BackgroundMolluscum contagiosum is a benign viral infection of the skin, caused by a double-stranded DNA virus of the Poxviridae family. Transmission occurs by direct bodily contact (eg, through sexual activity), fomites (eg, underwear), or self-inoculation. The incubation period is 14-50 days. The infection is most common in children, sexually active adults, and immunocompromised persons, and it occurs in 5-18% of HIV-infected patients. In immunocompetent persons, the infection usually lasts 6 to 12 months, although genital lesions in HIV-uninfected adults may persist longer. Persons with HIV infection may have extensive lesions and a strong correlation exists between the degree of immunosuppression and the risk of molluscum, the number of lesions, and their resistance to treatment. S: SubjectiveThe patient complains of new or increased papular lesions on the face, upper trunk, or genitals. Papules of molluscum contagiosum may cause no symptoms or can be pruritic or tender to the touch. Genital lesions are transmitted sexually; the patient may recall seeing such lesions on the genitals of a previous partner. Ask about fever or other systemic symptoms. O: ObjectivePerform a thorough evaluation of the skin, the genitals, and the mouth. Molluscum lesions are white, pink, or flesh-colored; smooth-surfaced, firm, pearly, and spherical (dome-shaped) papules (2-5 mm) or nodules (6-10 mm), with umbilicated centers. Lesions are usually found on the head or neck and the genital area, but may affect every part of the body except the palms and soles of the feet. Molluscum may occur intraorally. Molluscum commonly presents as multiple lesions. Patients with HIV infection may develop giant lesions (>1 cm) or clusters of hundreds of small lesions. A: AssessmentA partial differential diagnosis includes the following: - Disseminated cryptococcosis
- Other fungal infection
- Folliculitis
- Syphilis, condyloma acuminata, vulvar syringoma for multiple small molluscum genital lesions
- Squamous or basal cell carcinoma for large, solitary genital lesions
P: PlanDiagnostic EvaluationThe diagnosis of molluscum is usually based on the characteristic appearance of the lesions. Perform laboratory testing, if indicated, to exclude other infections or malignancies. TreatmentBecause molluscum does not cause illness and rarely causes symptoms, the goal of treatment is primarily cosmetic. Molluscum is difficult to eradicate in HIV-infected patients, and lesions often recur, particularly if immune suppression persists. Effective antiretroviral therapy may achieve resolution of lesions or significant improvement in the extent or appearance of molluscum. Refer complex cases to a dermatologist. Other therapeutic options include: - Local excision may be done by electrocautery, evisceration, curettage, or cryotherapy. Adverse effects include pain, irritation, soreness, and mild scarring. Repeated treatments are necessary.
- Imiquimod 5% (Aldara), an immune response modifier, stimulates production of interferon-alfa and other proinflammatory cytokines, inducing a tissue reaction known to be associated with viral clearance from the skin. Apply 3 times per week for up to 16 weeks or nightly for 4 weeks. Clearing can take up to 3 months.
- Tretinoin (Retin-A) 0.1% cream can be applied to lesions twice daily. Adverse effects include drying, peeling, irritation, and soreness.
- Podophyllum resin (podophyllin) is administered by a health care provider and washed off after 1-4 hours. This treatment is caustic and may cause significant irritation, is contraindicated in pregnancy, and has limited effectiveness.
- Patient-administered podophyllotoxin (Podofilox) may be a safer alternative to podophyllum. Adverse effects include burning, pain, inflammation, erosion, and itching.
- Trichloroacetic acid is administered by a health care provider. Controlling the depth of acid penetration is difficult. Adverse effects include pain and irritation; mild scarring is common.
- Laser therapy may be used to remove lesions.
- Cidofovir 1% to 3% topical cream, combined with a vehicle, is applied twice daily for 2 weeks, followed by a 30-day rest period and then 2 additional cycles. This treatment was effective in several small studies and case reports, but it is expensive and difficult to compound. No systemic adverse effects are noted.
- Investigational treatments include 5-aminolevulinic acid with subsequent photodynamic therapy and intravenous cidofovir.
Patient Education- Molluscum infection is benign but may be distressing.
- Patients should avoid shaving in areas with lesions because shaving could spread the lesions to other areas.
- Molluscum infection may be transmitted both sexually and nonsexually, through direct contact with lesions. Patients should avoid close contact between their molluscum lesions and the skin, mouth, and genitals of other people. Latex condoms may not prevent transmission.
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