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Pediatric Warts: 2023 Update

Teaser: 

Mahan Maazi, MEng,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Cutaneous warts or verruca are benign growths of the skin that affect 30 to 70% of school-age children and has a lifetime prevalence of 10 to 22% in children. It is caused by human papillomavirus (HPV) which spreads from skin-to-skin contact or fomites and infects squamous cell in areas like the hands and feet. There are different HPV subtypes that cause different types of warts including common warts (verruca vulgaris), plantar warts (verruca plantaris), flat warts (verruca plana), mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis, and condyloma acuminata (genital or venereal warts). Most warts will spontaneously clear within 2 years. Diagnosis is based on history and physical examination features which may include dermoscopy and rarely, histological confirmation. Management includes treatment with topical salicylic acid and cryotherapy, the two most common and effective modalities.
Key Words: warts (verruca), human papillomavirus (HPV), common warts (verruca vulgaris), plantar warts (verruca plantaris), flat warts (verruca plana), mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis (EV), condyloma acuminata (genital or venereal warts).
Cutaneous warts are a benign growth caused by human papillomavirus (HPV) infection that can cause discomfort. These are most common in school-aged children and in adolescents.
HPV infection is acquired through skin-to-skin contact, contact with fomites, or through maternal transmission during birth. The virus infects squamous cells on the skin and inserts its viral genome into the cells causing survival and proliferation of the virus.
History and physical examination help diagnose warts in children. Dermoscopy and histology may also aid in diagnosis, especially in more challenging presentations. A history of genital warts in children mandates ruling out sexual abuse.
There is a wide range of treatment modalities that can be used for warts. The most well-studied are destructive therapies such as salicylic acid and cryotherapy. There are side effects from treatments such as pain, blistering, scarring and dyspigmentation from cryotherapy. HPV vaccination in children is useful in preventing certain subtypes of genital warts and those that may cause cancer.
Warts often spontaneously resolve with 33% clearing within the first 6 months, 66% within the first 2 years, and 90% within the first 5 years.
Treatment can hasten resolution of warts and often involve destructive therapies such as salicylic acid and cryotherapy.
HPV subtypes causing cancer are rare. Vaccination can significantly decrease the chance of acquiring HPV subtypes that cause genital warts and cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancer.
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Related Terms: Dermatology, warts, common warts, plantar warts, flat warts, mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis, condyloma acuminata
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Spine Infections

Teaser: 

Jessica Albanese, MD,1 Brett Rocos, MB, ChB, MD, FRCS (Tr & Orth),2

1 Adult Spine Fellow, Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.
2 Assistant Professor of Orthopaedic Surgery, Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.

CLINICAL TOOLS

Abstract: Though they have significant morbidity and mortality, spine infections are a rare cause of back pain. Because they are uncommon, it is important to recognize the signs and symptoms of a spine infection, to establish the diagnosis, and to treat appropriately, guided by culture results, with antibiotic therapy. Surgical intervention is indicated in cases of significant neurologic deficit, significant spinal deformity, instability, and/or failed medical management.
Key Words:spinal infection, spondylodiscitis, discitis, vertebral osteomyelitis, epidural abscess, back pain.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

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Patients with spine infections often present with back pain and may have radicular pain, neurologic deficits, or constitutional signs and symptoms of infection
Workup begins with laboratory studies including, CBC, CRP, and ESR
The gold standard for imaging is MRI
Definitive diagnosis may require CT-guided biopsy and culture
The mainstay of treatment is at least 6 weeks of antibiotic therapy guided by culture results
Surgical intervention is indicated in cases of progressive neurologic deficit or spinal deformity, instability, or failed medical management
Spinal infections can present insidiously
Refer early if patients present with back pain and unexplained fever
Prompt identification with MRI improves likelihood of recovery
Antibiotic treatment for 6 weeks is recommended
Surgery is useful for neurological deficit or instability
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Related Terms: Back Health, spinal infection, spondylodiscitis, discitis, vertebral osteomyelitis, epidural abscess, back pain

Dermatological Findings in Body-focused Repetitive Behaviours

Teaser: 

Amir Gohari1 Joseph M. Lam, MD, FRCPC,2

1 University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Body-focused repetitive behaviours (BFRBs) are common yet poorly understood conditions with significant mental and physical implications. Dermatological findings associated with BFRBs can be atypical, and recognizing them can be very beneficial. This paper reviews the dermatological findings associated with BFRBs, including habit-tic nail deformity, onychophagia, onychotillomania, trichotillomania, lip/cheek biting, dermatillomania, and compulsive washing. Recognition of these classic dermatological signs can help clinicians differentiate them from other common dermatological conditions. Body-focused repetitive behaviours require multidisciplinary management, and dermatology can contribute to their recognition and treatment.
Key Words:body-focused repetitive behaviours, dermatological findings, nail, hair, oral mucosa, skin.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

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BFRBs are common yet poorly understood conditions with significant mental and physical implications.
Recognition of classic dermatological signs can help clinicians differentiate BFRBs from other common dermatological conditions.
Dermatological findings associated with BFRBs can be atypical, and recognizing them can be very beneficial.
BFRBs require multi-disciplinary management, and dermatology can contribute to their recognition and treatment.
Recognizing dermatological findings associated with BFRBs can help clinicians make an accurate diagnosis and develop an effective treatment plan.
BFRBs can cause significant physical and psychological harm and require a multi-disciplinary approach to management.
Early recognition and treatment of BFRBs can prevent long-term physical and psychological complications.
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Related Terms: Dermatology, body-focused repetitive behaviours, dermatological findings, nail, hair, oral mucosa, skin
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Principles of Geriatric Palliative Care

Teaser: 

Albert J. Kirshen, MD, FRCPC,

(Internal, Geriatric, Palliative Medicine), Emeritus Associate Professor, Dept. of Family and Community Medicine, Faculty of Medicine, University of Toronto, formerly consultant palliative care physician, The Temmy Latner Centre for Palliative Care, Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON.

CLINICAL TOOLS

Abstract: Palliative care aims to relieve suffering and enhance the quality of life for those with chronic, progressive or life-threatening illnesses. However, seniors' palliative care needs are often poorly recognized, assessed, or managed, resulting in adverse outcomes. This article explores the importance of recognizing, assessing, and managing symptoms for older adults needing palliative care. It offers insights into how physicians and healthcare providers can improve the quality of life for seniors by addressing their pain and symptom management needs.
Key Words: palliative care, symptom management, older adults, geriatrics, pain management, quality of life, recognition, assessment.
Palliative care aims to improve the quality of life for seniors with chronic, progressive or life-threatening illnesses.
Healthcare providers need to tailor symptom management to the unique characteristics of older adults, including cognitive and sensory impairments.
Recognition, assessment, and management of symptoms are critical components of palliative care.
A comprehensive approach that includes communication, pharmacological and non-pharmacological interventions can improve the quality of life for seniors in need of palliative care.
Communication with patients, caregivers, and other healthcare professionals is key to recognizing seniors’ palliative care needs.
Assessment of seniors’ symptoms should be tailored to their unique characteristics, including cognitive and sensory impairments.
A comprehensive approach that includes pharmacological and non-pharmacological interventions is essential for optimal symptom management in seniors.
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Related Terms: Caregiving, palliative care, symptoms, management, older adults, geriatric, pain management, quality of life, recognition, assessment

Diabetes Complications: Erectile Dysfunction

Teaser: 

Dean Elterman, MD, MSc, FRCSC,

Associate Professor, Division of Urology, University Health Network, University of Toronto, Toronto, ON.

CLINICAL TOOLS

A clear relationship, with shared risk factors, exists between diabetes, ED and CVD.
Use of ED as a harbinger of CVD is most predictive in younger men (ED may precede CVD by 2-5 yrs, 3 avg).
The identification of ED may allow for risk reduction and preventative measures in large numbers of men.
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Related Terms: Diabetes-Endocrine Disorders, diabetes, diabetic management, treatment, erectile dysfunction
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Diabetes Complications: Diabetic Nephropathy

Teaser: 

Louis-Philippe Girard, MD, MBT, FRCSC,

Clinical Nephrologist, Associate Professor, University of Calgary, Calgary, AB.

CLINICAL TOOLS

The hallmark of Diabetic Nephropathy is albuminuria. Albuminuria is a marker of poor renal and CV prognosis and should be identified in all patients where CKD is suspected.
Organ protection should be a priority in patients with DN. Very solid evidence exists for the SGTL2i class as it pertains to renal protection. Patients with DN are at very high risk of CV disease and its complications. There are robust data demonstrating CV protection when SGLT2i and GLP-1RAs are used in patients with DKD.
A1C control remains a critical component of preventing the progression of DN and can now be achieved in a safe manner with newer agents that do not cause hypoglycemia.
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Related Terms: Diabetes-Endocrine Disorders, diabetes, diabetic management, treatment, nephropathy
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Diabetes Complications: Diabetic Neuropathy

Teaser: 

Aaron Izenberg, MD, FRCSC,

Neurologist, Sunnybrook Health Sciences Centre, Assistant Professor, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Neuropathy is a very common complication of diabetes with sensorimotor neuropathy being the most common subtype of diabetic neuropathy
Other types of diabetic neuropathies include autonomic, treatment-induced, diabetic lumbosacral radiculoplexus, and mononeuropathies
Diagnostic testing for sensorimotor neuropathy includes bedside testing (e.g., Monofilament) and electrodiagnostic methods
Treatment of sensorimotor diabetic neuropathy includes achieving good glycemic control and appropriate use of pain medications
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Related Terms: Diabetes-Endocrine Disorders, diabetes, neuropathy, diabetic management, treatment
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Diabetes Complications: Diabetic Retinopathy

Teaser: 

Carol Schwartz, MD, FRCSC, DABO,

Assistant Professor, University of Toronto, Ophthalmologist, Sunnybrook Health Sciences Centre, Toronto, ON.

CLINICAL TOOLS

Appropriate screening
Good systemic control of blood sugar, hypertension, dyslipidemia and renal function
Timely treatment involving intra-vitreal anti-VEGF injections, laser photocoagulation when appropriate and surgical intervention when necessary
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Related Terms: Diabetes-Endocrine Disorders, diabetes, diabetic retinopathy, diabetic management, treatment
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Acne Vulgaris: 2023 Update

Teaser: 

Amir Gohari1 Joseph M. Lam, MD, FRCPC,2

1 University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Acne vulgaris is a chronic pilosebaceous inflammatory disorder that affects almost 85% of those aged 12 to 24 years. Its pathophysiology is an interplay between androgenic activity, follicular epidermal hyperproliferation, retention hyperkeratosis, and Cutibacterium acnes infection. Strong evidence exists for high glycemic index diet as a trigger. Diagnosis is clinical and management is based on lesion types, with options including retinoids, benzoyl peroxide, antibiotics, oral contraceptives, and spironolactone.
Key Words: acne vulgaris, inflammatory disorder, comedones, Cutibacterium acnes.
Acne vulgaris is the most common skin condition observed in adolescent and pre-adolescent patients and has a significant psychological burden.
The plugged follicles of acne allow for Cutibacterium acnes overgrowth which triggers the release of heat shock proteins, porphyrin, proteases, and squalene peroxides, leading to inflammation.
Topical retinoids are used for open and closed comedones, while topical antibiotics and benzoyl peroxide are used for inflammatory lesions. Oral antibiotics are added for moderate to severe inflammatory acne. Hormonal therapy and isotretinoin are used to target the excess sebum production.
Acne may reflect an underlying disease. Patients that present before 7 years of age may have an underlying endocrinopathy. For women with acne, the possibility of polycystic ovary syndrome (PCOS) should be addressed.
Acne lesions can be non-inflammatory, in the form of open or closed comedones, and/or inflammatory, in the form of papules, pustules, and nodules. Treatment should be targeted to the type of acne the patient presents with.
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Related Terms: Dermatology, acne vulgaris, inflammatory disorder, comedones, Cutibacterium acnes
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Degenerative Cervical Myelopathy: Navigating Management in the Primary Care Setting

Teaser: 

Karlo M. Pedro, MD,1 James Milligan, MD,2 Michael G. Fehlings, MD, PhD,3

1 Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada.
2 McMaster University, Department of Family Medicine, Hamilton, ON, Canada.
3Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.

CLINICAL TOOLS

Abstract: Degenerative cervical myelopathy (DCM) is a progressive and acquired spinal disorder that represents a potentially reversible cause of spinal cord impairment among adults. It remains underdiagnosed due to a low level of awareness amongst the public and healthcare professionals. Diagnosis is anchored on high clinical suspicion after a thorough history and physical examination and confirmed using magnetic resonance (MR) imaging of the cervical spine. Improving early diagnosis and ensuring timely surgical intervention are crucial in preventing long-term disability and optimizing long-term outcomes for DCM patients.
Key Words:degenerative cervical myelopathy, myelopathy, non-traumatic spinal cord injury, primary care.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Pre-test CME Quiz Post-test CME Quiz
DCM is the most common cause of non-traumatic spinal cord dysfunction among adults worldwide
DCM is a potentially reversible disease with profound neurologic implications if left untreated
A thorough history and physical examination, supplemented with MR imaging of the cervical spine, are key elements to avoid misdiagnosis and delays in management
The hallmark signs of DCM are deterioration of hand motor function (eg. decreased coordination/clumsiness) as well as gait instability
MRI is the imaging of choice to confirm a diagnosis of DCM
Surgery is the only proven therapy that can halt the progression of DCM
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Related Terms: Back Health, degenerative cervical myelopathy, myelopathy, non-traumatic spinal cord injury, primary care