Isn't Radiation Risky?

Patient Presentation
A 6-month-old male came to clinic for runny nose and coughing for several days. The night before he had post-tussive emesis twice, but continued to breast feed and have good wet diapers.
He had a fever to 102° Fahrenheit.
The past medical history revealed a term infant who had been seen for one ear infection and health maintenance visits.
The social history revealed that another child in his daycare room had been admitted to the hospital for pneumonia.
The review of systems was non-contributory.
The pertinent physical exam showed an alert male with growth parameters at ~90%. Respiratory rate was 30, pulse oximetry was 95% on room air. His capillary refill was brisk. Mucous membranes were moist.
Nose showed copious clear rhinorrhea. Tympanic membranes were dull, with a slightly splayed light reflex but normal mobility. Chest examination showed mild, intermittent intercostal retractions at the lower ribs. He had very mild end-expiratory wheezing at the bases.
The rest of his examination was negative.
The child was given an albuterol nebulizer treatment and monitored. Re-examination showed no intercostal retractions and resolution of the wheezing, but decreased breath sounds at the bases. No crackles were appreciated.
The physician discussed with the parents that although this could be a viral pneumonia, with the patient’s age, fever, pneumonia contact, and decreased breath sounds, that he was concerned about a possible bacterial lobar pneumonia. He wanted to obtain a chest radiograph but the father
vehemently refused stating that the radiation risk was too high and that he wanted to just have some antibiotics prescribed. The physician calmly asked him why the father felt this way. The father stated “the radiation will hurt him.”The physician tried to find out what other beliefs the father held about radiation, but the father could not give any other specific information as to why he held this belief.
The physician explained about why he wanted to do the test, what the benefits would be, and told the father that the radiation was about the same as if he flew in an airplane 500 miles.
The physician sensed that the parents wanted to talk alone so he left them. A few minutes later the physician returned and the mother said that the chest x-ray could be done.
The father did not speak to the physician for the rest of the visit despite attemps to engage him.
The radiologic evaluation of a chest radiograph showed a right lower lobe bacterial pneumonia.
The diagnosis of right lobar pneumonia was made and the patient was given azithromycin and albuterol. Before leaving the pulse oximeter read 98% on room air. The parents were instructed how to use the albuterol for increased work of breathing as well as signs and symptoms of respiratory distress.

Discussion
Life is inherently risky and everyday people make decisions that increase and decrease their risks.
But as Ropeik and Gray write, “Risk issues are often emotional. They are contentious. Disagreement is often deep and fierce. This is not surprising, given that how we perceive and respond to risk is, at its core, nothing less than survival. The perception of and response to danger is powerful and fundamental driver of human behavior, thought, and emotion.”

It can be very difficult for people to understand the real risks in their everyday life and also the benefits they can have from taking those risks.
People are more afraid of:

  • New risks than those that have been around for a while, i.e. newly approved medication versus older medication
  • Man-made risks than those of nature, i.e. medical radiation versus tornados
  • Risks that are “imposed” upon them, than those they choose, i.e. required new vaccine versus motorcycle riding
  • Risks that they feel they cannot control, i.e. flying in airplane that they cannot fly themselves versus driving a car that they can drive
  • Risks that do not confer some benefits they want, i.e. would not live in Florida which is hurricane prone if it did not have warm weather and enjoyable water
  • Risks that can kill or injure them in terrible ways, i.e. eaten by a shark verus heart attack
  • Risks that come from sources that they feel they do not trust, i.e. information about drinking water contaminants from the local government, chemical company or non-profit conservation club
  • Risks that they are more aware of then those they are less aware of, i.e. gun violence from school shootings versus daily gun violence
  • Risks where the uncertainty is higher than where the uncertainty is lower, i.e. new cancer medication versus standard cancer medication
  • Risks to children than to their own lives (for an adult), i.e. powerline radiation next to the child’s school than versus next to the workplace
  • Risks that could directly affect themselves versus risks that threatens others, i.e. automobile accidents versus sky diving accidents for non-sky divers

Learning Point
Two common concerns parents raise are risks from medical radiation and vaccines.

Medical radiation does have risks but also benefits including improved diagnosis and treatment. The radiation risk depends on many factors including the size of the patient, body part being imaged, and imaging modality.
Some radiation doses are listed below:

  • Natural background radiation (sea level) = 300 millirems/year
  • Natural background radiation (Denver, Colorado) = 400 millirems/year
  • Round trip airplane flight coast to coast = 12 millirem
  • Chest radiograph = 2 millirem
  • Computed tomography of head, or chest, or abdomen = ~ 300 millirem

Using the roundtrip airplane radiation of 12 millirems and an approximate distance from Los Angeles, CA to New York, NY of 2800 miles, the radiation from flying in a plane is .00428 millirems/mile. If a chest radiograph is 2 millirems, then the number of miles one would have to travel in an airplane to receive an equivalent radiation dose is ~ 500 miles.
A person would also need to have about 150 chest radiographs in a year to equal the background radiation they normally receive.

Vaccines also have risks and benefits. The Centers for Disease Control list the following as serious side effects for various vaccines. The date listed is the most current version of the information from the CDC:

  • DTP (Tetanus, Diphtheria and Pertussis, 2001) – Allergic reaction > 1 in 1,000,000 doses, other reported problems include seizures, coma, lower consciousness, permanent brain damage1
  • Tdap (Tetanus, Diphtheria and Pertussis, 2006) – Mild problems reported only, serious side effects being monitored for
  • Td (Tetanus and Diphtheria, 1994) – Allergic reaction, pain and muscle wasting in upper arm
  • Haemophilus influenza B (1998) – Not applicable, only mild problems reported
  • Hepatitis A (2006) – Allergic reaction – Very rare
  • Hepatitis B (2001) – Allergic reaction – Very rare
  • Human Papilloma virus (2007) – Mild problems reported only, serious side effects being monitored for
  • Inactivated influenza virus (2006) – Serious side effects being monitored for 2
  • Live, attenuated influenza virus (2006) – Allergic reaction – very rare
  • Measles, Mumps, Rubella (2003) – Allergic reaction > 1 in 1,000,000 doses, other reported problems deafness, seizures, coma, lower consciousness, permanent brain damage1
  • Inactivated polio (2000) – Mild problems reported only, serious side effects being monitored for
  • Pneumococcal conjugate (2002) – Mild problems reported only, serious side effects being monitored for
  • Rotavirus (2006) – Mild problems reported, serious side effects being monitored for
  • Varicella (2007) – Pneumonia – Very rare

1These happen so rarely experts cannot tell whether they are caused by the vaccine or not. If they are, it is extremely rare.
2Swine flu vaccine – Guillian-Barre syndrome is estimated at 1-2 cases/million people vaccinated.

As comparisons, the likelihood of death or harm for a U.S. citizen, per year and per lifetime (based on data from 1999-2003) are given below.
The numbers shown are odds ratios, and therefore are given as one event will occur in that number of people. For example, the one year odds ratio for a hurriane is that one person will die out of 17 million people, but the lifetime odds ratio is that one person will die out of 220,000.
These are statistical averages and are not the exact chances for an individual person which are influenced by many factors including activities and work participated in, where someone lives or drives, etc.

 			One Year Odds	Lifetime Odds
Nature
Hurricaine		17,000,000	220,000
Flood 			11,186,539 	144,156
Lightening or Tornado	3,000,000	39,000
Dog bite		19,000,000	240,000
Bear attack (death)	94,000,000	1,200,000
Hornets, wasps and bees 4,406,818	56,789
Shark attack (death)	280,000,000	3,700,000
Crime and Suicide
Homicide (all)		18,000		240
Homicide by gun		28,000		360
Suicide			9,200		120
Transportation
Motor vehicles		6,700		88
Motorcycling		79,121 		1,020
School bus		4,900,000	63,000
Bicycling		381,693		4,919
All-terrain vehicles	1,600,000	21,000
Snowmobile		7,200,000	94,000
Commercial aviation plane 3,100,000	40,000
Recreation
Football		59,000,000	770,000
Soccer			840,000,000	11,000,000
Skydiving		9,100,000	120,000
Accidents
Drowning (general)	79,121		1,020
Drowning in a bathtub	840,000		11,000
Electrocution from wiring
/appliances		300,000		4,000
Fireworks		26,440,910	340,733
Fire and smoke exposure 86,331		1,113
Health
Asthma			56,000		730
Cancer			510		7
Diabetes		4,100		53
Heart Disease		300		4
Pregnancy and Childbirth 760,000	99,00
Stroke			1,800		23
Infectious Diseases
Hepatitis (all types)	59,000		770
Human papillomavirus	51		Not available
Influenza		130,000		1,700
Measles			94,000,000	1,200,000
Meningitis		370,000		3,800
Mumps (cases)		800,000		10,000
Pneumonia		4,300		57
Pertussis		56,000,000	730,000
Varicella (cases)	4,400,000	57,000

Questions for Further Discussion
1. List various forms of natural radiation.
2. What is the risk of death from oral contraceptive pills?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Radiation Exposure

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Centers for Disease Control. Vaccine Information Statements. Available from the Internet at http://www.immunize.org/vis/ (rev. various- see specific vaccine above, website revised 4/20/07, cited 4/23/07).
(Note: most current statement date for each vaccine is given above)

Ropeik D, Gray G. Risk A Practical Guide for Decising What’s Really Safe and What’s Really Dangerous in the World Around You. Houghton Mifflin Co. Boston, MA. 2002.

National Safety Council. What are the odds of dying? Available from the Internet at http://www.nsc.org/lrs/statinfo/odds.htm (rev. 8/2/2006, cited 4/26/2007).

Huda W, Vance A. Patient Radiation Doses from Adult and Pediatric CT. AJR 2007;188:540-546.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 4, 2007

  • What is the Differential Diagnosis of Intoeing and Outtoeing?

    Patient Presentation
    A 2-month-old male came to clinic for his 2-month health supervision visit.
    His parents have no concerns other than his feet seem to turn in looking like a “C”.
    This has been present since birth and they think that perhaps it is slightly improving over time but they are not sure.
    The past medical history shows that he was the product of a 38 1/2 weeks gestation with spontaneous vaginal delivery birth with vertex presentation.
    There were no complications and he has not had health care visits other than routine care. Past medical records do not mention any physical abnormalities.
    The family history is negative for any orthopaedic problems.
    The pertinent physical exam shows a happy male infant with normal developmental milestones and growth parameters in the 50-75%.
    On inspection, both forefeet appear to turn inward with a curved lateral border. With the hindfoot stabilized, the forefoot can be brought to a normal neutral position with little effort and did not cause discomfort. There is no stiffness with motion of any of the toes, forefeet, ankle, knees or hips.
    The medial malleoli were anterior to the lateral malleoli. The hips had normal ab- and ad- duction and a negative Barlow and Ortolani test bilaterally.
    The diagnosis of bilateral metatarsus adductus was made. The parents were told that this is a common problem in infancy thought to be due to intrauterine positioning. They were instructed and shown how to do forefoot stretching exercise that could be done with each diaper change and they demonstrated the proper technique.
    They were also told that this generally corrects as the child begins to put more weight on his feet.

    Discussion
    Intoeing or outtoeing are common complaints by parents. For most children, it is a normal variant or developmental problem that often resolves with a tincture of time.
    In general, referral should be made to an orthopaedist if the body part cannot be brought back to a neutral position or if doing so involves pain or discomfort. If there is any stiffness or an incomplete range of motion is felt then patients should also be referred.
    Patients with other abnormalities that may indicate that the in- or outtoeing may be part of a syndrome or neuromuscular problem should be referred too. Parents generally will complain about the in- or outtoeing if it is obvious (as in the patient above), the child seems to trip more often, there is excessive shoe wear, or other parents, teachers or family members have noticed the same problems.

    Intoeing is complained about much more often than outtoeing because the children tend to trip more with intoeing. Outtoeing is common when children begin to bear weight and the outtoeing helps with balance. The outtoeing improves usually over the next several months as strength, coordination and balance are improved.
    A normal gait has a slight outtoeing (i.e.10-15° external rotation).

    Learning Point

    The differential diagnosis of intoeing includes:

    • Metatarsus adductus
      • Cause: Intrauterine positioning deformity, i.e. a “packaging” problem.
      • Age: Infants
      • Diagnosis: Hold the hindfoot in one hand to stabilize and use other hand to attempt to bring toes back to midline. If this can be easily done without stiffness of the foot, then this is metatarsus adductus. There is also a tranverse midline crease on the plantar surface.
      • Prognosis: is excellent and it spontaneously corrects especially with weight bearing
    • Internal tibial torsion
      • Cause: Normal in newborns. Caused by the effects of gravity and dominant tone in ankle plantar flexor muscles and foot invertors
      • Age: Toddler – often seen when child begins walking and is generally better by age 2 and almost all are corrected by age 4.
      • Diagnosis:
        • Intermalleolar axis – The medial malleoli lies approximately 10 – 15% anterior to the lateral malleoli normally. With tibial torsion, they lie in the same plane.
        • Thigh foot angle – With child prone on table, flex the knee. Draw an imaginary line through the axis of the femur and another imaginary line between the midpoint of the heel and toes. Normally the angle between these two lines is 10-30° with the foot turned outward. Refer to orthopaedics if the angle is > 20°.
      • Prognosis: is excellent, generally no treatment is necessary, rarely requires surgery only if persistent
    • Femoral anteversion
      • Cause: Angular difference between the axis of the neck of the femur and the transcondylar axis of the knee. Normally reaches the adult angle of 10 – 20° in 5 – 8 year olds.
      • Age: School age children can often sit in “W” position without any problems (this position does not exacerbate the condition)
      • Diagnosis: Check the internal and external rotation of the hips. Internal rotation > 70° and limited external rotation are suggestive of femoral anteversion.
      • Prognosis: Improves but is often slow to do so. Once external rotation increases to 10 – 20° then intoeing generally is resolved.
    • Cerebral palsy
    • Clubfoot – is rigid deformity with plantar flexion and medial deviation at the ankle
    • Hip dysplasia

    The differential diagnosis of outtoeing includes:

    • Normal gait when first learning to walk
    • Femoral retroversion
    • External tibial torsion – usually seen as a compensatory mechanism to femoral anteversion

    Questions for Further Discussion
    1. What causes knock-knees and bowlegs?
    2. What causes flat feet?
    3. What causes leg length discrepancies?
    4. When would radiographs be indicated for intoeing or outtoeing?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Foot Injuries and Disorders

    and at Pediatric Common Questions, Quick Answers for this topic: Intoeing and Outtoeing

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Mier RJ, Brower TD. Pediatric Orthopedics A Guide for the Primary Care Physician. Planum Medical Book Company, New York NY. 1994:95-102.

    Lincoln TL,
    Suen PW.
    External rotation contracture of the extended hip. A Journal of the American Academy of Orthopaedic Surgeons. 2003;11(5);312-20.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 28, 2007

  • What Organisms Cause Otitis Externa?

    Patient Presentation
    A 7-year-old male came to clinic with drainage from his left ear for 2 days. The small amount of drainage was clearish-yellow and came and went over the day.
    There was more dried discharge on his pillow in the morning. The ear was somewhat painful but not excruciating and was somewhat pruritic. He denied sore throat, teeth pain or other pain.
    He had been swimming in a chlorinated pool and hot tub for several days before the onset of the drainage.
    The pertinent physical exam showed a well-appearing male with growth parameters in the 10-50%. His right ear was normal.
    His left external canal had pale yellow, thin discharge with white macerated skin and areas of erythema. Part of the tympanic membrane could be visualized and appeared non-erythematous and in normal position.
    There was mild pain produced with pressure on the tragus.
    There was shoddy anterior cervical adenopathy bilaterally.
    The diagnosis of otitis externa was made. The patient was begun on ciprofloxacin otic drops to be used for 5 days and to return if symptoms were not improved.
    He was also told to use a few drops of vinegar after swimming and baths to help prevent otitis externa from recurring.

    Discussion
    Otitis externa, also known as swimmer’s ear, is a common infection, especially in school age children. Moisture in the ear causes edema, skin breakdown and bacteria to grow. Swelling and debris may obstruct the external canal exacerbating the problem.
    Common predisposing factors include swimming (especially in water with high bacterial counts), foreign body (including hearing aids, retained cerumen, insects, etc.), dermatitis, viral infections and local trauma (i.e. finger nails, cotton-tipped applicators, etc.).
    Patients usually complain of unilateral ear pain or pruritus, drainage or decreased hearing. On physical examination, pressure on the tragus may elicit pain, and debris/drainage can be seen in the canal.
    The skin may look macerated with edema and erythema. The tympanic membrane may or may not be visible. Lymphadenopathy may be palpable and a conductive hearing loss may be measured. Unless infections extend beyond the canal, serious auricular problems usually do not occur.
    Cultures are not obtained unless there is an unusual history or physical examination such as a patient who is immunocompromised.

    Treatment for pain is usually acetaminophen or ibuprofen but occasionally oral narcotics are needed. Topical anesthetics such as antipyrine/benzocaine can be used but not if there is tympanic membrane perforation as it causes ototoxicity.
    Topical antibiotics are usually used. Fluoroquinolones such as ciprofloxacin and ofloxacin are the drugs of choice. Polymyxin B/neomycin/hydrocortisone has been used in the past with good results but increasing bacterial resistance and pain during administration along with sensitivity to neomycin and potential for ototoxicity is limiting it use.
    Systemic antibiotics are usually not necessary for most patients but may be used with infections beyond the canal or immunocompromised patients. Historically, some physicians have used a small cotton wick placed into the ear to aid medication delivery but this has not been systematically evaluated.
    Prevention centers on trying to keep the external canal as dry as possible. Using ear plugs and/or bathing cap, or blow drying with a low dryer setting after swimming may help. Decreasing the pH of the ear also helps by using a few drops of isopropyl alcohol, acetic acid or boric acid after swimming..

    Ofloxacin and ciprofloxacin with dexamethasone may be used with tympanic membrane perforation or pressure-equalizing tubes as they are not ototoxic.

    Learning Point
    Otitis externa is most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus. These often co-exist.

    Questions for Further Discussion
    1. What diseases should be considered in the differential diagnosis of otitis externa?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Infections

    and at Pediatric Common Questions, Quick Answers for this topic: Otitis Externa

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Stone KE. Otitis Media. Pediatr Rev. 2007 Feb;28(2):77-8.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1255-1256.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 21, 2007

  • What is the Best Treatment for Molluscum Contagiosum?

    Patient Presentation
    A 3-year-old male came to clinic because of ‘bumps’ on his arms. The lesions have been there for several weeks but the mother noted that they seem to be spreading.
    The lesions were always skin colored, raised, pinpoint or slightly larger and didn’t appear to itch or bother the boy. She hadn’t tried anything to help them.
    He was in daycare but no one had a rash that the mother knew. She denied other contacts, new soaps, lotions, etc.
    The past medical history was non-contributory and he had no underlying dermatological conditions.
    The pertinent physical exam showed a well-appearing male with growth parameters around the 75%. The lesions were on the dorsal and volar surfaces of both forearms. They were flesh-colored, papular with central umbilication and 1-4 mm in size.
    There were 5 lesions on the right arm and 8 on the left and they appeared in a sporadic distribution.
    The diagnosis of of molluscum contagiosum was made. After discussion with the mother including that most lesions resolve spontaneously but also that autoinoculation or transmission to others could occur, she refused cryotherapy and wanted to try salicylic acid/lactic acid treatment which she applied 3 times per week at night and washed the residue off in the morning.
    The patient’s clinical course after one month of treatment showed 3 lesions were almost completely gone and some of the larger ones appeared to be smaller. The mother continued the treatment and 2 months after his initial appointment, the lesions were gone.

    Discussion
    Molluscum contagiosum is a common viral skin infection caused by a poxvirus. They are small flesh-color papular lesions with central umbilication where the virus resides. They are painless and generally are 1-10 mm in size.
    They can occur anywhere on the skin. They often spontaneous resolve in 6-9 months, but can also have widespread dissemination (especially in patients with underlying dermatological conditions), pruritus, secondary bacterial superinfection, acute and chronic inflammatory changes, and scar formation. They can also be transmitted to others.

    There have been many treatments advocated. One recent prospective randomized trial in 124 children ages 1-18 years found that curettage was the most effective treatment with the lowest side effects, but it needed adequate anesthesia and was time-consuming.
    The Cochrane Collaboration project recently reviewed the medical literature and found that there was insufficient evidence to determine if treatments are effective.
    The randomized trial above concluded by stating “???the ideal treatment for mollusca depends on the individual patient preference, fear, and financial status, distance from the office, and whether they have dermatitis or blood-borne infections.”

    Learning Point
    Potential treatments for molluscum contagiosum include:

    • Watchful waiting
    • Cryotherapy – generally only used with a few lesions, may cause pain, psychological fear, blistering or secondary bacterial superinfection
    • Curettage – coring out of the central viral core with a curette, can be time consuming and needs adequate anesthesia. May cause pain, psychological fear, and secondary bacterial superinfection
    • Expression or pricking with a sterile needle – time consuming, may not obtain all the viral core material
    • Duct tape occlusion
    • Topical therapy – may cause irritation, blistering, secondary bacterial superinfection
      • Cantharidin (Cantharone®)
      • Hydrogen peroxide
      • Imiquimod (Aldara®) – works as an immunomodulator
      • Phenol
      • Podofilox (Condylox®)
      • Potassium hydroxide
      • Salicylic acid with or without lactic acid (Duofilm®)
      • Silver nitrate
      • Tretinoin (Retin-A®])
      • Trichloroacetic acid
    • Pulsed dye laser therapy
    • Systemic treatment – Cimetidine (Tagamet®) works as an immunomodulator

    Questions for Further Discussion
    1. How is molluscum contagiosum related to other warts?
    2. What treatments does the local dermatologist offer?
    3. What are indications for referral to a dermatologist?

    Related Cases

      Symptom/Presentation

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Skin Conditions

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Hanna D,
    Hatami A,
    Powell J,
    Marcoux D,
    Maari C,
    Savard P,
    Thibeault H,
    McCuaig C.
    A prospective randomized trial comparing the efficacy and adverse effects of four recognized treatments of molluscum contagiosum in children. Pediatr Dermatol. 2006 Nov-Dec;23(6):574-9.

    Lindau MS,
    Munar MY. Use of duct tape occlusion in the treatment of recurrent molluscum contagiosum. Pediatr Dermatol. 2004 Sep-Oct;21(5):609.

    van der Wouden JC, et al. Interventions for cutaneous molluscum contagiosum. Cochrane Database Syst Rev 2006;(2):CD004767. Available from the Internet at http://www.cochrane.org/reviews/en/ab004767.html (cited 4/16/07).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 14, 2007