By Gary M. White, MD
Multiple pink to white, delled papules in a child.
Molluscum contagiosum (MC) is a common viral infection of the skin. Small, delled, flesh-colored bumps in children and immunocompromised individuals, e.g., HIV, are characteristic. MC may be transmitted sexually in adults.
Molluscum appears as multiple flesh-colored to pink papules. A white area or dell in the center is classic. There may be only a few or over 50. They may be grouped or scattered. Often, the surrounding skin is irritated and red. It is most common in children 2-6 years of age. Untreated, the average duration is 8 months, but can last 3-5 years. Most adults probably have been exposed and have immunity but they may also be affected.
If the child's parents call and say s/he has developed "hundreds of new molluscum lesions," consider Gianotti-Crosti syndrome-like reaction to molluscum [Arch Dermatol. 2012 Nov;148(11):1257-64].
Curettage is the most rapidly effective treatment. In a prospective study of 1879 patients, 70% were cured after one treatment and 96% (70 + 26% more) after one or two treatments [Pediatrics 2016;Sept Ahead of print]. Details of that study are as follows. The patient and parent(s) were counseled initially on the procedure. Any eczema or infection was treated with a topical low-potency steroid and/or a topical antibiotic several days before. EMLA was prescribed and the parents applied it to all visible lesions with occlusion (e.g., with a bandage) 1 hour before the procedure. All visible lesions were curetted. Bleeding was minimal and controlled with pressure from a cotton sponge for several seconds. For 16% of patients, the procedure was performed under sedation with either propofol or nitrous oxide gas because of anxiety, facial or genital lesions, and/or extensive lesions. Topical gentamycin was applied BID for 1 week after the curettage.
Molluscum in young children is often best observed as it usually remits spontaneously within months to years, with the average duration 8 months in one study and 13 months in another [Lancet Infect Dis 2015;15;190]. Often, however, the parent does not want to wait. In another study MCV lesions completely resolved in approximately 50% of children within 12 months and in 70% within 18 months--whether they were treated or not. Treatment did not shorten the time to resolution [Pediatr Dermatol 2015 Jan 30; EPub Ahead of Print].
A small DBPCT found no difference between cantharidin and placebo in the treatment of molluscum [Pediatr Dermatol 2014;31:440]. The bottom line is that if cantharidin has benefit, it is probably small. Still, for many, cantharidin is first-line treatment for the body but not the face or intertriginous areas. There have been lawsuits from scarring resulting from use in these areas. Some experts recommend against using Cantharone Plus as it can be too aggressive.
Cantharidin (although not available in the US in commercial form, it may be compounded) may be tried. One approach is the following: Use a toothpick for precise application of a tiny amount to each lesion. Allow to dry without touching, e.g., 3-5 minutes--or else spread and larger blister formation will occur. Cover with bandage. Have parents remove bandage and wash areas in 4-6 hours or overnight. Any blisters may be popped but don't remove the roof. Covering any open areas with a bandage may be done for comfort of the patient. Book patient back in 3 weeks. Let them know that multiple treatments are usually needed. For the first visit, consider treating only 4-5 lesions to see how patient and parents do. At follow-up visits, one can treat up to 20. Never treat the face.
Tape stripping is a very safe at-home approach and may have benefit. Have the parent do the following:
"Roll a piece of tape around your finger sticky side out. Then tap the largest of the lesions 20 times twice a day until it becomes red and inflamed. Then stop and see if it clears. You may treat multiple lesions with this approach, but use a new piece of tape for each as it is both more effective and less likely to spread the virus. Make sure to carefully throw away the tape and keep it away from anyone's skin."
Tretinoin 0.05% cream may be applied QHS by a parent with the blunt end of a cotton-tipped applicator (or Q-tip with end cut off). This often causes enough inflammation and peeling to induce resolution. The parent should stop applying the tretinoin to any lesion that has become inflamed.
Topical salicylic acid is an at-home approach that can clear molluscum. Have the parent do the following:
"Use the following for any molluscum not on the face or anogenitals. Apply 1-3 drops of 17% salicylic acid (e.g., DuoFilm) directly to the molluscum once a day. Each drop should be permitted to dry before the next is added. Try to keep the salicylic acid off normal skin. You can cover with a bandage. Repeat daily. If the molluscum gets significantly inflamed (e.g., red and tender), stop treatment on that lesion, wait for the irritation to go away, and see if the molluscum does as well."
Potassium hydroxide 10% KOH aqueous solution, applied twice daily with a cotton stick to all lesions, has been very successful in a few studies including patients as young as 1 year of age [J Dermatolog Treat. 2014 Jun;25(3):246-8]. There was complete clearance of lesions in 37 (92.5%) patients after a mean period of four weeks. Local side effects (mainly irritation, but one with hypopigmentation) were observed in 12 children (32.4%).
In a DBPCT, 10% KOH was compared to normal saline. Twenty patients, aged 2-12 years, were recruited. Parents applied a solution twice daily to lesional skin until signs of inflammation appeared. Seventy percent of children receiving topical potassium hydroxide cleared, compared with 20% in the placebo group [Pediatr Dermatol. 2006 May-Jun;23(3):279-81].
Podofilox (Condylox) has been studied and seems to be a viable and effective treatment. As with warts, it is applied BID x 3 consecutive days a week.
Liquid nitrogen (cryotherapy) or curettage may be done to individual lesions, but unfortunately, these approaches are both frightening and painful to the young patient. Still, if treatment is desired, EMLA cream 5% may be applied 30-60 minutes prior to cryotherapy or curettage in order to reduce the pain. The patient should be seen Q3 weeks to treat new lesions.
Alternatively, Nanorap (Biolab Indústria Farmacêutica Ltd., Sao Paulo, Brazil) is a hydrogel with 2.5% lidocaine and 2.5% prilocaine, with 50% of the active products in nanocapsules. It achieves satisfactory analgesia within 10 minutes of topical administration in healthy adults. It was used with success in children 2-11 years of age, applied 20 minutes before cryotherapy, without occlusion [PD 2016;33;214].
IL candida can do well for molluscum. In one review of 29 patients, 55% had complete resolution. In addition, 37.9% experienced partial resolution, yielding an overall response rate of 93% [Pediatr Dermatol. 2011 May-Jun;28(3):254-8].
Ingenol mebutate has been used successfully [J Am Acad Dermatol. 2014 May;70:e105]. Ingenol mebutate 0.015% cream was applied to the lesions of a 4-year-old child once daily for 6 days which led to resolution of the lesions.
Imiquimod does NOT work for molluscum contagiosum. The original maker of imiquimod (3M) conducted two large randomized trials of imiquimod for molluscum but neither study showed any difference between imiquimod and placebo [JAMA Derm 2015;151;125]. Neither study was published.
There is some evidence for the benefit of oral zinc sulfate 10 mg/kg (not to exceed 600 mg/day). Give it in divided doses and after meals. In a randomized trial, researchers who evaluated oral zinc supplementation versus placebo for two months found complete clearance in 20 out of 23 patients in the treatment group, compared with none of the 20 patients in the placebo group [BJD; 2002]. All patients in the zinc group reported nausea. Another placebo-controlled study of zinc sulfate 10 mg/kg per day up to 600 mg per day for up to two months [JAAD 2009] showed complete clearance of all warts was achieved in 78% of patients in the treatment group, compared with 13% in the placebo group. No recurrence of warts was observed at the six-month follow-up. Nausea can limit the use of this treatment.
Heating pad for 30 minutes, once weekly for 12 weeks. Goal temperature is 44 C (111 F). Check the heating pad package to make sure it gets to this tempurature. Don't go longer and burn. [British Journal of Dermatology 2017;176;809–812].
Various studies have shown PDL to clear molluscum, even with just one treatment.
Some use cantharidin on the face [JAAD 2018;78;198], but great care must be exercised, especially around the eyes. Inflammation, blistering, dyspigmentation and rarely scarring may occur.
Tretinoin 0.1% to irritate is a good choice. Curettage can do well (see above). Can consider potassium hydroxide and ingenol mebutate (see above).
One group has used topical 20% to 35% TCA to treat hundreds of pediatric patients with facial molluscum over 13 years without resulting in any significant irritation or pigment alteration [PD 2009;26;425]. They present the following technique for proper application. "The pointed edge of broken cotton-tipped applicator is used to repeatedly apply the TCA until a white frost appears. We do not apply vaseline to the skin surrounding the lesion to be treated; however, as TCA is a caustic agent, care is taken to apply the solution only to the center of individual lesions while avoiding the surrounding healthy skin. Patients describe only a mild stinging sensation and generally tolerate application well. Given the mild discomfort associated with application, we treat as many lesions as the patient tolerates."
Refer to ophthalmology.
Multiple delled papules in the groin of a sexually active adult is one typical presentation.
Multiple delled papules in a young child is the other typical presentation.
This solitary red papule in a child was thought to be a Spitz Nevus and was surgically removed. (Molluscum on histology).
Giant Molluscum in HIV
Rarely, subungual. Indian J Dermatol Venereol Leprol 2014;80:278
Giant molluscum of the face in a 10 year old girl. Indian Dermatol Online J 2015;6:58-9
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