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Molluscum Contagiosum

Simeon Lauer, MD; Samuel Gelnick, MD

Reviewed by Edward J. Wladis, MD, FACS on March 24, 2020

Establishing the diagnosis

Etiology

    • Pox Virus infection
    • Moderate to heavy T-lymphocyte infiltration in the epidermis.
    • No T-lymphocytes found in the central area (Charteris, 1995)
    • Molluscum bodies stain with anti-CD3 antibody (Charteris, 1995)

Epidemiology

    • Common in Children
    • In a study of 696 patients with molluscum at all body sites (Berger, 2012), the gender distribution was even (336 boys, 360 girls).
      • Mean age at presentation was 5.5 years (7 months-17 years).
    • Transmitted through direct person to person contact
    • Can also be transmitted through towels, sheets, etc. (Schaffer, 2016)

History

    • Lesions usually multiple, spread throughout the body
    • Appear 2-6 weeks after exposure
    • May be itchy or sore
    • No particular area of predilection – face, neck, arms, legs, abdomen, and genital area
    • Periocular lesions common
    • Can develop along the lid margin
    • Can be single lesion or limited number
    • Can develop and resolve sequentially
      • Do not arise and resolve at once

Clinical features

    • Small, raised, flesh-colored, dimple or pit in the center.
    • Often have a pearly appearance.
    • Smooth and firm.
    • May be red and/or swollen
    • May be single or in groups.
    • Can appear on the bulbar conjunctiva (Ringeisen, 2016)  
    • In the study by Berger (2012), lesions were limited to one region in 213 of 696 patients (30%)
    • Rarely found on palms or soles.

Laboratory testing

    • Can confirm diagnosis by biopsy
    • Intracytoplasmic inclusion bodies

Risk factors

  • In the study by Berger (2012), only seven children had potential immune deficiency (IgA deficiency, treatment with colchicine, prednisone, cyclosporine, Mediterranean Fever).
    • 37% (259 of 696) had atopic dermatitis.
    • 20% (n=138) had asthma or allergies.
  • Most often occurs in healthy children (Schaffer, 2016)
  • Linberg (1990) described giant molluscum after splenectomy.
  • Weakened immune system such as HIV (Kohn, 1987) including giant molluscum (Nair, 2016)

Differential diagnosis

    • Trachoma
    • Follicular Conjunctivitis (Mathur, 1995)
    • Basal cell carcinoma
    • Papilloma
    • Chalazion
    • Sebaceous cyst
    • Keratoacanthoma

Patient management

Natural history

    • Resolves without treatment within 12-18 months.
    • Red and swollen with mild purulence ofter sign of impending spontaneous resolution. 
    • Patients with inflammation around lesions are less likely to have new lesions.
      • Treatment of inflammation around lesions with topical steroid cream does not increase likelihood of new lesions (Berger, 2012).
    • Avoid scratching which can cause auto-innoculation.
    • Recurrent conjunctivitis resolves once lid lesions are treated (Mathur, 1960).
    • Delay of diagnosis in patients with conjunctivitis, without evident lid nodules (Charteris, 1995)

Medical therapy

    • Imiquimod 5% cream has been studied in 4 placebo-controlled randomized trials in the United States
      • Treated immune competent children age 2-12 years.
      • Short term cure rates were not statistically significantly different between imiquimod (79 of 544 [14.5%]) and placebo (36 of 306 [11.8%]) (Van der Wouden, 2018).
      • The Center for Disease Control cautions against use of imiquimod to treat molluscum contagiosum (see link). 
    • Oral cimetidine is used for non-facial lesions, not useful for periocular lesions.
    • Podophyllotoxin cream (0.5%) is used for non-facial lesions, not useful for periocular lesions.
    • Cantharidin – blistering anti-wart solution, not useful for periocular lesions.
      • Blisters form within 24 hours
      • Blisters resolve within 4 days
      • Skin heals within a week
    • Low level clinical evidence for alternative treatments most of which cannot be used around the eye (Van der Wouden, 2018)
      • Australian lemon myrtle oil 10%
      • Benzoyl peroxide, 10%, cream
      • Tretinoin 0.05% cream
      • Sodium nitrite, 5%, with salicylic acid, 5% – more effective than salicylic acid alone
      • Iodine plus tea tree oil – more effective than either alone
      • Potassium hydroxide, 10%, solution
      • Calcarea carbonica – homeopathic, pellets, dissolved in liquid and applied to lesion
    • Associated eczematous skin reaction can be treated with corticosteroid ointment

Radiation therapy

    • Not applicable.

Surgery

    • Curettage of soft central contents can facilitate excision.
      • Can access through dimpled opening
      • Can use fine chalazion curette
      • Remove core contents completely
    • Not necessary to encircle lesion or remove cyst wall
    • Leave healthy skin intact
    • Usually no need for suture closure
    • Can gently cauterize to shrink after curettage
    • Among 35 patients treated with excision alone (n=16) versus excision and cautery (n=19), two patients after excision and cautery had recurrence (Charteris, 1995).
      • Retrospective study
      • Cautery not necessary to improve cure rate.
    • Among12 AIDS patients treated with cryotherapy there were no recurrent lesions after 1 year (Bardenstein, 1995).

Management considerations

    • Ointment after excision to facilitate epidermal repair.
    • Immunodeficient patients, such as those with AIDS, are at increased risk of infection (Bardenstein, 1995)

Response to treatment

    • Without infection epidermal healing should be rapid and complete

Disease-related complications

    • Scarring is rare despite epidermal disruption.
    • Primary concern is spread by contact.
    • Encourage early removal to avoid spread.

Historical perspective

    • Pathologic description of elementary bodies in 1911 (Lipschutz).
    • Viral origin established in 1905 (Juliusberg).

References and additional resources

    • Bardenstein DS, Elmets C: Hyperfocal Cryotherapy of Multiple Molluscum Contagiosum Lesions in Patients with the Acquired Immune Deficiency Syndrome. Ophthalmology 1995; 102:1031.
    • Berger EM, Orlow SJ, Patel RR: Experience with molluscum contagiosum and associated inflammatory reactions in the pediatric practice. The bump that rashes. Arch Dermatol 2012; 148:1257.
    • Charteris DG, Bonshek RE, Tullo AB: Ophthalmic Molluscum Contagiosum: clinical and immunopathological features. Br J Opthalmol 1995; 79:476.
    • Juliusberg M:  Zur Kenntnis des Virus des Molluscum contagiosum des Menschen, Deutsche med Wchnschr 1905; 31:1598.
    • Kohn SR: Molluscum contagiosum in patients with acquired immunodeficiency syndrome. Arch Ophthalmol 1987; 105:458.
    • Linberg JV, Blaylock WK: Giant molluscum contagiosum following splenectomy. Arch Ophthalmol 1990; 108:1076.
    • Lipschütz B: Weitere Beiträge zur Kenntnis des Molluscum contagiosum. Arch f Dermat. u Syph 1911; 107:387.
    • Mathur SP: Ocular Complications in Molluscum Contagiosum. Br J Ophthalmol 1960; 44:572.
    • Nair AG, Desai RJ, Gopinathan I: Giant eyelid molluscum contagiosum in a child with AIDS. Ophthalmology 2016; 123:1925.
    • RIngeisen AL, Raven ML, Barney NP: Bulbar conjunctival molluscum contagiosum. Ophthalmology 2016; 123:294.
    • Schaffer JV, Berger EM: Molluscum Contagiosum. JAMA Dermatol 2016; 152:1072.
    • Van der Wouden JC, Koning S, Katz KA: Interventions for nongenital molluscum contagiosum in persons without immune deficiency. JAMA Dermatol 2018; 154:203.  
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