWH attending a South African district-level hospital. Prospective studies conducted in other district-level centres across the country are required to determine the lifetime prevalence and spectrum of dermatoses in PLWH in the ART era.

An Update on Adverse Cutaneous Drug Reactions in HIV/AIDS

Background

The global mortality from HIV and the cutaneous burden of infective, inflammatory and malignant diseases in the setting of AIDS have significantly declined following the advent of highly active antiretroviral therapy. Regrettably, there has been a contemporaneous escalation in the incidence of adverse cutaneous drug reactions (ACDR), with studies attesting that HIV-positive individuals are a hundred times more susceptible to drug reactions than the general population, and advanced immunodeficiency portending an even greater risk. Several variables are accountable for this amplified risk in HIV.

Summary

Adverse reactions to trimethoprim-sulfamethoxazole are the most common, increasing from approximately 2–8% in the general population over to 43% amongst HIV-positive individuals to approximately 69% in subjects with AIDS. Antituberculosis drugs and antiretrovirals are also well-known instigators of ACDR. Cutaneous reactions range from mild morbilliform eruptions to severe, life-threatening manifestations in the form of Stevens-Johnson syndrome/toxic epidermal necrolysis. Histological features vary from vacuolar interface changes to full-thickness epidermal necrosis with subepidermal blister formation. A precipitous diagnosis of the ACDR, clinically and histologically if necessary, together with the isolation of the causative drug is critical. The identification process, however, is often complex and multifaceted due to polypharmacy and inconclusive data on which drugs are the most likely offending agents, especially against the background of tuberculosis co-infection.

Key Messages

Whilst milder cutaneous reactions are treated symptomatically, severe reactions mandate immediate treatment discontinuation without rechallenge. Further studies are required to establish safe rechallenge guidelines in resource-limited settings with a high HIV and tuberculosis prevalence.

To Treat Molluscum Contagiosum or Not-Curettage: An Effective, Well-Accepted Treatment Modality

BACKGROUND/OBJECTIVES

Molluscum contagiosum (MC) is a common viral disease primarily affecting children. The objective was to compare the effectiveness of curettage as a treatment modality for MC with no treatment.

METHODS

We performed a retrospective study of 2,022 children with MC between 2008 and 2012. Epidemiologic, clinical, and treatment data, including effectiveness, safety, and satisfaction, were reviewed.

RESULTS

Fifty-six percent of the children were 2 to 5 years of age. The duration of the infection was 1 to 2 years for 51%, less than 1 year for 32%, and more than 2 years for 17% of the children. Seventy percent of the children were self-referrals; 86% had had a previous examination and 76% of those had been advised not to treat the infection. The disease was mild (22%), moderate (64%), or severe (14%). A total of 1,879 patients underwent curettage; 70% were cured after one treatment and 26% after two treatments. Satisfaction was high: 97% of children and parents.

CONCLUSION

Active treatment should be offered despite the fact that MC is self-limiting. Curettage in an appropriate setting is very effective, with high patient satisfaction and fast cure rates.

Initiation of antiretroviral therapy in HIV-infected adults with skin complaints in northern Tanzania

Abnormal skin findings are identified in over 90% of human immunodeficiency virus (HIV)-infected persons globally. A prospective cohort study of HIV-infected patients with skin complaints commencing antiretroviral therapy (ART) in northern Tanzania was undertaken. Consecutive HIV-infected subjects presenting with skin complaints, who met criteria for ART initiation, were recruited at a Tanzanian Regional Dermatology Training Center. A single dermatologist evaluated all subjects; baseline skin biopsies were performed, and CD4(+) cell counts and plasma HIV RNA levels were measured. All subjects received a fixed-dose combination of stavudine, lamivudine, and nevirapine. A total of 100 subjects were enrolled; 86 subjects completed six months of follow-up. Median baseline CD4(+) cell counts and plasma HIV RNA levels were 120 cells/μl and 5.2 log10 copies/ml. The most common dermatologic condition was papular pruritic eruption (47%). The median baseline score on the Burn Scale was 38%. After six months, 10 subjects had achieved the complete resolution of skin abnormalities. In those without complete resolution, the median Burn Scale score improved to 7%. Five patients developed new eruptions by month 3, which in two cases were attributed to drug reactions. In the 86 subjects remaining on ART after six months, the median CD4(+) cell count had increased to 474 cells/μl, and plasma HIV RNA levels were <400 copies/ml in 85 (99%) subjects. Patients with HIV infection with skin complaints experienced marked clinical improvements following ART initiation.

The impact of human immunodeficiency virus-related diseases on pigmented skin types

Infection with human immunodeficiency virus (HIV) remains a significant problem globally. Early diagnosis and treatment with antiretroviral drugs has considerably improved health outcomes and decreased disease-related morbidity. HIV infection is associated with a wide range of skin disorders enabling dermatologists to diagnose HIV as well as associated opportunistic infections early in the course of disease. Despite concerted efforts by international health organizations to limit disease incidence, the prevalence of HIV infection remains high and is highest in sub-Saharan Africa. The diagnosis of HIV-related skin diseases is challenging as immunosuppression often results in atypical disease presentation. In addition, the clinical presentation will vary in pigmented skin types. The aim of this article is to describe disease variation in pigmented skin types.

Skin Diseases and Sexually Transmitted Infections among Patients with HIV infection/AIDS referred at the City Institute for Skin and Venereal Diseases in Belgrade: a Case Series of 38 Patients

Human immunodeficiency virus (HIV) infection may be associated with a wide spectrum of dermatological disorders. This study reports the prevalence of dermatologic diseases and sexually transmitted infections among 38 HIV-infected adults who consecutively sought treatment at the City Institute for Skin and Venereal Diseases in Belgrade. Patients were referred by their primary HIV providers between January 2011 and June 2012. More than 80% of patients were men who have sex with men. The most prevalent diseases were anogenital warts (36.8%) and syphilis (34.2%), followed by folliculitis and dermatophyte infections (7.9% each). Thirty-four patients (89.5%) were on highly active antiretroviral therapy (HAART) before the first visit to the dermatologist. Although, the pattern of skin disorders was consistent with literature data, high prevalence of sexually transmitted infections among our patients was rather peculiar. These facts point to the need for education of sexually active persons with HIV about the consequences of sexually transmitted infections, risks of transmission of drug resistant HIV strains, as well as safe sex practice and consistent condom use.

Pruritus in HIV-infected patients in the era of combination antiretroviral therapy: a study of its prevalence and causes

Pruritus is a common symptom in HIV-infected patients. However, there is a lack of studies examining this symptom. We investigated the prevalence of pruritus and its causes in this population by offering the possibility of participating in a skin health programme to all HIV-infected patients who attended our service in Alicante, Spain. Those who accepted (n = 303) underwent an interview and a detailed physical examination by specialists from the Dermatology Department. Between May 2003 and October 2003, 94 patients (31%) reported pruritus: xerosis, seborrhoeic eczema and interdigital tinea pedis were the most frequent dermatological entities responsible for this symptom. Patients with pruritus had higher viral loads (P = 0.006). We conclude that pruritus is still a frequent symptom in HIV-infected patients. To the best of our knowledge this is the first prevalence study of pruritus in an HIV population in the combination antiretroviral therapy (cART) era.

An inflammatory reaction surrounding molluscum contagiosum as possible manifestation of immune reconstitution inflammatory syndrome in HIV infection

Highly active antiretroviral therapy can restore specific immune responses and control of microorganism infections in human immunodeficiency virus-positive patients. This immune recovery may cause an inflammatory reaction to microbial and autoimmune antigens known as immune reconstitution inflammatory syndrome. We describe a clinical case with an intense inflammatory response surrounding molluscum contagiosum after highly active antiretroviral therapy. The clinical and laboratory findings suggested that the reaction was due to immune reconstitution inflammatory syndrome occurring during a period of immune recovery in a child with acquired immune deficiency syndrome.

HIV Tat potentiates cell toxicity in a T cell model for sulphamethoxazole-induced adverse drug reactions

HIV infection results in severe immune dysfunction with ensuing sequelae that includes characteristic opportunistic infections. Pneumocystis pneumonia (PCP) is one of the most common of these infections and is routinely treated with sulphamethaxazole (SMX). Although this drug is known to cause hypersensitivity adverse drug reactions (ADRs) in 0.1% of the general population, the incidence of these ADRs increases tenfold in the HIV-positive population. The HIV-1 trans-activator of transcription (HIV-1 Tat) together with the drug metabolite sulphamethaxazole-hydroxylamine (SMX-HA) have both been reported to be factors in these hypersensitivity ADRs. In this study, we use an inducible, Tat-expressing vector system to show that the level of Tat expression contributes to the cellular sensitivity of Jurkat T cells to SMX-HA. We further demonstrated that apoptosis is the likely mechanism by which this occurs. Thus, our data provide insight into the significant increase of SMX-related ADRs during the transition between HIV-1 infection and AIDS.

Inflammatory papillomatous hyperplasia and epidermal necrosis in a transgenic rat for HIV-1

BACKGROUND

Skin lesions commonly affect AIDS patients. The pathogenesis of certain dermatologic disorders primarily associated to HIV-1 is unclear, and better forms of therapy for these conditions need to be discovered. Transgenic animal models represent a novel approach for the study of these disorders and for the quest of more effective forms of treatment.

OBJECTIVE

Characterize this HIV-1 transgenic rat as a model to study skin diseases related to HIV/AIDS.

METHODS

A transgenic rat was developed, using an HIV-1 construct with deleted gag and pol genes. Morphological and genotypical evaluations were followed by cytokine profile characterization of the lesions.

RESULTS

We report the characterization of a colony of HIV-1 transgenic rats that developed skin lesions in a frequency of 22.5%. Cutaneous expression of functional HIV-1 transgenes correlated precisely with the severity of the phenotype. In early stages, rats manifested localized areas of xerosis and dispersed papulosquamous lesions. These hyperplastic manifestations were observed in conjunction with an increased epidermal expression of tat protein and a Th1/Th2 profile of cytokines. As the lesions progressed, they formed inflammatory plaques that subsequently ulcerated. Histologically, these lesions displayed a profound lymphocytic infiltrate, epidermal necrosis, and a marked increase of both Th1 and Th2 derived cytokines. Moreover, the presence of circulating IgG antibodies against HIV-1 gp120 was detected.

CONCLUSION

This animal model as other HIV-1 transgenic mice described in the past, is not able to fully explain the myriad of skin findings that can occur in HIV-infected humans; however, it represents a potential animal model system for the study of immune-mediated inflammatory skin diseases.

Dermatologic Immune Restoration Syndrome: Report of Five Cases from a Tertiary Care Center in North India

Background:

Dermatologic conditions are often an early clue to human immunodeficiency virus (HIV) infection. As the disease progresses and the host immunity fails, patients may develop a number of skin conditions. At this point, they have a dominant T helper 2 immunologic response. After the initiation of antiretroviral therapy, the T helper 1 response is restored, and some skin problems, paradoxically, make their appearance then.

Conclusion:

Herpes zoster, mucocutaneous herpes, eosinophilic folliculitis, and mycobacterial infections have been known to occur at this stage. This may be because immune restoration of a host's immunity causes recognition of silent or latent infection and results in development of the condition. We report five cases that were seen at our center during a 2-year period.

Progressive supravenous granulomatous nodular eruption in a human immunodeficiency virus-positive intravenous drug user treated with highly active antiretroviral therapy

We describe a 41-year-old human immunodeficiency virus-infected woman with a previous history of intravenous drug abuse, who developed multiple linear nodules following the superficial veins on both arms. Histopathological examination disclosed a dermal histiocytic inflammatory reaction with sarcoid-like granuloma formation occasionally showing an intracytoplasmic refractile material in the histiocytic cells. Nodular lesions developed progressively after starting on highly active antiretroviral therapy (HAART) which increased her CD4 cell count and suppressed her viral load. The appearance of latent inflammatory or autoimmune disease following HAART is a well-recognized phenomenon. We consider that this peculiar 'progressive supravenous granulomatous nodular eruption' should be included within the spectrum of the so-called immune reconstitution inflammatory syndrome.

HIV/AIDS in sub-Saharan Africa

The impact that HIV/AIDS has made on modern society is unquestionable. It has ravaged societies across the globe without the discrimination. It has swept across the globe like no other plague in human history, leaving nothing in its path untouched. Like all catastrophes, the havoc wreaked by HIV/AIDS most impacts people living in the poorest nations of the world. This article deals with the impact of HIV/AIDS in sub-Saharan Africa.

Stem cell apoptosis in HIV-1 alopecia

BACKGROUND

Diffuse alopecia occurs in almost 7% of HIV-1-infected patients. Telogen effluvium is the main pathogenic mechanism involved. Apoptotic keratinocytes in the outer root sheath at bulge level was described as the most characteristic histopathologic finding of this kind of hair loss.

METHODS

A case-control study was conducted to investigate the occurrence of apoptosis of follicular stem cells at the bulge in diffuse alopecia of HIV-1 infection. We applied a double-staining procedure to transverse scalp sections from 15 HIV-1-infected patients and 12 controls, with the monoclonal antibody anticytokeratin 19 as stem cell marker and TUNEL technique to identify apoptosis.

RESULTS

Eighty percent of cases and 25% of controls presented at least one double-stained follicle. The proportion of positive follicles per section was 48% (+/-7%) for cases and 26% (+/-13%) for controls.

CONCLUSION

Our study demonstrated that diffuse alopecia related to HIV-1 infection represents a hair cycle disturbance and that part of the follicular stem cell population become apoptotic in a higher proportion than normal subjects. We found no cytotoxic folliculitis. Owing to its cell-cycle interaction and caspase-induction capacities, we propose HIV-1 viral protein R as a possible follicular stem cell apoptosis inductor.

Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: An institutional urban clinic experience

BACKGROUND

Widespread introduction of highly active antiretroviral therapy (HAART) in the mid 1990s has altered the presentation of the cutaneous manifestations associated with HIV infection.

OBJECTIVE

Our purpose was to evaluate the use of HAART on the prevalence and spectrum of cutaneous manifestations in HIV-infected patients.

METHODS

A study of the initial visits of 897 HIV-infected patients at an urban dermatology clinic between 1996 and 2002 was performed.

RESULTS

Folliculitis was the most common cutaneous disorder identified. Patients with CD4-positive cell counts less than 200 cells/mm3 had an increased prevalence of folliculitis and prurigo nodularis, whereas those with HIV viral loads higher than 55,000 copies/mL had a higher prevalence of idiopathic pruritus and candidiasis. Patients not receiving HAART had increased rates of folliculitis and prurigo nodularis. Patients receiving HAART had increased rates of photosensitivity and molluscum contagiosum.

LIMITATIONS

This was a cross-sectional study in which temporality was unable to be determined.

CONCLUSION

With ongoing therapeutic advancements, the cutaneous manifestations associated with HIV infection will continue to evolve.

Impact of highly active antiretroviral therapy on organ-specific manifestations of HIV-1 infection

In the last 10 years, interesting results have been reported concerning the impact of highly active antiretroviral therapy (HAART) on the changing pattern of organ‐specific manifestations of HIV‐1 infection. There has been a clear step‐wise reduction in the incidence of several opportunistic infections (OIs), particularly Pneumocystis carinii pneumonia, whereas a nonsignificant reduction in incidence has been observed for other organ‐specific diseases, including invasive cervical cancer and Hodgkin disease. In addition, several organ‐specific manifestations, including HIV‐associated nephropathy, wasting syndrome and cardiomiopathy, are a direct consequence of damage by HIV‐1, and so HAART may have a therapeutic effect in improving or preventing these manifestations. Finally, the introduction of HAART has seen the emergence of several complications, termed immune reconstitution inflammatory syndrome, which includes OIs such as cytomegalovirus vitritis, Mycobacterium avium complex lymphadenitis, paradoxical responses to treatment for tuberculosis, and exacerbation of cryptococcosis. Because not all HIV‐1 organ‐specific manifestations are decreasing in the HAART era, this review will analyse the influence of HAART on several organ‐specific manifestations, and in particular OIs related to several organs, cerebral disorders and HIV‐1‐related neoplasia.

Advances in Antiviral Therapy

Infections with five of the herpesviruses (herpes simplex virus 1 [HSV-1], HSV-2, varicella zoster virus, Epstein-Barr virus, and cytomegalovirus) are treated with topical or systemic antiviral therapies. There are more than 100 genotypes of human papillomaviruses (HPVs), which may manifest as warts, skin cancers, cervical cancer, anogenital cancers, and upper digestive tract cancers. Molluscum contagiosum (MC) is a common, benign viral infection of the skin. Immunomodulating agents, such as imiquimod, act on HPV and MC indirectly by inducing host immune responses, such as cytokines and cell-mediated immunity, and thereby reduce recurrences. There are multiple vaccines available for certain viral diseases and others in development for HSV-2 and HPV.

Normal skin of HIV-infected individuals contains increased numbers of dermal CD8 T cells and normal numbers of Langerhans cells

Dysregulation of the skin immune system (SIS) could explain the high prevalence of skin disorders in HIV+ individuals. The present study was carried out to determine whether alterations in the cell population of SIS and epidermal immunoactivation occur in the normal skin of HIV+ individuals. Forty-five biopsies were taken from the normal upper arm skin of 45 HIV+ patients and of 15 healthy controls. HIV+ individuals were divided into three categories according to their CD4 cell blood count (<200, 200-499 and > or = 500/microl). Hematoxylin-eosin was used to stain tissue sections for morphological analysis and immunohistochemistry was used for the evaluation of the frequency of macrophages, Langerhans cells, and CD lymphocyte subsets. In addition, semiquantitative analysis of LFA-1, ICAM-1 and HLA-DR was determined in epidermal cells. Macrophages, Langerhans cells, and CD lymphocyte subsets did not differ significantly between any of the patient categories and the control group. When all HIV+ individuals were compared as a group to the control group, a significant increase in dermal CD8+ T lymphocytes (P < 0.01) and lower CD4-CD8 ratios (P < 0.01) were observed in the HIV+ individuals. Epidermal ICAM-1 and HLA-DR expression was negative in both HIV+ and normal skin biopsies. No evidence of a depletion of the SIS population or of epidermal immunoactivation in normal skin from HIV+ individuals was demonstrable, suggesting that alterations in the central immune system are not necessarily reflected in the SIS of HIV-infected patients.

The Effect of Highly Active Antiretroviral Therapy on Dermatologic Disease in a Longitudinal Study of HIV Type 1–Infected Women

The effect of highly active antiretroviral therapy (HAART) on skin diseases was evaluated in 878 human immunodeficiency virus type 1 (HIV-1)-infected women in the Women's Interagency HIV Study, a multicenter prospective study. HIV-1-infected women receiving HAART were less likely to have eczema, folliculitis, tinea pedis, and xerosis than were women who had not initiated HAART, independent of CD4+ cell count. Participants who had a prior history of a nadir CD4+ cell count of <200 cells/microL and recent CD4+ cell counts of 200-349 cells/microL were more likely to have eczema and xerosis than were women with a nadir CD4+ cell count of >200 cells/microL and recent CD4+ cell counts of >349 cells/microL. An HIV-1 RNA load of >100,000 copies/mL was associated with increased prevalence of herpes zoster infection (odds ratio, 6.10; 95% confidence interval, 2.00-18.65). History of injection drug use was associated with a higher prevalence of onychomycosis, tinea pedis, and xerosis. Molluscum contagiosum was more prevalent among younger women.

Pediatric molluscum contagiosum: optimal treatment strategies

Pediatric molluscum contagiosum virus (MCV) is a common pox viridae infection that represents a common public health issue. The spread of the virus among children is rapid and easy. The virus produces a number of substances that block immune response formation in the infected host. Despite the benign and self-limited nature of the condition, one-third of children have symptoms from, or secondary reactions to the infection, including pruritus, erythema and, occasionally, inflammation and pain. Patients with pruritus autoinoculate the virus through scratching, thereby exacerbating their conditions. While adults cope well with unanesthetized curettage of lesions, children require less painful therapeutic options. The options for therapy are manifold. Therapy should begin with gentle skin care and antipruritics to prevent symptoms, and to prevent the spread of the disease. Therapies with good efficacy and low risk of pain for the patient include in-office usage of cantharidin and the use of local anesthetics, such as topical lidocaine (lignocaine) preparations in combination with the curettage of visible lesions. Alternatively, cryosurgery can be performed to eradicate lesions in-office. At-home therapeutics are often preferred by parents and children, and include imiquimod, retinoids, and alpha-hydroxy acids. Although a variety of such at-home therapies are available, none are as effective or as rapid acting as in-office therapy. Further research in large clinical trials is required to increase knowledge on prevention, optimal treatment, and long-term outcome with this disease.