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
- Disease
-
Molluscum Contagiosum
Sexually Transmitted Diseases
Skin Conditions
- Symptom/Presentation
- Age
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
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.
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.
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
Pediatric Education 