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Molluscum Contagiosum
Article Last Updated: Apr 1, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Ashish C Bhatia, MD, FAAD, Assistant Professor of Clinical Dermatology, Department of Dermatology, Northwestern University, Feinberg School of Medicine; Director of Clinical Research, Department of Dermatology and Dermatologic Surgery, River North Dermatology and Dermatologic Surgery, DuPage Medical Group
Ashish C Bhatia is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, and Connective Tissue Oncology Society
Coauthor(s):
Tracy Campbell, MD, Staff Physician, Department of Dermatology, Rush Medical Center;
Seth Forman, MD, Department of Dermatology, Medical College of Virginia;
David Rowe, MD, Pathologist, Laboratory Medicine, Martha Jefferson Hospital;
Robert Orenstein, DO, Associate Professor, Department of Medicine, Medical College of Virginia, Virginia Commonwealth University; Medical Director, Infectious Disease Clinic, Medical College of Virginia Hospitals;
Julia R Nunley, MD, Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center
Editors: Daniel R Lucey, MD, MPH, Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; John W King, MD, Professor of Medicine, Section of Infectious Diseases, Louisiana State University Health Sciences Center; Director, Viral Therapeutics Clinics for Hepatitis; Consulting Staff, Department of Infectious Diseases, Overton Brook Veterans Affairs Medical Center; Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital; Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Author and Editor Disclosure
Synonyms and related keywords:
molluscum contagiosum, MC, molluscum contagiosum virus disease, MCV disease, opportunistic infection, sexually transmitted disease, STD, Henderson-Paterson body, Orthopoxvirus genus, renal transplantation, tacrolimus, topical immune suppressants, molluscum body
Background
In 1817, long before the recent increased incidence of molluscum contagiosum (MC), Bateman first described milky fluids that could be expressed from characteristic lesions. Henderson and Paterson, 2 researchers studying molluscum contagiosum independently 25 years later, described the milky fluid to be cellular. Only later did the 2 researchers realize they had discovered the hallmark intracytoplasmic inclusion body, appropriately named the Henderson-Paterson body (molluscum body). Until the early 20th century, the medical community remained unsure of the etiology of molluscum contagiosum. Certain authorities believed the papules to be enlarged sebaceous glands, while others postulated that a parasitic infestation caused the lesions. A breakthrough in the study of molluscum contagiosum occurred in 1905 when Juliusburg discovered and documented the viral nature of molluscum contagiosum.
Pathophysiology
The molluscum contagiosum virus, which contains linear double-stranded DNA, causes molluscum contagiosum. Restriction endonucleases have elucidated 4 discrete viral subtypes: molluscum contagiosum virus subtypes I, II, III, and IV. All subtypes are classified as members of the Orthopoxvirus genus or as unspecified poxviruses. When human infection occurs, the epidermal keratinocytes are targeted. Viral replication occurs within the cytoplasm of the infected cell, generating the characteristic cytoplasmic inclusion bodies. Histologically, these inclusion bodies are most evident within the stratum granulosum and stratum corneum layers of the epidermis. Hyperproliferation of the epidermis also occurs because of a doubling in the rate of cellular division of the epidermal basal layer. The molluscum contagiosum virus causes 3 distinct disease patterns in 3 different patient populations: children, immunocompetent adults, and immunocompromised patients (children or adults). Children acquire the molluscum contagiosum virus through either direct skin-to-skin contact or indirect skin contact via fomites such as gymnasium equipment and public baths. Lesions typically occur on the chest, arms, trunk, legs, and face. In adults, molluscum contagiosum is considered a sexually transmitted disease (STD). In almost all cases involving healthy adults, patients exhibit few lesions, which are limited to the perineum, genitalia, lower abdomen, or buttocks. Generally, in immunocompetent populations, molluscum contagiosum is a self-limited disease. Patients infected with human immunodeficiency virus (HIV) or patients who are otherwise severely immunologically compromised may experience a longer course with more extensive and atypical lesions. In patients infected with HIV, lesions generally are distributed more widely, frequently occur on the face, and may number in the hundreds. The cutaneous manifestations of other opportunistic infections, such as cutaneous cryptococcosis, histoplasmosis, and aspergillosis, may mimic molluscum contagiosum and must be ruled out in immunocompromised hosts. For additional information on HIV, see Medscape's HIV Transmission & Prevention Resource Center.
Frequency
United States
The incidence of molluscum contagiosum rose from 1960-1980. It is less common than other STDs, occurring in about 1% of the general population. In a 1984 paper published in the Urologic Clinics of North America, Margolis of the Centers for Disease Control and Prevention reportedthat 1 case of molluscum contagiosum occurs for every 42-60 cases of gonorrhea infection.22
The prevalence rate in the population infected with HIV is reported to be 5-18%. In patients who are infected with HIV and who have CD4 cell counts of less than 100 cells/μL, the prevalence of molluscum contagiosum is reported to be as high as 33%.
Mortality/Morbidity
- Molluscum contagiosum is a self-limited disease in immunocompetent individuals, with no long-term complications or sequelae.
- In contrast, molluscum contagiosum infection in patients who are infected with HIV may result in conspicuous cosmetic deformities that may have significant adverse psychological effects.
- Although superinfection and cellulitis have been reported to occur in the setting of molluscum contagiosum in the population infected with HIV, no mortality has been associated directly with the molluscum contagiosum virus.
Race
No racial predilection has been reported.
Sex
The incidence in men reportedly is greater than that in women.
Age
Molluscum contagiosum has been reported in all age groups but is observed most commonly in children and adults who are sexually active. Molluscum contagiosum may occur at any age in immunocompromised patients.
History
- Children
- Parents may report recent exposure to other children affected with molluscum contagiosum at school, camp, or public recreational facilities (eg, gymnasiums, swimming pools).
- Children frequently have active atopic dermatitis.
- Immunocompetent adults
- Affected adults who are otherwise healthy uniformly are sexually active but may not know that their partners are affected.
- Having multiple sexual partners increases the risk of infection; the frequency of unprotected sex increases the risk of transmission.
- Patients infected with HIV
- Patients generally have low CD4 counts, and the severity of infection is inversely related to the patient's CD4 count.
- Patients who are poorly compliant or noncompliant with highly active antiretroviral therapy (HAART) for the treatment of HIV are at an increased risk, as are those who have multiple sexual partners.
- The frequency of unprotected sex also increases the risk of transmission.
- Miscellaneous
- A recent report detailed an eruption of molluscum contagiosum in a patient who had undergone a renal transplant.21
- Case reports detail molluscum contagiosum eruptions in areas that are treated with tacrolimus 0.1% (Protopic).2, 14, 42
Physical
Individual lesions are typically discrete, waxy, flesh-colored, dome-shaped, umbilicated papules with a smooth surface. Lesions may be few or numerous, depending on the immunological status of the host. In all patients, lesions generally are asymptomatic, but pruritus and/or perilesional eczematous reactions may develop. - In children and healthy adults
- Lesions are usually 1-2 mm in diameter and number fewer than 20.
- In children, lesions generally are distributed on the trunk, arms, legs, and face.
- In immunocompetent adults, lesions usually are found on the genitalia, lower abdomen, inner upper thighs, and/or buttocks.
- The average duration of an untreated lesion is 6-9 months but may be as long as 5 years.
- Individuals who are HIV positive
- The disease is generally more severe in patients infected with HIV. Lesions may number in the hundreds and are generally larger (can be >2 cm in diameter) and more deforming and may be confluent.
- In addition to groin involvement, lesions frequently are found on the face. The duration of untreated lesions may be 5 years or more because molluscum contagiosum may not be self-limiting in this population.
- In both immunocompetent and immunocompromised individuals, molluscum contagiosum is rarely found in the oral mucosa and conjunctiva.
Causes
Risk factors include the following: - Children - Skin-to-skin contact with another affected child or sharing equipment (eg, equipment in a gymnasium)
- Healthy adults - Primarily sexual contact with an affected partner
- Immunocompromised patients - Sexual contact with an affected partner, as well as nonsexual skin-to-skin contact with an affected individual
- Immune suppressant use - Local application of immune suppressants (tacrolimus) may cause a more severe localized eruption.
Aspergillosis
Basal Cell Carcinoma
Coccidioidomycosis (Infectious Diseases)
Condyloma Acuminatum
Cryptococcosis
Epitheliomas, Basal Cell
Histoplasmosis
Varicella-Zoster Virus
Other Problems to be Considered
Lichen planus
Flat warts (verruca plana)
Pyoderma
Lab Studies
- Consider testing for HIV infection in patients with facial lesions.
Procedures
- Skin biopsy: A biopsy of a lesion may be obtained to confirm the diagnosis of molluscum contagiosum histologically.
- Squash preparation (microscopic examination of cellular exudate)
- The cellular material contained within the central umbilication may be extracted manually, flattened between 2 microscope slides, and stained.
- Microscopic examination of this preparation reveals the intracytoplasmic molluscum inclusion bodies (Henderson-Paterson bodies).
Histologic Findings
The prototypical hematoxylin and eosin (H&E)–stained histological section of molluscum contagiosum reveals a cup-shaped indentation of the epidermis into the dermis (see Image 4). Within the region of the indentation, the epidermis appears thickened (acanthosis) compared to the surrounding uninvolved skin, and the cornified layer typically is disintegrated. The striking feature is the presence of intracytoplasmic, eosinophilic, granular inclusions within the keratinocytes of the basal, spinous, and granular layers of the epidermis (see Image 5). These inclusions, termed molluscum bodies or Henderson-Paterson bodies, can measure 35 µm in diameter and tend to displace the nucleus to the periphery of the cell. Ultrastructural studies have shown that the molluscum bodies are membrane-bound sacs that contain numerous molluscum contagiosum virions. The surrounding dermis is relatively unremarkable. In nonprototypical cases, in which intradermal rupture of molluscum bodies occurs, an intense dermal inflammatory infiltrate consisting of lymphocytes, histiocytes, and occasional foreign body–type multinucleated giant cells may be observed. Rarely, metaplastic ossification may occur. Exceptionally, the dermal inflammatory infiltrate may be intense enough to simulate a cutaneous lymphoma (pseudolymphoma).
Medical Care
The course of molluscum contagiosum usually is self-limited, and lesions generally heal without scarring. Intervention may be indicated if lesions persist. Therapeutic modalities include topical application of various medications, radiation therapy, and/or surgery. Each technique might result in scarring or postinflammatory pigmentary changes. Frequently, multiple treatment sessions are necessary because of the recurrence of treated lesions and/or the appearance of new lesions by autoinoculation. The benefit of therapy must exceed the risk. The Food and Drug Administration (FDA) has approved none of the topical or intralesional agents for treatment of molluscum contagiosum. - Topical therapy: Clinical success has been reported with the use of the following topical agents, which may act as irritants, stimulating an immunological response.
- Imiquimod cream is an immune response modifier approved for the treatment of external genital and perianal warts in adults. It has been reported to be effective in the treatment of molluscum contagiosum.7, 38 Imiquimod cream may be used in conjunction with cantharidin.33
- Several studies report that cantharidin, a chemovesicant, is effective in treating molluscum contagiosum. To test the patient's response to therapy, treat only a few lesions on the initial visit. Cantharidin may be used in combination with imiquimod.33
- Tretinoin has reportedly been successful in the treatment of small molluscum contagiosum lesions. Tretinoin, cantharidin, and imiquimod may be dispensed to the patient with application instructions and close follow-up.
- Bichloracetic acid, trichloroacetic acid, salicylic acid, lactic acid, glycolic acid, and silver nitrate also have been used, but the physician must apply them in the office.
- Topical podophyllotoxin 0.5% cream self-administered twice daily for 3 weeks has been reported effective in one placebo-controlled, double-blind study.37
- Reports have suggested that subcutaneous interferon alfa (IFN-alfa) administered intralesionally may be useful in immunocompromised children.
- A recent case report noted the efficacy of topical cidofovir in the treatment of disseminated molluscum in immunodepressed patients.14 Cidofovir diphosphate was reported to inhibit molluscum contagiosum virus DNA polymerase activity.39
Surgical Care
Frequently, multiple treatment sessions are necessary because of recurrence of treated lesions and/or the appearance of new lesions by autoinoculation. Each technique may result in scarring or postinflammatory pigment changes.
- Curettage: Individual lesions may be removed with a hand-held curette, with little discomfort. Follow curettage with application of a topical irritant.
- Cryosurgery: Apply liquid nitrogen for 10-15 seconds per lesion. Liquid nitrogen therapy may be painful and can result in blistering. Temporary or permanent depigmentation may occur in individuals who are more darkly pigmented.
- Electrodesiccation may be used for lesions that are refractory to curettage or cryosurgery. This technique can cause significant discomfort; consider using local anesthesia. Use caution in patients with pacemakers.
- Pulsed dye laser has been used with some success.25
- Intense pulsed light (IPL) has also been used in conjunction with the application of 5-aminolevulinic acid with success in a 6-case patient series.
Topical medications usually are the first category used in treating active disease. Use acid and intralesional therapies when topical therapy fails.
Drug Category: Immune response modifiers, topical
These agents are one of the first-line topical treatments for molluscum contagiosum, although not FDA approved for the indication.
| Drug Name | Imiquimod (Aldara) |
|---|
| Description | Induces secretion of IFN-alfa and other cytokines. Mechanisms of action are unknown. May be more effective in women than in men. |
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| Adult Dose | Apply 3 times qwk before hs; leave on skin for 6-10 h |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity |
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| Interactions | None reported |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
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| Precautions | Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal human papilloma infection; following surgery or drug treatment, do not use until genital/perianal tissue is healed |
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Drug Category: Chemovesicants
These are first-line topical agents, although they are not FDA approved for molluscum contagiosum. Effectiveness against warts may result from exfoliation.
| Drug Name | Cantharidin (Verr-Canth) |
|---|
| Description | Lytic action does not affect basal layer and has minimal effect on the corium. Scarring does not occur. |
|---|
| Adult Dose | Remove keratin covering wart (avoid cutting viable tissue), apply topically (wart and 1-3 mm around), allow to dry, secure with nonporous tape
Protective cutout cushion over tape is helpful; patient may bathe and replace dressing in 24 h
Debride in 1-2 wk; if viable wart tissue remains, re-treat; > 3 treatments for large lesions
Treat one portion at a time in large mosaic warts, pare carefully because stinging may result from solvent on open tissue, treat 2 wk apart |
|---|
| Pediatric Dose | Apply as in adults |
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| Contraindications | Documented hypersensitivity; diabetes; impaired peripheral circulation; surrounding tissue that is swollen or irritated |
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| Interactions | None reported |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Strong vesicant to be used sparingly; not for use in the anogenital area; do not apply to eyes or mucosal tissue; avoid use in intertriginous sites because of problems with spreading and body occlusion, which often lead to more intense, painful reactions; do not use on birthmarks or unusual warts with hair; do not use on lesions with other agents |
|---|
Drug Category: Keratolytics
The agents are used to aid in the removal of keratin in hyperkeratotic skin disorders, including corns, ichthyoses, common warts, flat warts, and other benign verrucae.
| Drug Name | Tretinoin (Avita, Retin-A) |
|---|
| Description | Inhibits microcomedo formation and eliminates lesions. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.
Begin with lowest tretinoin formulation and increase as tolerated. |
|---|
| Adult Dose | Apply hs or qod; decrease frequency of application if irritation develops |
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| Pediatric Dose | <12 years: Not established
>12 years: Apply as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Toxicity increases with coadministration of benzoyl peroxide, salicylic acid, and resorcinol; avoid topical sulfur, resorcinol, salicylic acid, other keratolytics, abrasives, astringents, spices, and lime |
|---|
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Photosensitivity may occur with excessive sunlight exposure; caution in eczema; do not apply to mucous membranes, mouth, or angles of nose |
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| Drug Name | Trichloroacetic acid (Tri-Chlor) |
|---|
| Description | Cauterizes skin, keratin, and other tissues. Although caustic, causes less local irritation and systemic toxicity than other medications in the same class. Response often is incomplete, and recurrence is frequent.
Must be applied by physician in office setting. |
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| Adult Dose | Paint on lesions, avoiding uninvolved skin; can be used in anal areas; repeat q 1-2 wk |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity; not for use on premalignant or malignant lesions |
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| Interactions | None reported |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | External use only; restrict use to treatment areas only |
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| Drug Name | Silver nitrate (AgNO3) |
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| Description | Second-line therapy after failure with first-line agents. Coagulates cellular protein and removes granulation tissue.
Must be applied by physician in office setting. |
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| Adult Dose | Apply to lesion for approximately 5 d |
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| Pediatric Dose | Apply as in adults |
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| Contraindications | Documented hypersensitivity; broken skin; cuts |
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| Interactions | Decreases effects of sulfacetamide preparations |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Not for internal use |
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Drug Category: Immune response modifiers, systemic
These are second-line agents for use in immunocompromised children.
| Drug Name | Interferon alfa 2a and 2b (Roferon-A [alfa-2a], Intron A [alfa-2b]) |
|---|
| Description | Protein product manufactured by recombinant DNA technology. Mechanism of antitumor activity is not understood clearly; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles. |
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| Adult Dose | 1 million U (10 million U/mL) SC per lesion 3 times qwk qod for 3 wk; inject intralesionally, preferably using a 25- to 30-gauge needle; as many as 5 lesions can be treated at once |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Theophylline may increase toxicity; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Caution in severe hepatic or renal insufficiencies, seizure disorders, multiple sclerosis, or compromised CNS |
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Drug Category: Herbal formulations
These agents are over-the-counter, herbal alternatives.
Warning: Herbal formulations are not regulated by the FDA.
| Drug Name | Australian lemon myrtle (Backhousia citriodora) |
|---|
| Description | 10% solution of essential oil of Australian lemon myrtle. |
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| Adult Dose | Apply topically to lesions qd |
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| Pediatric Dose | Apply as in adults |
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| Contraindications | None documented, but presumed allergy to Australian lemon myrtle is a contraindication |
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| Interactions | None documented |
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| Pregnancy | |
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| Precautions | Safety in pregnancy not tested |
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Further Outpatient Care
- Repeat examination is recommended 2-4 weeks after treatment.
- Re-treatment often is necessary.
- Consider combination therapy in patients whose lesions respond poorly.
Deterrence/Prevention
- Discontinue all topical immune suppressants (eg, tacrolimus).
Complications
- Autoinoculation may result from trauma, such as shaving, as well as manipulation of lesions by the patient.
- Cellulitis is an unusual complication of molluscum contagiosum in patients who are HIV infected.15 Secondary infection with Staphylococcus aureus has resulted in abscess formation, whereas Pseudomonas aeruginosa can cause necrotizing cellulitis.
Prognosis
- Spontaneous resolution generally occurs by 18 months in immunocompetent individuals; however, lesions have been reported to persist for as long as 5 years.
- The duration of infection is uncertain in populations with HIV infection and in populations that are otherwise immunocompromised (eg, patients who have undergone renal transplant) because molluscum contagiosum may not be self-limiting in these cases.
Patient Education
Medical/Legal Pitfalls
- Histological or microscopic confirmation of molluscum contagiosum is indicated in immunocompromised patients because several life-threatening opportunistic infections may clinically mimic molluscum contagiosum.
Special Concerns
- Therapeutic approach in children
- Choose conservative therapy first because this is a self-limiting condition, and aggressive treatment risks scarring. Use caution when treating facial lesions.
- When intervention is necessary, prior application of eutectic lidocaine/prilocaine cream (eutectic mixture of local anesthetics [EMLA]) as a local anesthetic before curettage or cryotherapy may be helpful.6
- Studies suggest that cimetidine may hasten resolution of molluscum contagiosum in children, although the FDA has not approved this therapy.
- Therapeutic approach in patients who are infected with HIV
- Confirm molluscum contagiosum histologically based on biopsy or squash preparation to exclude the diagnoses of cutaneous cryptococcosis, aspergillosis, or histoplasmosis.
- Restoration of immune competence using HAART therapy may allow spontaneous resolution of cutaneous molluscum contagiosum. If this cannot be accomplished or if lesions do not improve with restoration of the CD4 cell count, surgical and/or medical therapies may be used.
- The combination of an aggressive surgical approach with use of 1 or more topical agents is usually necessary in severely immunosuppressed individuals.
- Intralesional IFN-alfa has been reported to be effective in patients who are infected with HIV, although this is not FDA approved.
- The use of topical imiquimod cream therapy has been described for the treatment of chronic molluscum contagiosum in a patient with advanced HIV disease; however, this is not FDA approved.7
- Although no controlled studies exist, radiation therapy has been used to treat molluscum contagiosum in individuals infected with HIV.
| Media file 1:
Presented here are the classic umbilicated papules of molluscum contagiosum (MC) lesions on the cheek of a child. Facial lesions occur frequently in children, although lesions generally are few. |
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| Media file 2:
Molluscum contagiosum (MC) rarely occurs on the face in an adult unless the patient is infected with HIV. When MC occurs in individuals infected with HIV, facial lesions are common and frequently numerous. |
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Media type: Photo
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| Media file 3:
Molluscum contagiosum (MC) lesions in individuals infected with HIV may number in the hundreds. In addition, they may become quite large and prominent. |
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Media type: Photo
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| Media file 4:
This low-power view of a molluscum contagiosum (MC) lesion shows the classic cup-shaped invagination of the epidermis into dermis. The Henderson-Paterson bodies are identified readily and stain purple-to-red in this image. |
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Media type: Photo
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| Media file 5:
This is a medium-power view of a molluscum contagiosum (MC) lesion (see Image 4). Magnification allows better demonstration of the intracytoplasmic molluscum bodies (staining purple-pink) within the keratinocytes. |
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Media type: Photo
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| Media file 6:
This molluscum contagiosum body is an intracytoplasmic inclusion body. Notice in the image that the keratinocyte nuclei are displaced to the periphery of the cell and the intracytoplasmic inclusions have a granular quality. |
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Media type: Photo
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Molluscum Contagiosum excerpt Article Last Updated: Apr 1, 2008
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