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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 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 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 to 10 days post tick exposure but the range is 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 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