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ABSTRACT
M
olluscum contagiosum is very com- of the social stigma of visible lesions. No one
mon. In this article we discuss the treatment is uniformly effective.
use of cantharidin as a treatment Treatment options include destructive
option for molluscum contagiosum and give therapies (curettage, cryotherapy, canthari-
detailed information about distribution sources, din, and keratolytics, among others), immu-
how to apply it, and caveats regarding its use. nomodulators (imiquimod, cimetidine, and
Molluscum contagiosum is a common vi- Candida antigen), and antivirals (cidofovir).
ral disease of childhood caused by a poxvirus, In this article we discuss and describe our first-
which presents with small, firm, dome-shaped, line treatment approach for those molluscum
umbilicated papules. It is generally benign and needing treatment — cantharidin.
self-limited, with spontaneous resolution within
6 months to several years. Watchful waiting can Erin F. Mathes, MD, is Pediatric Dermatology
often be an appropriate management strategy; Fellow, Department of Dermatology University of
however, some patients either desire or require California, San Francisco. Ilona J. Frieden, MD, is
treatment. Reasons for actively treating mol- Professor of Dermatology and Pediatrics, Depart-
luscum contagiosum may include alleviation of ments of Dermatology and Pediatrics University of
discomfort and itching (particularly in patients California, San Francisco.
where an eczematous eruption — the so-called Address correspondence to: Erin F. Mathes, MD,
“molluscum eczema” — is seen in association) 1701 Divisadero St., Box 0316, San Francisco, CA
or in patients with ongoing atopic dermatitis 94143-0316; fax 415-353-7850; e-mail mathese@
where more lesions are likely to be present. derm.ucsf.edu.
Other reasons for treatment include limitation Dr. Mathes and Dr. Frieden have disclosed no rel-
of spread to other areas and people, prevention evant financial relationships.
of scarring and superinfection, and elimination doi: 10.3928/00904481-20100223-03
Editor’s note: Each month, this department features a discussion of an unusual diagnosis in genetics, radiology,
or dermatology. A description and images are presented, with the diagnosis and an explanation of how the diagnosis
was determined following. As always, your comments are welcome. E-mail pedann@slackinc.com.
T R E A T M E N T SIDEBAR 1.
or pharmacist for individual patients. Over-the-counter oral analgesics, such as ibuprofen or acetaminophen, may help
with discomfort.
The Food and Drug Administration
Topical petrolatum may help soothe irritated skin. Before applying petrolatum, make sure
(FDA) has included cantharidin in
that the cantharidin has been thoroughly washed off. Liberal petrolatum application to
the proposed list of bulk substances areas with active cantharidin can cause spread of cantharidin and widespread blisters.10
that physicians and pharmacists are If surrounding dermatitis is present, treat it with 1% hydrocortisone ointment
permitted to compound for use in in- (over-the-counter).
dividual patients.5
APPLICATION ring, we (and others) believe the safety tage, is that application of cantharidin
Treating molluscum with canthari- profile is sufficiently favorable to con- is painless. Although pain (typically
din is not technically difficult. Although tinue using it for this purpose.1,3-5,7,8 very minor) may occur several hours
there is a small risk for adverse effects, A major advantage over certain treat- to a day later, children rarely associate
such as excessive blistering and scar- ments, such as cryotherapy and curet- this with their recent doctor visit, and
SIDEBAR 3.
Anticipatory Guidance11
Several hours after application, mild discomfort at the site of application occasionally
occurs. This can be treated by using cool compresses and by administering over-the-
counter analgesics, although, in our experience, this is rarely necessary.
One day after application, a small blister often forms, although, in some cases, only
redness or mild crusting is noted. If the blister is tense and uncomfortable, draining
with a sterilized needle may help diminish pain, although this is also rarely necessary.
Two to 4 days after application, the blister will crust or drain, leaving a superficial ero-
sion. Apply an antibiotic ointment or sterile petrolatum to the eroded area to encour-
age re-epithelialization.
Within 1 week, the area is typically healed, although postinflammatory erythema may
persist for a week or two. In darker skin types, postinflammatory hyper- or hypopig-
mentation may persist, at times for several months.
Scarring is rare. Occasionally, even untreated molluscum leave tiny pitted scars.
are usually willing to have the medica- lation, which combines a higher con- these adverse effects occur in ap-
tion applied on subsequent visits. centration of cantharidin (1%) mixed proximately 6% to 46% of patients,
We disagree with a recent review with podophyllin and salycilic acid, in our experience, the rate is at the
by Silverberg that suggested that can- and has a much greater risk for caus- low end of this range.3,4,8 Temporary
tharidin should not be applied by pedi- ing excessive blistering, scarring, and erythema can occur in up to 37% of
atricians in their offices.9 Pediatricians even chemical cellulitis. patients.4,5 Care should be taken to
and family physicians perform many Cantharidin can only be applied avoid spreading the cantharidin to
procedures that are more complicated in a physician’s office and should unaffected areas or to the eyes. There
than cantharidin application, such as never be dispensed to patients for may be temporary pigment alteration
splinting, venipuncture, lumbar punc- that should resolve without scarring.
ture, intramuscular injection, lacera- Several “helpful hints” to use the
tion repair, and incision and drainage. Cantharidin can only be medication effectively and minimize
In this article, we give detailed instruc- size effects are summarized in Sidebar
tions regarding the use of cantharidin,
applied in a physician’s 2 (see page 125). The first time can-
including sources for purchasing, office and should never be tharidin is used, it is prudent to treat
techniques for application, potential only three or four lesions to assess the
pitfalls and adverse effects, and billing dispense to patients for individual patient’s response. Warn
codes for in-office treatment with this self-application. parents that although the medication is
medication. We believe that with the applied sparingly, there is a 1% to 5%
following information and guidance, chance of a larger blister developing.
cantharidin can become a very useful self-application (see Sidebar 1, page There is controversy regarding wheth-
tool for treating molluscum in the pri- 125, and Figure 1, and Figure 2, er the medication should be washed
mary physician’s office. page 127, for application instruc- off a few hours after application. Some
Cantharidin is commercially avail- tions). Most patients improve after authors recommend this practice, but
able in a 0.7% concentration, in a one or two visits.3,4,8 Complications because cantharidin is dissolved in
collodion base (see Table, page 127, include excessive blistering, pain, collodion, it forms a film upon drying,
for sources). This 0.7% formulation pruritis, and burning (see Figure 3, which is probably not easily removed
is strongly preferred for molluscum page 128, and Figure 4, page 128). with soap and water.7 Follow-up visits
treatment over a more potent formu- Although some authors estimate that to assess efficacy and perform further
TABLE.
Cantharidin
crystals and
608 13th Ave., Council Bluffs,
collodion base
Delasco Cantharidin IA 51501-6401; (800) 831-6273; questions@delasco.com
sold separately
fax: (800) 320-9612
for in-office
compounding
*Cantharidin’s use is limited to in-office treatment by a physician. Please contact the suppliers for ordering requirements.
OTHER CONSIDERATIONS
Another problem that often Figure 2. Application of cantharadin to molluscum.
arises is the presence of so-called
“molluscum eczema,” a dermatitis present. Although the individual treated with a low to mid-potency
virtually identical to atopic derma- molluscum can be treated with can- topical steroid to alleviate it and
titis, which preferentially occurs in tharidin, even in sites of dermati- prevent autoinnoculation with fur-
areas of skin where molluscum are tis, the dermatitis itself should be ther spread of the virus.
CONCLUSIONS
With appropriate precautions and
information provided, we believe
that the use of this medication by
pediatricians and other primary care Figure 5. Verruca vulgaris ring wart from cantharadin application.
providers is safe and well within 2. Wolverton SE. Comprehensive Derma- views 2006, Issue 2. Art. No.: CD004767.
tologic Drug Therapy. Philadelphia, PA: DOI:10.1002/14651858.CD004767.pub2.
the technical expertise of any well-
Saunders; 2001;532. 7. Coloe J, Morrell DS. Cantharadin use
trained practitioner. 3. Hanna D, Hatami A, Powell J, et al. A among pediatric dermatologists in the treat-
Finally, although cantharidin is an prospective randomized trial comparing ment of molluscum contagiosum. Pediatr
excellent treatment option for mollus- the efficacy and adverse effects of four Dermatol. 2009;26(4):405-408.
recognized treatments of molluscum con- 8. Cathcart S, Coloe J, Morrell DS. Parental
cum, we do not recommend its use for tagiosum in children. Pediatr Dermatol. satisfaction, efficacy, and adverse events
common warts. For unknown reasons, 2006;23(6):574-579. in 54 patients treated with cantharidin for
the noninflammatory blisters caused 4. Silverberg NB, Sidbury R, Mancini AJ. molluscum contagiosum infection. Clin
Childhood molluscum contagiosum: Pediatr (Phila). 2008;48(2):161-165.
by the medication can result in so- experience with cantharidin therapy 9. Silverberg NB. A practical approach to
called “ring warts” (see Figure 5, page in 300 patients. J Am Acad Dermatol. molluscum contagiosum. Part 2. Contem-
128), leading to wart spread, rather 2000;43(3):503-507. porary Pediatrics. 2007;24(9):63-72.
5. Moed L, Shwayder TA, Chang MW. 10. Shah A, Treat J, Yan AC. Spread of can-
than improvement.
Cantharidin revisited: a blistering defense tharidin after petrolatum use resulting
of an ancient medicine. Arch Dermatol. in a varicelliform vesicular dermatitis.
REFERENCES 2001;137(10):1357-1360. J Am Acad Dermatol. 2008;59(2 Suppl
1. Brown J, Janniger CK, Schwartz CZ, Sil- 6. Van der Wouden JC, et al. Interventions 1):S54-S55.
verberg NB. Childhood molluscum conta- for cutaneous molluscum contagiosum. 11. Cantharone brochure. www.dormer.ca.
giosum. Int J Dermatol. 2006;45(2):93-99. Cochrane Database of Systematic Re- Dormer Laboratories, Canada.