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The tendency for recurrence of warts makes the treatment of this condition
frustrating. Because most warts disappear spontaneously with time, procedures
that are least traumatic for the child should be attempted first. The simple,
nontraumatic method of airtight occlusion with plain adhesive tape or duct tape
for 1 month is often successful. Topical application of 17% salicylic acid in
flexible collodion (Duofilm) or duct/occlusive tape is good for home use. Plantar
warts can be treated with 40% salicylic acid plasters applied nightly as tolerated.
When simple methods are unsuccessful, touching the warts with liquid nitrogen
or volatile cryogens such as dimethyl ether, propane, or isobutane (VerrucaFreeze) for 10 to 30 seconds or surgical removal can be attempted on a 2- to 4week schedule until the lesions clear completely. Both procedures are painful, and
are typically not performed in the emergency department.
Anogenital warts can be treated with topical preparations such as
podophyllotoxin gel (Condylox) or imiquimod cream. Podophyllotoxin gel is
applied on the condylomata three consecutive nights each week while imiquimod
is used every other night three times weekly. Both agents may be used for up to 3
months or so or until the warts clear. Topical cidofovir in 1% or 3% preparation
can also be used for warts and molluscum in refractory cases. Child abuse should
be considered in any child with genital warts but keep in mind that maternal
transmission can occur during delivery, and patients or caregivers can transfer
wart virus from the hands to genital areas.

Xanthomas
Papules, plaques, nodules, and tumors that contain lipid are called xanthomas.
These rare lesions can appear on any skin surface and are often associated with
disturbances of lipoprotein metabolism.

Insect Bites
Mosquitoes are probably the most common cause of insect bites in children,
followed by fleas ( Fig. 88.3 ) and bed bugs. Mosquito bites are generally limited
to the warm months of the year. In contrast, flea bites, which predominate from
spring to fall, can also occur during the winter months as a result of cats, dogs,
and rodents who live indoors.

FIGURE 88.3 Insect bite in a child.

The distribution of lesions is a valuable clue in making the diagnosis of
mosquito or flea bites. Insect bites generally involve the exposed surfaces of the
head, face, and extremities. The lesions are usually urticarial papules that occur in
groups or along a line on which the insect was crawling. Some lesions may
manifest a central punctum. On occasion, both mosquito bites and flea bites can
cause blistering lesions. These lesions are not indicative of secondary infection
but rather represent an immune response to the bite.
Excoriation with resulting secondary infection with Staphylococcus aureus or
Group A streptococci can complicate a simple bite. Because swelling and redness


can be prominent features of the inflammatory reaction, a common conundrum in
the ED is determining whether an insect bite has become infected. In our
experience, cellulitis, indicative of infection, is tender and tends to be firmer than
a simple inflammatory reaction.
Unfortunately, no specific treatment exists for insect bites. Antihistamines,
calamine lotion, or topical steroids have a limited or temporary effect. Prevention
through the prophylactic use of insect repellents and protective clothing offers the
best solution. Elimination of the biting insects by treatment of the homes with
insecticides or treatment of the infested animals is important.
For additional information about insect bites, see Chapter 67 Rash:
Vesiculobullous .

Tick Bites
Tick bites usually cause only local reactions. Erythema migrans is the
characteristic rash of Lyme disease and looks like large bull’s eye; the rash

generally appears 7 to 10 days post tick exposure but the range is 3 to 30 days and
is not always seen. Rarely, tick bites are associated with significant systemic
illness, including Rocky Mountain spotted fever (RMSF), tick paralysis, and
Lyme meningitis.
When ticks are removed, it is important not to leave fragments of the
mouthparts in the skin or to introduce body fluids containing infectious
organisms. Various methods have been recommended for removal of ticks from
the skin. The safest method is to use a blunt-curved forceps, tweezers, or fingers
protected by rubber gloves. The tick is grasped close to the skin surface and
pulled upward with a steady even force. The tick should not be squeezed,
crushed, or punctured. If mouthparts are left in the skin, they should be removed.

Spider Bites
Loxosceles reclusa , or the brown recluse spider ( Fig. 88.4 ), found most
commonly in the south central United States (from southeastern Nebraska
through Texas, east through southern Ohio and Georgia), is responsible for most
skin reactions caused by the bite of a spider. This spider is small, the body being
only 8 to 10 mm long, and bears a violin-shaped band over the dorsal
cephalothorax. The venom contains necrotizing, hemolytic, and spreading factors.
The initial symptoms include mild stinging and/or pruritus. A hemorrhagic
blister then appears, which can develop into a gangrenous eschar. Severe bites can
cause a generalized erythematous macular eruption, nausea, vomiting, chills,
malaise, muscle aches, and hemolysis. Treatment includes tetanus prophylaxis
and surgical removal of the necrotic area to prevent spread of the toxin.


Antibiotics are indicated if there are signs of secondary infection. Some authors
recommend corticosteroids if the patient presents within 12 hours of a bite but the
efficacy of this approach is unproven. An antivenom exists if there are systemic
signs.

FIGURE 88.4 Spider recluse.

It is important to point out that spider bites are often blamed for solitary or
several skin lesions. There is a literature that suggests spiders are unfairly
maligned in this regard, and that misdiagnosis is extremely common. Especially
in areas where the brown recluse spider is rare or totally absent, it is important to
consider mimics such as Staphylococcus aureus abscess, herpes zoster, and
Sporothrix schenckii infections, to name a few.

Scabies Infestation
Please see Chapter 67 Rash: Vesiculobullous for more details. The cardinal
symptom of any infestation with scabies is pruritus. Two clues should be
considered when attempting to make this diagnosis: (i) Distribution (small red
papules with concentration on the hands, feet, and folds of the body, especially
the finger webs and genital areas) and (ii) involvement of other family members.
It is important not only to ask other family members if they have pruritus but also