Molluscum contagiosum

Molluscum contagiosum is caused by up to four closely related

types of poxvirus, MCV-1 to 4 and their variants. Although
the proportion of infection caused by the various types varies
geographically, throughout the world MCV-1 infections are
most common. In small children virtually all infections are
caused by MCV-1. There is no difference in the anatomic
region of isolation with regard to infecting type (as opposed
to HSV, for example). In patients infected with HIV, however,
MCV-2 causes the majority of infections (60%), suggesting that
HIV infection-associated molluscum does not represent recrudescence
of childhood molluscum.
Infection with MCV is worldwide. Three groups are primarily
affected: young children, sexually active adults, and
immunosuppressed persons, especially those with HIV infection.
Molluscum is most easily transmitted by direct skin-toskin
contact, especially if the skin is wet. Swimming pools
have been associated with infection.
In all forms of infection, the lesions are relatively similar.
Individual lesions are smooth-surfaced, firm, dome-shaped,
pearly papules, averaging 35 mm in diameter (Fig. 19-32).
Giant lesions may be up to 1.5 cm in diameter. A central
umbilication is characteristic. Irritated lesions may become
crusted and even pustular, simulating secondary bacterial
infection. This may precede spontaneous resolution. Lesions



Fig. 19-34 Molluscum contagiosum, child with atopic dermatitis.
that rupture into the dermis may elicit a marked suppurative
inflammatory reaction that resembles an abscess.
The clinical pattern depends on the risk group affected. In
young children the lesions are usually generalized and number
from a few to more than 100. Dermatitis surrounding a lesion
usually heralds the resolution of that lesion. Lesions tend to
be on the face, trunk, and extremities. Genital lesions occurring
as part of a wider distribution occur in 10% of childhood cases.
When molluscum is restricted to the genital area in a child, the
possibility of sexual abuse must be considered.
In adults, molluscum is sexually transmitted and other
STDs may coexist. There are usually fewer than 20 lesions;
these favor the lower abdomen, upper thighs, and the penile
shaft in men (Fig. 19-33). Mucosal involvement is very
uncommon.
Immunosuppression, either systemic T-cell immunosuppression
(usually HIV, but also sarcoidosis and malignancies)
or abnormal cutaneous immunity (as in atopic dermatitis or
topical steroid use), predisposes the individual to infection. In
atopic dermatitis, lesions tend to be confined to dermatitic skin
(Fig. 19-34).
Secondary infection may occur. In addition, in about 10% of
lesions, a surrounding eczematous reaction is present (molluscum
dermatitis). Rarely, erythema annulare centrifugum
may be associated. Lesions on the eyelid margin or conjunctiva
may be associated with a conjunctivitis or keratitis. Rarely, the
molluscum lesions may present as a cutaneous horn (molluscum
contagiosum cornuatum).
Between 10 and 30% of AIDS patients not receiving antiretroviral
therapy have molluscum contagiosum. Virtually all
Fig. 19-33 Molluscum contagiosum of the penis.
Fig. 19-34 Molluscum contagiosum, child with atopic dermatitis.
HIV-infected patients with molluscum contagiosum already
have an AIDS diagnosis and a helper T-cell count of less than
100. In untreated HIV disease, lesions favor the face (especially
the cheeks, neck, and eyelids) and genitalia. They may be few
or numerous, forming confluent plaques. Giant lesions are not
uncommon and may be confused with a basal cell carcinoma.
Involvement of the oral and genital mucosa may occur, virtually
always indicative of advanced AIDS (helper T-cell count
less than 50). Facial disfigurement with numerous lesions can
occur.
Molluscum contagiosum has a characteristic histopathology.
Lesions primarily affect the follicular epithelium. The lesion is
acanthotic and cup-shaped. In the cytoplasm of the prickle
cells, numerous small eosinophilic and later basophilic inclusion
bodies, called molluscum bodies or HendersonPaterson
bodies, are formed. Eventually, their bulk compresses the
nucleus to the side of the cell. In the fully developed lesion
each lobule empties into a central crater. Inflammatory changes
are slight or absent. Characteristic brick-shaped poxvirus particles
are seen on electron microscopy in the epidermis. Latent
infection has not been found, except in untreated AIDS
patients, in whom even normal-appearing skin may contain
viral particles. Molluscum contagiosum virus contains an
IL-18 binding protein gene it apparently acquired from
humans. This blocks the hosts initial effective Th1 immune
response against the virus by reducing local IFN-
production.
The diagnosis is easily established in most instances because
of the distinctive central umbilication of the dome-shaped
lesion. This may be enhanced by light cryotherapy that leaves
the umbilication appearing clear against a white (frozen) background.
For confirmation, express the pasty core of a lesion,
squash it between two microscope slides (or a slide and a cover
glass) and stain it with Wright, Giemsa, or Gram stains. Firm
compression between the slides is required.
Treatment is determined by the clinical setting. In young
immunocompetent children, especially those with numerous
lesions, the most practical course may be not to treat or
to use only topical tretinoin. Aggressive treatment may be
emotionally traumatic and can cause scarring. Spontaneous
resolution is virtually a certainty in this setting, avoiding
these sequelae. Individual lesions last 24 months each;
the duration of infection is about 2 years. Continuous application
of surgical tape to each lesion daily after bathing for
16 weeks led to cure in 90% of children so treated. Topical
cantharidin, applied for 46 h to approximately 20 lesions per
setting, led to resolution in 90% of patients and 8% of patients
improved. This therapy is well tolerated, has a very high
satisfaction rate for patients and their parents, and has rare
complications. If lesions are limited and the child is cooperative,
nicking the lesions with a blade to express the core (with
or without the use of a comedo extractor), light cryotherapy,
application of trichloroacetic acid (35100%), or removal by
curettage are all alternatives. The application of EMLA cream
for 1 h before any painful treatments has made the management
of molluscum in children much easier. Topical 5%
sodium nitrite with 5% salicylic acid cures about 75% of
patients. No controlled trials have confirmed the efficacy of
imiquimod and it cannot be recommended for the treatment
of molluscum.
In adults with genital molluscum, removal by cryotherapy
or curettage is very effective. Neither imiquimod nor podophyllotoxin
has been demonstrated to be effective. In fact, the
failure of these agents to improve genital warts suggests the
diagnosis of genital molluscum contagiosum. Sexual partners
should be examined; screening for other coexistent STDs is
mandatory.
In patients with atopic dermatitis, application of EMLA followed
by curettage or cryotherapy is most practical. Caustic
chemicals should not be used on atopic skin. Topical steroid
application to the area should be reduced to the minimum
strength possible. A brief course of antibiotic therapy should
be considered after initial treatment, since dermatitic skin is
frequently colonized with S. aureus.
In immunosuppressed patients, especially those with AIDS,
management of molluscum can be very difficult. Aggressive
treatment of the HIV infection with HAART, if it leads to
improvement of the helper T-cell count, is predictably associated
with a dramatic resolution of the lesions. This response
is delayed 68 months from the institution of the treatment.
Molluscum occurs frequently in the beard area, so shaving
with a blade razor should be discontinued to prevent its
spread. If lesions are few, curettage or core removal with a
blade and comedo extractor is most effective. EMLA application
may permit treatment without local anesthesia. Cantharone
or 100% trichloroacetic acid may be applied to individual
lesions. Temporary dyspigmentation and slight surface irregularities
may occur. Cryotherapy may be effective but must be
used with caution in persons of pigment. When lesions are
numerous or confluent, treatment of the whole affected area
may be required because of the possibility of latent infection.
Trichloroacetic acid peels above 35% concentration (medium
depth) or daily applications of 5-fluorouracil (5-FU) to the
point of skin erosion may eradicate lesions, at least temporarily.
At times, removal by curette is required. In patients with
HIV infection, continuous application of tretinoin cream once
nightly at the highest concentration tolerated seems to reduce
the rate of appearance of new lesions. Topical 13% cidofovir
application and systemic infusion of this agent have been
reported to lead to dramatic resolution of molluscum in
patients with AIDS.

The curette has long been a standard tool in the dermatologists
surgical management of neoplasm. This round, semisharp
knife is available in sizes from 0.5 to 10 mm, allowing
for the removal of a variety of lesions. Since it is not as sharp
as a scalpel, the curette does not easily cut through normal
skin. Therefore, it is best suited for use on soft or friable lesions,
such as warts, seborrheic and actinic keratoses, the papules of
molluscum contagiosum, or selected basal and squamous cell
carcinomas. The proper selection of lesion, location, and the
size of the curette, combined with the surgeons technique, all
play a role in both the therapeutic and cosmetic outcome.
The skin should be stabilized with the nondominant hand
while the curette is held like a pencil. Curettage should be
performed in a centripetal manner (from the outside in) to
avoid stripping sun-damaged skin and creating a larger
wound. To ensure complete destruction, curettage should be
performed in multiple directions to produce symmetrical
wound margins. A large curette is used for initial debulking,
followed by a smaller curette to remove any residual foci
or extensions. Curettage is complete when the gritty, firm
sensation of normal dermis is felt and slight punctate dermal
bleeding occurs.
Curettage, combined with electrodesiccation (C&E), is
widely used for the treatment of BCC and squamous cell carcinomas
(SCC) (Fig. 37-15). Silverman et al reviewed the cure
rates of primary BCC treated with C&E over a 27-year period
at New York University. The result of the study stratified low-,
middle-, and high-risk anatomic locations and the risk of
recurrence following C&E of primary BCC. Low-risk anatomic
sites (neck, trunk, and four extremities) had a 5-year recurrence
rate of 3.3%. Middle-risk sites (scalp, forehead, pre- and
post-auricular, and malar areas) had an overall recurrence
rate of 12.9%, but this was reduced to 5% when limited to
noninfiltrative carcinomas of less than 1 cm. High-risk sites
(nose, paranasal, nasolabial groove, ear, chin, mandibular,
perioral, periocular areas) had an overall recurrence rate of
17.5%, but a more acceptable 5% recurrence rate was achieved
when treatment was limited to lesions of less than 6 mm.
In addition to size and anatomic location, the histologic
subtype is an important factor in the effectiveness of C&E.
Infiltrative and micronodular BCC are not appropriate for
C&E, while it can be considered a therapeutic option in superficial
and nodular subtypes. SCC in situ may be appropriately
treated with C&E, while in most circumstances invasive SCC
would not typically be amenable to this modality