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Molluscum Contagiosum

- Cantharidin 0.7 " 0.9% solution: In office application to lesions, cover with dressing; wash off in 2 to 6 hours or sooner if blistering. Repeat treatment every 2 to 4 weeks until lesions resolve (1)[B],(2,3)[C]. - Not commercially available in the United States but may be obtained from Canada - Adverse effects: blistering, erythema, pain, pruritus - Precautions: Do not use on face or on genital mucosa.

- For immunocompromised patients with refractory lesions, consider - Starting or maximizing HAART therapy in patients with HIV/AIDS (4)[C] - Cidofovir - 3% cream applied to lesions once daily, 5 days/week for 8 weeks (4)[C] - 1% cream applied to lesions once daily, 5 days/week for 2 weeks, repeat in 1 month, if necessary (4)[C] - Adverse effects with topical use: erythema, pain, pruritus, erosions - 3 to 5 mg/kg IV weekly for 1 to 2 weeks, followed by IV infusions every other week, until clinical clearance or up to 9 infusions (5)[C] - Adverse effects with IV use: nephrotoxicity, neutropenia - Monitoring with IV use: renal function and complete blood counts prior to and 24 to 48 hours after infusions - Precaution: Must coadminister oral probenecid and provide IV hydration with each IV infusion; refer to cidofovir manufacturer 's recommendations on dosing.

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  • Infants <3 months, consider vertical transmission
  • Children: fever, >50 lesions, limited response to therapy, consider immunodeficiency
  • Children: anogenital lesions, consider autoinoculation/possible sexual abuse

DIFFERENTIAL DIAGNOSIS

  • AIDS patients: cryptococcus, penicilliosis, histoplasmosis, coccidioidomycosis
  • Basal cell carcinoma
  • Benign appendageal tumors: syringomas, hydrocystomas, ectopic sebaceous glands
  • Condyloma acuminatum
  • Dermatofibroma
  • Eyelid: abscess, chalazion, foreign-body granuloma
  • Folliculitis/furunculosis
  • Keratoacanthoma
  • Oral squamous cell carcinoma
  • Trichoepithelioma
  • Verruca vulgaris
  • Warty dyskeratoma

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Virus cannot be cultured.
  • Culture lesion if concern is secondary infection
  • Sexual transmission: Test for other sexually transmitted infections, including HIV.
  • Microscopy: scrape lesionCore material has characteristic Henderson-Paterson intracytoplasmic viral inclusion bodies.Crush prep with 10% potassium hydroxide will show characteristic inclusion bodies as well.Alternatively, hematoxylin-eosin-stained formalin-fixed tissue shows same confirmatory features.

Diagnostic Procedures/Other

Clinical; using magnifying lens

Tests Interpretation

Molluscum cytoplasmic inclusion bodies within keratinocytes

TREATMENT

GENERAL MEASURES

  • In healthy patients, molluscum contagiosum is generally self-limited and heals spontaneously.
  • No single intervention is shown to be convincingly more effective than any other in treating molluscum contagiosum (1)[B].
  • No treatment is FDA-approved for treatment of molluscum contagiosum.
  • Three categories of treatment: destructive, immune-enhancing, and antiviral

MEDICATION

First Line

  • Cantharidin 0.7 " 0.9% solution: In office application to lesions, cover with dressing; wash off in 2 to 6 hours or sooner if blistering. Repeat treatment every 2 to 4 weeks until lesions resolve (1)[B],(2,3)[C].Not commercially available in the United States but may be obtained from CanadaAdverse effects: blistering, erythema, pain, pruritusPrecautions: Do not use on face or on genital mucosa.

Second Line

  • Benzoyl peroxide 10% cream: Apply to each lesion twice daily for 4 weeks (1)[B].InexpensiveAdverse effects: mild dermatitis
  • For immunocompromised patients with refractory lesions, considerStarting or maximizing HAART therapy in patients with HIV/AIDS (4)[C]Cidofovir3% cream applied to lesions once daily, 5 days/week for 8 weeks (4)[C]1% cream applied to lesions once daily, 5 days/week for 2 weeks, repeat in 1 month, if necessary (4)[C]Adverse effects with topical use: erythema, pain, pruritus, erosions3 to 5 mg/kg IV weekly for 1 to 2 weeks, followed by IV infusions every other week, until clinical clearance or up to 9 infusions (5)[C]Adverse effects with IV use: nephrotoxicity, neutropeniaMonitoring with IV use: renal function and complete blood counts prior to and 24 to 48 hours after infusionsPrecaution: Must coadminister oral probenecid and provide IV hydration with each IV infusion; refer to cidofovir manufacturer 's recommendations on dosing.Ingenol mebutate 0.015% gel applied to lesions once daily for 3 days; may repeat once if needed (6)[C] very expensiveAdverse effects: erythema, irritation

SURGERY/OTHER PROCEDURES

Considered first line

  • Cryotherapy: 5 to 10 seconds with 1- to 2-mm margins; repeat every 3 to 4 weeks as needed until lesions disappear (7)[B].Adverse effects: erythema, edema, pain, blisteringContraindications: cryoglobulinemia, Raynaud disease
  • Curettage under local or topical anesthesia (1)[A],( 8)[B]Adverse effects: pain, scarring

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Australian lemon myrtle oil: Apply 10% solution once daily for 21 days (9)[B].
  • Potassium hydroxide 5 " 10% solution: Apply 1 to 2 times a day until the lesions disappeared completely (10)[B].

Pediatric Considerations

Pregnancy Considerations

Safe in pregnancy: curettage, cryotherapy, incision, and expression

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Depends on type of treatment

PATIENT EDUCATION

  • Cover lesions to prevent spread.
  • Avoid scratching.
  • Avoid contact sports.
  • Avoid sharing towels and clothing.
  • Avoid sexual activity when lesions present.

PROGNOSIS

  • Immunocompetent: self-limited, resolves in 3 to 12 months (range: 2 months to 4 years)
  • Immunocompromised: lesions difficult to treat; may persist for years

COMPLICATIONS

  • Secondary infection
  • Scarring, hyper-/hypopigmentation

REFERENCES

11 van der Wouden JC, Menke J, Gajadin S, et al. Interventions for cutaneous molluscum contagiosum. Cochrane Database Syst Rev. 2006;(2):CD004767.22 Moye V, Cathcart S, Burkhart CN, et al. Beetle juice: a guide for the use of cantharidin in the treatment of molluscum contagiosum. Dermatol Ther. 2013;26(6):445 " 451.33 Silverberg NB, Sidbury R, Mancini AJ. Childhood molluscum contagiosum: experience with cantharidin therapy in 300 patients. J Am Acad Dermatol. 2000;43(3):503 " 507.44 Chen X, Anstey AV, Bugert JJ. Molluscum contagiosum virus infection. Lancet Infect Dis. 2013;13(10):877 " 888.55 Erikson C, Driscoll M, Gaspari A. Efficacy of intravenous cidofovir in the treatment of giant molluscum contagiosum in a patient with human immunodeficiency virus. Arch Dermatol. 2011;147(6):652 " 654.66 Javed S, Tyring SK. Treatment of molluscum contagiosum with ingenol mebutate. J Am Acad Dermatol. 2014;70(5):e105.77 Al-Mutairi N, Al-Doukhi A, Al-Farag S, et al. Comparative study on the efficacy, safety, and acceptability of imiquimod 5% cream versus cryotherapy for molluscum contagiosum in children. Pediatr Dermatol. 2010;27(4):388 " 394.88 Hanna D, Hatami A, Powell J, et al. A prospective randomized trial comparing the efficacy and adverse effects of four recognized treatments of molluscum contagiosum in children. Pediatr Dermatol. 2006;23(6):574 " 579.99 Burke BE, Baillie JE, Olson RD. Essential oil of Australian lemon myrtle (Backhousia citriodora) in the treatment of molluscum contagiosum in children. Biomed Pharmacother. 2004;58(4):245 " 247.1010 Can B, Topaloglu F, Kavlale M, et al. Treatment of pediatric molluscum contagiosum with 10% potassium hydroxide solution. J Dermatolog Treat. 2014;25(3):246 " 248.

ADDITIONAL READING

  • Brown J, Janniger CK, Schwartz RA, et al. Childhood molluscum contagiosum. Int J Dermatol. 2006;45(2):93 " 99.
  • Dohil MA, Lin P, Lee J, et al. The epidemiology of molluscum contagiosum in children. J Am Acad Dermatol. 2006;54(1):47 " 54.
  • Olsen JR, Gallacher J, Piguet V, et al. Epidemiology of molluscum contagiosum in children: a systematic review. Fam Pract. 2014;31(2):130 " 136.
  • Ting PT, Dytoc MT. Therapy of external anogenital warts and molluscum contagiosum: a literature review. Dermatol Ther. 2004;17(1):68 " 101.

CODES

ICD10

B08.1 Molluscum contagiosum

ICD9

078.0 Molluscum contagiosum

SNOMED

  • 40070004 Molluscum contagiosum infection (disorder)
  • 240467006 Genital molluscum contagiosum
  • 397515005 Molluscum contagiosum blepharoconjunctivitis
  • 314901000 Molluscum contagiosum with eyelid involvement (disorder)

CLINICAL PEARLS

  • Natural resolution is preferred treatment in healthy patients.
  • Reassure parents that lesions will heal naturally and generally resolve without scarring.
  • No specific treatment has been identified as superior to any other.
  • Consider topical corticosteroids for pruritus or associated dermatitis.