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Molluscum Contagiosum. Medical Student Core Curriculum in Dermatology. Last updated March 25, 2011. Goals and Objectives.

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molluscum contagiosum

Molluscum Contagiosum

Medical Student Core Curriculum

in Dermatology

Last updated March 25, 2011

goals and objectives
Goals and Objectives
  • The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with molluscumcontagiosum.
  • By completing this module, the leaner will be able to:
    • Identify and describe the morphology of molluscumcontagiosum
    • List treatment options for molluscumcontagiosum
    • Provide patient education about molluscumcontagiosum
    • Determine when to refer a patient with molluscumcontagiosum to a dermatologist
case one history
Case One: History
  • HPI: Susie, an 8-year-old girl, is brought to clinic by her frantic mother. The mother reports a “rash” that has been present for eight weeks and is spreading. Her pediatrician gave her an antifungal cream which they applied twice a day for two weeks without improvement. She scratches the areas often.
  • PMH: History of eczema which has been well controlled in the last couple years. History of asthma.
  • Allergies: Grasses and molds. No known drug allergies.
  • Medication: Antifungal cream, 2.5% hydrocortisone cream, albuterol inhaler as needed
  • Family history: Mother has sinus problems; no one else has a rash
  • Social history: Lives with parents and a 12-year-old brother; dog in the home; swims often
  • ROS: Negative
case one question 1
Case One: Question 1
  • What should you tell the mother?
    • Susie might have a malignancy because the cream should have improved the dermatitis
    • They must be more compliant with Susie’s medications
    • This is a bacterial infection
    • This is caused by a virus which is treated with acyclovir
    • This is not uncommon in children and she may need treatment if the lesions do not clear on their own
case one question 11
Case One: Question 1

Answer: e

  • What should you tell the mother?
    • Susie might have a malignancy because the cream should have improved the dermatitis
    • They must be more compliant with Susie’s medications
    • This is a bacterial infection
    • This is caused by a virus which is treated with acyclovir
    • This is not uncommon in children and she may need treatment if the lesions do not clear on their own

6

case one question 2
Case One: Question 2
  • How would you describe the papules that are present?
    • Dome-shaped, pearly, and umbilicated
    • Scaly
    • Thick and endophytic
    • Vesicular (small blisters)
case one question 21
Case One: Question 2

Answer: a

  • How would you describe the papules that are present?
    • Dome-shaped, pearly, and umbilicated
    • Scaly
    • Thick and endophytic
    • Vesicular (small blisters)
case one question 3
Case One: Question 3
  • What causes these lesions?
      • Bacteria
      • Fungus
      • Parasite
      • Virus
case one question 31
Case One: Question 3

Answer: d

  • What causes these lesions?
      • Bacteria
      • Fungus
      • Parasite
      • Virus

10

case one question 4
Case One: Question 4
  • What type of virus causes molluscum contagiosum?
      • A herpes virus
      • A pox virus
      • Human immunodeficiency virus
      • Human papillomavirus
      • Varicella-zoster virus
case one question 41
Case One: Question 4

Answer: b

  • What type of virus causes molluscum contagiosum?
    • A herpes virus
    • A pox virus
    • Human immunodeficiency virus
    • Human papillomavirus
    • Varicella-zoster virus
molluscum contagiosum1
Molluscum Contagiosum
  • Molluscum contagiosum (MC) is a benign, usually asymptomatic viral infection of the skin with no systemic manifestations
  • Usually is characterized by 2 to 20 discrete, 5-mm-diameter, flesh-colored to translucent, dome-shaped papules, some with central umbilication
  • Lesions commonly occur on the trunk, face, and extremities but are rarely generalized
molluscum contagiosum2
Molluscum Contagiosum
  • An eczematous reaction encircles lesions in approximately 10% of patients
  • Three groups of people are primarily affected:
    • Young children, especially those with atopy
    • Sexually active adults
    • Immunosuppressed individuals
  • People with eczema and immunocompromising conditions have more widespread and prolonged eruptions.
case one question 5
Case One: Question 5
  • Susie’s mother is relieved to have a diagnosis but now wants to hear about treatment. What do you tell her?
      • Cantharidin
      • Cryotherapy
      • Curettage
      • No treatment because it may resolve on its own
      • All of the above are options
case one question 51
Case One: Question 5

Answer: e

  • Susie’s mother is relieved to have a diagnosis but now wants to hear about treatment. What do you tell her?
    • Cantharidin (topical keratolytic agent)
    • Cryotherapy(freezing with liquid nitrogen)
    • Curettage (scraping out tissue with a curette)
    • No treatment because it may resolve on its own (infection is usually self-limited and spontaneously resolves after a few months in immunocompetent patients)
    • All of the above are options
case one question 6
Case One: Question 6
  • You recommend no treatment as an initial trial. What fact(s) would support that decision?
    • Most children will clear eventually
    • She attends day care
    • She is pruritic
    • She has atopic dermatitis
case one question 61
Case One: Question 6

Answer: a

  • You recommend no treatment as an initial trial. What fact(s) would support that decision?
    • Most children will clear eventually
    • She attends day care
    • She is pruritic
    • She has atopic dermatitis

19

treatment principles
Treatment Principles
  • Children with atopy are less likely to clear on their own
  • Scratching can spread the lesion in a linear mode (Koebner phenomenon)
treatment principles1
Treatment Principles
  • There is no consensus on the management of MC in children and adolescents
  • Therapy may be warranted to:
    • Alleviate discomfort, including itching
    • Reduce autoinoculation
    • Limit transmission of the virus to close contacts
    • Reduce cosmetic concerns
    • Prevent scarring
    • Prevent secondary infection
  • Genital lesions should be treated to prevent spread to sexual contacts
treatment options
Treatment Options
  • First-line treatments include:
    • Cantharidin – a vesicant that causes blistering on the applied area (not painful when applied)
    • Curettage – scraping to remove
    • Cryotherapy – liquid nitrogen therapy
    • Topical retinoids (the same ones we use in acne)
    • Imiquimod – a cream that stimulates the immune system
referral information
Referral Information
  • Refer a patient with MC to a dermatologist if:
    • Recalcitrant/prolonged cases
    • Diffuse involvement
    • Extensive facial involvement
    • Significant discomfort
    • Coexisting severe dermatitis
    • Immunocompromised
case one question 7
Case One: Question 7
  • Susie’s mother wants a “quick fix.” If this is “some kind of wart,” she wants “those things frozen.” You explain the potential side effects of cryotherapy may include:
      • Blisters
      • Color change
      • Pain
      • Scarring
      • All of the above
case one question 71
Case One: Question 7

Answer: e

  • Susie’s mother wants a “quick fix.” If this is “some kind of wart,” she wants “those things frozen.” You explain the potential side effects of cryotherapy may include:
      • Blisters
      • Color change
      • Pain
      • Scarring
      • All of the above
case one question 8
Case One: Question 8
  • As you pause to consider the potential treatment, you review the facts that contributed to Susie having molluscum. The following may contribute:
      • Being a swimmer
      • Having a dog
      • Her atopy
      • a and b
      • a and c
case one question 81
Case One: Question 8

Answer: e

  • As you pause to consider the potential treatment, you review the facts that contributed to Susie having molluscum. The following may contribute:
      • Being a swimmer
      • Having a dog
      • Her atopy
      • a and b
      • a and c
molluscum transmission
Molluscum Transmission
  • Spread via skin-to-skin contact, fomite exposure, and autoinoculation
  • Associated with public water exposures (pools, bath houses, hot tubs)
  • Wrestlers are particularly at risk because of prolonged skin contact and friction
  • MC should not prevent a child from attending child care or school or from swimming in public pools
  • When possible, lesions not covered by clothing should be covered by a watertight bandage. The bandage should be changed daily or when soiled.
case one question 10
Case One: Question 10
  • Susie’s mother now wants to know for sure if this is molluscum. You declined to biopsy because of the typical appearance but she leaves your office and finds a physician who does a biopsy. What would the characteristic histopathology show?
      • Budding yeast
      • Henderson-Paterson bodies
      • Multi-nucleated giant cells
      • Necrotic keratinocytes
      • Subepidermal blister
case one question 101
Case One: Question 10

Answer: b

  • Susie’s mother now wants to know for sure if this is molluscum. You declined to biopsy because of the typical appearance but she leaves your office and finds a physician who does a biopsy. What would the characteristic histopathology show?
    • Budding yeast (seen in candida infections)
    • Henderson-Paterson bodies
    • Multi-nucleated giant cells (seen in herpes virus infections)
    • Necrotic keratinocytes (seen in Stevens-Johnson syndrome)
    • Subepidermal blister (seen in fixed drug eruptions)
henderson paterson bodies
Henderson-Paterson Bodies
  • Henderson-Patterson Bodies, aka Molluscum bodies
    • Intracytoplasmic inclusion bodies, containing poxvirus particles, seen in keratinocytes
molluscum contagiosum as a std
Molluscum Contagiosum as a STD

When it occurs in the genital region, MC is classified as a sexually transmitted disease. Most adults with MC present with genital disease.

molluscum contagiosum in immunosuppressed patients
Molluscum Contagiosum in Immunosuppressed Patients
  • Giant lesions can occur
  • HAART leads to clearance but may have lag time before improvement is seen
    • Adults with chronic MC outside the genital area should be evaluated for immunosuppression
  • Patients with untreated HIV often have lesions concentrated on the face or genitalia. Oral and genital mucosa may be involved
molluscum contagiosum summary
Molluscum Contagiosum Summary
  • Viral infection due to a pox virus
  • Three main groups at risk (children, sexually active adults and immunosuppressed patients)
  • Various treatment options available
  • In children spontaneous remission frequently occurs and no treatment is a reasonable option
acknowledgements
Acknowledgements
  • This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.
  • Primary authors: Susan K. Ailor, MD, FAAD; Kari L. Martin, MD.
  • Peer reviewers: Timothy G. Berger, MD, FAAD; Brandon D. Newell, MD; Maria C. Garzon, MD, FAAD.
  • Revisions and editing: Sarah D. Cipriano, MD, MPH; Meghan Mullen Dickman.
  • Last revised March 2011.
references
References
  • Braue A, et al. “Epidemiology and impact of childhood molluscum contagiosum: A case series and critical review of the literature.” Ped Derm. 22(4):287-294. 2005.
  • James WD, Berger TG, Elston DM. “Chapter 19. Viral Diseases” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 394-397.
  • Mancini AJ, Shani-Adir A. “Chapter 80. Other Viral Diseases” (chapter). Bolognia JL, Jorizzo JL, Rapini R: Dermatology. 2nd ed. Mosby Elsevier; 2008. 1229-1233.
  • Silverberg NB. “Warts and molluscum in children”. Adv Dermatol. 20:23-73. 2004.
  • Tom W, Friedlander SF. “Chapter 195. Poxvirus Infections” (chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick’s Dermatology in General Medicine. 7th ed. McGraw-Hill Companies, Inc; 2008: 1911-1913.
  • van der Wouden JC, et al. “Interventions for cutaneous molluscum contagiosum.” Cochrane Rev. Vol 2. 2010.