NR 602 Molluscum Contagiosum Soap Note
A benign common childhood viral skin infection with little health risk, molluscum contagiosum often disappears on its own in a few weeks to months and is not easily treated (Fig. 37-18). This poxvirus replicates in host epithelial cells. It attacks skin and mucous membranes and is spread by direct contact, by fomites, or by autoinoculation (typically scratching).
It is commonly found in children and adolescents. The incubation period is about 2 to 7 weeks but may be as long as 6 months (Weston and Morelli, 2013). Infectivity is low but the child is contagious as long as lesions are present.
FIGURE 37-18 Molluscum contagiosum. (From Weston WL, Lane AT, Morelli JG: Color textbook of pediatric dermatology, ed 4, St. Louis, 2007, Mosby/Elsevier, p 144.)
- Itching at the site
- Possible exposure to molluscum contagiosum
- Very small, firm, pink to flesh-colored discrete papules 1 to 6 mm in size (occasionally up to 15 mm)
- Papules progressing to become umbilicated (may not be evident) with a cheesy core; keratinous contents may extrude from the umbilication
- Surrounding dermatitis is common
- Face, axillae, antecubital area, trunk, popliteal fossae, crural area, and extremities are the most commonly involved areas; palms, soles, and scalp are spared
- Single papule to numerous papules; most often numerous clustered papules and linear configurations
- Sexually active or abused children can have genitally grouped lesions
- Children with eczema or immunosuppression can have severe cases; those with human immunodeficiency virus (HIV) infection or AIDS can have hundreds of lesions
Warts, closed comedones, small epidermal cysts, blisters, folliculitis, and condyloma acuminatum are included in the differential diagnosis.
- Untreated lesions usually disappear within 6 months to 2 years but may take up to 4 years to completely go away. There is no consensus on the management of molluscum contagiosum and no evidence-based literature to show that any treatment is superior to placebo. Therapy may be necessary to alleviate discomfort, reduce itching, minimize autoinoculation, limit transmission, and for cosmetic reasons. Genital lesions may need to be treated to prevent spread to sexual partners.
- Mechanical removal of the central core is to prevent spread and autoinoculation. Using eutectic mixture of local anesthetics (EMLA) cream (lidocaine/prilocaine) 30 to 45 minutes before the procedure reduces discomfort. Curettage is done with a sharp blade to remove the papule. Piercing the papule and expressing the plug is an option but is painful.
- There are reports that irritants (such as surgical tape, adhesive tape, or duct tape) applied each night can result in lesion resolution.
- Topical medications may prove beneficial. Recheck the patient in 1 to 2 weeks to determine the need for retreatment.
- Liquid nitrogen applied for 2 to 3 seconds (easiest but also painful).
- Trichloroacetic acid 25% to 50% applied by dropper to the center of the lesion, followed by alcohol (use with caution). Surround the lesion first with petroleum jelly.
- Cantharidin 0.7% in collodion applied by dropper to the center of the lesion, followed by alcohol. Salicylic or lactic acid or KOH or podophyllin can also be used.
- Podofilox 0.5% topical solution or gel, or imiquimod 5% applied daily with a toothpick or cotton-tipped swab.
- Tretinoin or tazarotene cream or gel applied to lesion each night.
- Silver nitrate, iodine 7% to 9%, or phenol 1% applied for 2 to 3 seconds.
- Cimetidine 30 to 40 mg/kg/day in two divided doses orally for 6 weeks if topical treatment fails.
- Sexual abuse of children with genitally grouped lesions should be suspected and evaluated.
- Evaluate for HIV infection if hundreds of lesions are found.
- Wait and see approach—spontaneous clearing occurs over years.
Molluscum dermatitis, a scaly, erythematous, hypersensitive reaction, can occur and will respond to moisturizer; avoid hydrocortisone because it causes molluscum to flare. Impetiginized lesions, inflammation of the eyes or conjunctiva, and scarring can occur.
Patient and Family Education
Patients are contagious, but there is no need to exclude them from daycare or school. Children with impaired immunity, atopic dermatitis, or traumatized skin are at greater risk for broader spread. Severe inflammation is possible several hours after application of cantharidin. Scarring is unusual.