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Ophthalmology > INFECTIOUS DISEASE
Molluscum Contagiosum
Article Last Updated: Apr 10, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Mounir Bashour is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Editors: Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
MC, viral infection, toxic keratoconjunctivitis
Background
Molluscum contagiosum (MC) is a common, self-limited viral infection of the skin. Although usually of minor importance clinically, when located around the eye, it can incite a toxic keratoconjunctivitis.
Pathophysiology
MC is an inflammatory tumor caused by a poxvirus. Lesions located in the eyelid margin may cause an associated conjunctivitis, and lesions frequently cause keratitis. Often, a small umbilicated tumor, sometimes partially hidden in the eyelashes, is not recognized; antibiotic and corticosteroid eye drops fail to cure the associated conjunctivitis and the patient seeks another ophthalmologist who provides an immediate and dramatic cure by simple excision or curettement of the lesion.
Frequency
United States
Reported data for 1969-1983 by the National Disease and Therapeutic Index Survey, which compiles information about patterns of disease in office-based practices in the continental United States, showed an increase in the number of patient visits for MC. Prevalence of MC in patients with HIV may be as high as 5-18%. The severity of MC is inversely related to the CD4 T-lymphocyte count.
International
MC is common in the tropics and subtropics probably due to the increased desquamation associated with hydration. Childhood MC is common in Papua New Guinea, Fiji, and certain parts of Africa. Epidemiological studies suggest that transmission may be related to poor hygiene and climatic factors (eg, warmth, humidity).
In England and Wales, the incidence has increased from 1971-1978 in sexually transmitted disease (STD) clinics from 1.43 cases per 100,000 to 11 cases per 100,000.
Race
All races are affected.
Sex
MC affects both sexes equally; however, in STD clinics in England and Wales from 1971-1978, slightly more than twice as many men as women were diagnosed with MC.
Age
Although MC can occur at any age, population surveys conducted in Papua New Guinea and Fiji have found the peak incidence of the disease is among children younger than 5 years, with a prevalence of approximately 25%. The range of ages in the West Sepik District of New Guinea was 3 months to 57 years.
History
- In children, this condition is quite common, and a detailed history is not important, except to ask if any siblings or friends have the same condition.
- In adults, it is important to ask for a history of HIV, sexual history, immune status, and symptoms of other opportunistic infections.
- Most patients are asymptomatic; some patients complain of pruritus, tenderness, and pain. Some patients develop eczema around lesions (10% in a series of 95 and 200 cases by Block).1 The incubation period ranges from weeks to months (14-50 d). If patients have eczema or other diseases altering skin barrier function, molluscum may spread more rapidly in affected areas.
Physical
A person who contracts MC will notice the appearance of firm, doughnut-shaped bumps, which are about one sixteenth inch in diameter. The bumps have a sunken center containing a whitish, waxy substance. When this condition is transmitted sexually, these bumps frequently are found on the genitals, thighs, and buttocks. The bumps remain for months and then disappear. It is important to check these areas.
- Skin (primary lesion)
- Firm, smooth, umbilicated papules, usually 2-6 mm in diameter (range 1-15 mm) may be present in groups or widely disseminated on skin and mucosal surfaces.
- Lesions greater than 15 mm have been described, particularly in patients with AIDS.
- The lesions can be flesh-colored, white, translucent, or even yellow in color.
- The number of lesions varies from 1-20, up to hundreds in some reports.
- Some lesions do become confluent to form a plaque.
- Lesions generally are self-limited, but they can persist for several years.
- Skin (distribution)
- Children - Mainly on trunk and extremities
- Adults - Often located on lower abdominal wall, inner thighs, pubic area, and genitalia
- Although rarely found in the mouth or on palms and soles, cases of MC involving oral mucosa, including lips, buccal mucosa, hard palate, retromolar pad, and tongue, have been reported.
- Immunocompromised conditions - In some conditions (eg, sarcoidosis, lymphocytic leukemia, congenital immunodeficiency, selective immunoglobulin M [IgM] deficiency, thymoma, treatment with prednisone and methotrexate, AIDS, malignancy, atopic dermatitis), multiple widespread, persistent, disfiguring lesions can occur, especially on the face and possibly involving the neck and trunk.
Causes
- Direct virus transmission is an important means of spread and is responsible for outbreaks traced to community swimming pools, Turkish baths, and gymnasiums. While spread within families does occur, it is not common. Although most often an infection of children, MC can be transmitted sexually and has been transmitted by tattooing in adults.
- Virus
- The causative virus for MC can be obtained in abundance but has never been able to be grown outside the human host. It is a member of the poxvirus family (which contains the largest of the vertebrate viruses) and measures 300 by 250 micrometers.
- Two subtypes are identified by different cleavage patterns. Molluscum contagiosum virus (MCV) type I exhibits 13 out of the 14 isolated cleavage patterns that are similar. MCV type II exhibits a distinct cleavage pattern from a vaginal isolate. The biologic and clinical significance of these 14 isolates is not known.
Basal Cell Carcinoma, Eyelid
Conjunctivitis, Viral
Juvenile Xanthogranuloma
Keratitis, Herpes Simplex
Ocular Manifestations of HIV
Papilloma, Eyelid
Other Problems to be Considered
Childhood blepharitis
Chronic follicular conjunctivitis
Toxic follicular conjunctivitis
Zoster
Chickenpox
Ulcerative blepharitis with keratitis due to staphylococcal infection
Dermatitis herpetiformis
Fibrous papule of the face
Juvenile xanthogranuloma (nevoxanthoendothelioma)
Keratoacanthoma
Lichen planus
Milia
Spitz nevus
Warts (nongenital)
Histiocytoma
Nevus (intradermal)
Varicella
In patients with AIDS, cutaneous cryptococcus presenting as molluscumlike eruptions has been reported.
Lab Studies
- Diagnosis generally is made on clinical grounds based on the appearance of the lesions. Identification of characteristic intracytoplasmic inclusion bodies in histological or cytological preparations by hematoxylin and eosin (H&E) staining of biopsy sections.
- Serum antibodies have been measured by complement fixation, tissue culture neutralization, fluorescent antibody, and gel agar diffusion techniques; however, they are not well standardized.
- Smears from scrapings of lesions stained by Papanicolaou or Wright, Giemsa, or Gram reveal inclusion bodies.
- Antigen of MCV may be identified by fluorescent antibody technique.
Imaging Studies
- Electron micrographs of fixed material from a papule are taken.
Procedures
- Biopsy is performed if diagnosis is uncertain.
- Patients who are sexually active also may have other concomitant venereal diseases, such as syphilis and gonorrhea, so their partners should be examined to prevent reinoculation.
Histologic Findings
Lesions of MC often affect the periorbital and lid skin as 1- to 3-mm dome-shaped, waxy, pearly white papules with a small central dell or umbilication. This large poxvirus multiplies in the cytoplasm, and, histologically, homogeneous purple intracytoplasmic inclusion bodies (molluscum bodies) are seen in an acanthotic epidermis.
MC produces eosinophilic cytoplasmic inclusions (Henderson-Patterson inclusion), especially from expressed lesions. These inclusions are best seen with H&E stain. The eosinophilic cytoplasmic inclusions are in contrast to the intranuclear eosinophilic inclusions (Lipschutz inclusions) found in herpes simplex virus (HSV) and cytomegalovirus (CMV) infections. These eosinophilic Henderson-Patterson bodies become more basophilic in the higher granular and horny layers as they increase in size.
Medical Care
MC generally is self-limited and heals after several months or years. Any one lesion is present for about 2 months. To prevent autoinoculation or transmission to close contacts, therapy may be beneficial. The common goal of the different treatment methods is the destruction of the lesions. Controlled studies have not been completed with the various treatments. Commonly used treatments are not approved by the US Food and Drug Administration (FDA). - Topical applications
- Cantharidin - A single application may need to be repeated once or twice every 3-4 weeks.
- Tretinoin - Cream 0.1% or gel 0.025% applied daily
- Podophyllin
- Trichloracetic acid
- Tincture of iodine
- Silver nitrate or phenol
- Potassium hydroxide (KOH)2
- Cryotherapy with liquid nitrogen - One of the popular treatment modalities
- Systemic agents
- Griseofulvin
- Methisazone (1-methylisatin 2-thiosemicarbazone)
- Cimetidine
- In immunocompromised patients, improvement of lesions was seen in individual cases with the use of ritonavir, cidofovir (intravenous and topical), AZT, intralesional interferon alpha, and topical injections of streptococcal antigen OK-432.
Surgical Care
Curettage followed by light electrodesiccation, cryotherapy, or application of a caustic agent to cauterize bleeding points has been shown to be an effective treatment both in children and in adults. The topical anesthetic cream eutectic mixture of local anesthetics (EMLA) can be applied under occlusion an hour before curettage to decrease the discomfort associated with the procedure. Caution should be exercised if considering cryotherapy in darkly pigmented people because there is a high risk of depigmentation, which may be permanent. Hyperfocal cryotherapy with topical anesthesia was the best therapy for patients with HIV with molluscum.
Currently, the best therapy for all patients with multiple lesions may be pulsed dye laser (585 nm). A recent study showed "in the treated group, 70.5% of lesions healed after the first treatment; the remaining 10.6% after the second treatment (2 weeks later). The overall cure rate was significantly different from the control group (p< 0.01). The therapy was also well tolerated. Only mild transient hypopigmentation and erythema were observed. None encountered infectious events."3
Consultations
If many severe lesions are seen, especially if they are nonresponsive to therapy, consider an infectious disease consult to rule out the possibility of HIV.
Activity
Since MC is known to spread by direct contact, patients need to be educated regarding the disease.
The goal of pharmacotherapy is to reduce morbidity and to prevent complications.
Drug Category: Vesicants
Cause cornified epithelium to swell, soften, macerate, and then desquamate.
| Drug Name | Cantharidin (Verr-Canth) |
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| Description | Vesicant obtained from blister beetle. Effectiveness against warts may result from exfoliation. Lytic action does not affect basal layer and has minimal effect on the corium. Scarring does not occur. Benefits of removing blister include prevention of progression to ring wart and prevention of recurrence. |
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| Adult Dose | Allow liquid to dry over wart; cover with occlusive tape (eg, Blenderm); remove tape after 24 h (remove earlier if there is significant discomfort); in 2-3 d remove blister under local anesthesia; snip off near base or curette |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity; diabetes; impaired peripheral circulation; do not use on eyes, mucous membranes, anogenital or intertriginous areas, moles, birthmarks, or unusual warts with hair; do not use on lesions with other agents or if surrounding tissue 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 | Apply only in office; avoid touching normal skin |
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| Drug Name | Podophyllin (Podo-Ben 25, Podocon-25, Podofin) |
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| Description | Arrests mitosis in metaphase; active agent is podophyllotoxin; type of podophyllum resin used determines strength. American podophyllum contains one fourth the amount of Indian source. Because podophyllin is a powerful caustic and severe irritant, it is recommended that the first application be left in contact for only a short time (30-40 min) to determine patient's sensitivity. To avoid systemic absorption, time of contact should be minimum time necessary to produce the desired result (1-4 h, depending on condition of lesion and of patient), the physician's experience, and technique. Large areas or numerous warts should not be treated at once. |
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| Adult Dose | Thoroughly cleanse affected area; use supplied applicator to apply podophyllin sparingly to lesion; avoid contact with healthy tissue; allow to dry thoroughly; only intact (no bleeding) lesions should be treated
After treatment time has elapsed, remove dried podophyllin thoroughly with alcohol or soap and water |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity; diabetes; impaired peripheral circulation; avoid use on mucous membranes, eyes, bleeding warts, moles, birthmarks, or unusual warts with hair |
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| Interactions | None reported |
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| Pregnancy | X - Contraindicated; benefit does not outweigh risk
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| Precautions | Do not use if wart or surrounding tissue is inflamed or irritated; do not use on bleeding warts, moles, birthmarks, or unusual warts with hair growing from them; topical use has been known to result in paresthesia, polyneuritis, paralytic ileus, pyrexia, leukopenia, thrombocytopenia, coma, and death |
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Drug Category: Retinoids
Decrease cohesiveness of abnormal hyperproliferative keratinocytes and may reduce potential for malignant degeneration. Modulate keratinocyte differentiation. Have been shown to reduce risk of skin cancer formation in renal transplant patients.
| Drug Name | Tretinoin (Avita, Retin-A) |
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| Description | Although exact mode of action of tretinoin is unknown, current evidence suggests that topical tretinoin decreases cohesiveness of follicular epithelial cells with decreased microcomedo formation. Additionally, tretinoin stimulates mitotic activity and increases turnover of follicular epithelial cells, causing extrusion of the comedones. |
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| Adult Dose | Apply 0.1% cream, liquid, or gel qd for 3-6 wk |
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| Pediatric Dose | Not established |
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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 |
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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 | Photosensitivity may occur with excessive sunlight exposure; caution in eczema; do not apply to mucous membranes, mouth, and angles of nose |
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Drug Category: Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
| Drug Name | Griseofulvin (Fulvicin P/G, Grifulvin V) |
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| Description | Derived from a species of Penicillium. Binds to keratin precursor cells. Keratin is gradually replaced by noninfected tissue, which is highly resistant to fungal invasions. |
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| Adult Dose | 500 mg PO qd |
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| Pediatric Dose | 30-50 lb: 125-250 mg PO qd
>50 lb: 250-500 mg PO qd
Alternatively, 5 mg/lb PO |
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| Contraindications | Documented hypersensitivity; porphyria; hepatocellular failure |
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| Interactions | May decrease hypoprothrombinemic activity of warfarin; contraceptives may lose their effectiveness; may reduce effects of cyclosporine; may decrease serum salicylate concentrations; barbiturates may decrease serum griseofulvin levels |
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| Pregnancy | X - Contraindicated; benefit does not outweigh risk
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| Precautions | On prolonged therapy, observe patients closely; monitor renal, hepatic, and hematopoietic function regularly; lupuslike syndromes or exacerbation of lupus erythematosus may occur; photosensitivity also may occur and, thus, patients should take protective measures against exposure to ultraviolet light or sunlight |
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Deterrence/Prevention
- Since the disease is spread by direct contact, patients should be educated to avoid skin-to-skin contact with others to prevent transmission.
- Patients should avoid scratching to prevent autoinoculation.
Complications
- Complications include irritation, inflammation, and secondary infections. Lesions on eyelids may be associated with follicular or papillary conjunctivitis. Recurrence is the main complication.
- Risk of pigmentary changes with cryotherapy exists.
Prognosis
- Prognosis is excellent, except in the case of patients with HIV in which the lesions are resistant to treatment.
Patient Education
Medical/Legal Pitfalls
- Child abuse: This condition is not suggestive for it, unless other clues are present.
Special Concerns
- HIV/AIDS
- MC is the most common infection of the eyelids in patients infected with HIV. The responsible DNA virus is ubiquitous throughout the world and commonly infects healthy adults and children, causing small nodular lesions on the skin. In the general population, lesions involving the eyelid margins characteristically cause a chronic follicular conjunctivitis.
- Patients infected with HIV tend to have more lesions, and they are much larger; it is common to see numerous lesions covering the face and eyelids. However, even large eyelid margin lesions do not tend to cause follicular conjunctivitis probably because of the patient's suppressed cellular immunity.
- Lesions usually are well tolerated, but very large, bulky lesions or lesions involving the inner portion of the eyelid margin may be uncomfortable; these lesions will shrink with cryotherapy, but it is difficult to eradicate lesions completely.
- Wiskott-Aldrich syndrome
- Wiskott-Aldrich syndrome is a sex-linked congenital immunodeficiency disease with both humoral and cellular disorders. It is characterized by deficiencies in IgM and elevations in immunoglobulin A (IgA) and immunoglobulin E (IgE). Patients develop eczema, thrombocytopenia, and recurrent infections, including laryngitis, bronchitis, gastroenteritis, pyoderma, and otitis.
- Pyogenic bacteria most frequently cause infection, but patients also are susceptible to a variety of fungi, viruses, and protozoa.
- Kaposi varicelliform eruption, a disseminated form of cutaneous HSV infection, may occur.
- Patients will be thrombocytopenic at birth. Infections become apparent by 6 months, and susceptibility to infection increases with age.
- Death frequently occurs in the first decade of life because of bleeding or infection.
- Several ophthalmic disorders are associated with Wiskott-Aldrich syndrome. Patients may develop ocular surface disease, including eczema on the eyelids, blepharoconjunctivitis, and pannus formation associated with MC lesions, and recurrent, sometimes bilateral, HSV keratitis.
- In many reported cases, the specific pathogens responsible for conjunctivitis are not mentioned. Marginal infiltrates and episcleritis also have been reported; these findings have been attributed to an altered immune response to infectious agents. Papilledema and oculomotor disorders have been attributed to intracranial lesions. Hemorrhage both intraocularly and on the ocular surface may occur.
- In a review of reported cases, Podos and associates found that ophthalmic disease (excluding eczema of the eyelids) had been mentioned in 18 of 80 cases.4 Fifteen patients had infections, and 5 patients had bleeding of the conjunctiva, periorbital tissues, retina, or into the vitreous. Excision of MC lesions by expression and curettage should be performed with caution in these patients because of the increased risk of hemorrhage.
- Block SH. Eczema and molluscum contagiosum. JAMA. Jan 8 1973;223(2):195. [Medline].
- Mahajan BB, Pall A, Gupta RR. Topical 20% KOH--an effective therapeutic modality for moluscum contagiosum in children. Indian J Dermatol Venereol Leprol. Mar-Apr 2003;69(2):175-7. [Medline].
- Chatproedprai S, Suwannakarn K, Wananukul S, Theamboonlers A, Poovorawan Y. Efficacy of pulsed dyed laser (585 nm) in the treatment of molluscum contagiosum subtype 1. Southeast Asian J Trop Med Public Health. Sep 2007;38(5):849-54. [Medline].
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- Bardenstein DS, Elmets C. Hyperfocal cryotherapy of multiple Molluscum contagiosum lesions in patients with the acquired immune deficiency syndrome. Ophthalmology. Jul 1995;102(7):1031-4. [Medline].
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Molluscum Contagiosum excerpt Article Last Updated: Apr 10, 2008
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