Molluscum Contagiosum

C r o w e , M a r k A . Moluscum Contagiosum. Diakses dari:

http://emedicine.medscape.com/article/221901-clinical.2011. Pada tanggal 27
Desember 2016

Background

Molluscum contagiosum virus causes a benign viral

infection that is largely (if not exclusively) a disease of
humans. Molluscum contagiosum virus causes
characteristic skin lesions consisting of single or, more
often, multiple, rounded, dome-shaped, pink, waxy
papules that are 2-5 mm (rarely up to 1.5 cm in the case
of a giant molluscus) in diameter. The papules are
umbilicated and contain a caseous plug. See the images
below for examples.

Note the central umbilication in these classic lesions of

molluscum contagiosum.

Approximately 10% of patients develop eczema around

lesions. Eczema associated with molluscum lesions
spontaneously subsides following removal.

Larger lesions may have several clumps of molluscum

bodies rather than the more common single central
umbilication. This may make them difficult to recognize
as molluscum contagiosum.
Bateman first described the disease in 1817, and
Paterson demonstrated its infectious nature in 1841. In
1905, Juliusburg proved its viral nature. Infection
follows contact with infected persons or contaminated
objects, but the extent of epidermal injury necessary is
unknown. Lesions may spread by autoinoculation.
Complications
Complications of molluscum contagiosum include irritation, inflammation, and
secondary infections. Lesions on eyelids may be associated with follicular or papillary
conjunctivitis. Bacterial superinfection may occur but is seldom of clinical significance.
Cellulitis is an unusual complication of molluscum contagiosum in patients who are HIV
infected. [2] Secondary infection with Staphylococcus aureus has resulted in abscess
formation, whereas Pseudomonas aeruginosa can cause necrotizing cellulitis.

Etiology
Transmission
The molluscum contagiosum virus may be inoculated along a line of minor skin trauma
(eg, from shaving), resulting in lesions arranged in a linear pattern (see the image
below). This process, termed autoinoculation, can also result from manipulation of
lesions by the patient. Autoinoculation is different from the Koebner phenomenon, which
is also called an isomorphic response. In the Koebner phenomenon, new lesions
develop along a line of trauma and the etiology of the underlying condition is unknown.
Psoriasis and lichen planus are examples of skin
conditions that commonly koebnerize.
In a patient who had preexisting molluscum
contagiosum, the virus was inoculated along a line
of minor skin trauma, resulting in the development
of the 3 new lesions.
Molluscum contagiosum virus transmission through
direct skin contact between children sharing a bath
and between athletes sharing gymnasium
equipment and benches has been reported. An
association between school swimming pool use and molluscum contagiosum infection
has also been reported. [3, 4]

Three distinct disease patterns are observed in 3 different patient populations: children,
adults who are immunocompetent, and patients who are immunocompromised (children
or adults). The prognosis and therapy are different for each of these groups.
Molluscum contagiosum is most common in children who become infected through
direct skin-to-skin contact or indirect skin contact with fomites, such as bath towels,
sponges, and gymnasium equipment. Lesions typically occur on the chest, arms, trunk,
legs, and face. Hundreds of lesions may develop in intertriginous
areas, such as the axillae and intercrural region (see the image
below). Lesions may rarely occur on the mucous membranes of the
lip, tongue, and buccal mucosa. The palms are spared. Patients with
atopic dermatitis may develop large numbers of lesions.
Molluscum lesions may become quite numerous in intertriginous
areas. This child has autoinoculated lesions to both inner thighs.
In adults, molluscum contagiosum most commonly is a sexually transmitted disease
(STD). Healthy adults tend to have few lesions, which are limited to the perineum,
genitalia, lower abdomen, or buttocks. Molluscum contagiosum in healthy children and
adults is usually a self-limited disease.
Widespread, persistent, and atypical molluscum contagiosum may occur in patients who
are significantly immunocompromised or have acquired immunodeficiency syndrome
(AIDS) with low CD4 T-lymphocyte counts (see the images below). Molluscum
contagiosum may be the presenting complaint in patients with AIDS. Molluscum
contagiosum virus infection in immunocompromised patients may be particularly
resistant to therapy. Other opportunistic infections in these patients may closely
resemble molluscum contagiosum.

Molluscum contagiosum rarely occurs on the face in an adult unless the patient is
infected with HIV. When molluscum contagiosum occurs in individuals infected with HIV,
facial lesions are common and frequently numerous.

Molluscum contagiosum lesions in individuals infected with HIV may number in the
hundreds. In addition, they may become quite large and prominent.
 Multiple papules on the face of a man with HIV.
Case reports have detailed molluscum contagiosum eruptions in areas that were treated
with tacrolimus 0.1% (Protopic). [5, 6, 7]
Infection
The molluscum contagiosum virus replicates in the cytoplasm of epithelial cells,
producing cytoplasmic inclusions and enlargement of infected cells. This virus infects
only the epidermis. Infection follows contact with infected persons or contaminated
objects, but the extent of necessary epidermal injury is unknown. The initial infection
seems to occur in the basal layer, and the incubation period is usually 2-7 weeks. This
is suggested by the fact that, although viral particles are noted in the basal layer, viral
deoxyribonucleic acid (DNA) replication and the formation of new viral particles do not
occur until the spindle and granular layers of the epidermis are involved. Infection may
be accompanied by a latent period of as long as 6 months.
Following infection, cellular proliferation produces lobulated epidermal growths that
compress epidermal papillae, while fibrous septa between the lobules produce pear-
shaped clumps with the apex upwards. The basal layer remains intact.
Cells at the core of the lesion show the greatest distortion and are ultimately destroyed,
resulting in large hyaline bodies (ie, molluscum bodies, Henderson-Paterson bodies)
containing cytoplasmic masses of virus material. These bodies are present in large
numbers and appear as a white depression at the center of fully developed lesions.
Occasionally, the lesions can progress beyond local cellular proliferation and become
inflamed with attendant edema, increased vascularity, and infiltration by neutrophils,
lymphocytes, and monocytes.
As with other poxviruses, molluscum contagiosum virus does not appear to develop
latency but evades the immune system through the production of virus-specific proteins.
Cell-mediated immunity is most important in modulating and controlling the infection.
Children and patients with HIV infection generally have more widespread lesions.
Prevalence of molluscum contagiosum virus in patients with HIV may be as high as 5-
18%, and the severity of infection is inversely related to the CD4 T-lymphocyte count.
More extensive and resistant infections also are noted in patients receiving prednisone
and methotrexate.
The virus is not strongly immunogenic, as it infrequently induces antibody formation.
Specific antibodies have been found in approximately 80% of patients and in about 15%
of control subjects. A role for humoral immunity in regression of lesions is not
established. Reinfection is common.
Viral characteristics
Molluscum contagiosum is a viral disease caused by a DNA poxvirus and is largely, if
not exclusively, a disease of humans. It is an unclassified member of the Poxviridae
family (ie, poxviruses).
The poxviruses are a large group of viruses with a high molecular weight. They are the
largest animal viruses, only slightly smaller than the smallest bacteria, and are just
visible using light microscopy. They are complex DNA viruses that replicate in the
cytoplasm and are especially adapted to epidermal cells. They cannot be grown in
tissue culture or eggs. Molluscum contagiosum virus has been grown in human foreskin
grafted to athymic mice but not in other laboratory animals.
Humans are the host for the following 3 types of molluscum contagiosum virus:
Orthopoxvirus - This resembles variola (smallpox) and vaccinia, which are ovoid
(300 x 250 nm)
Parapoxvirus - These are orf and milkers nodule viruses, which are cylindrical
(260 x 160 nm)
Unclassified (with features that are intermediate between those of the orthopox
and parapox groups) - These are intermediate in structure (275 X 200 nm); they
include molluscum contagiosum virus and tanapox
The primary structure and coding capacity of molluscum contagiosum virus was
determined by Senkevich et al. [8] Analysis of the molluscum contagiosum virus genome
has revealed that it encodes approximately 182 proteins, 105 of which have direct
counterparts in orthopoxviruses.
Restriction endonuclease analysis of the genomes has identified 4 types. Molluscum
contagiosum virus I and molluscum contagiosum virus II have genomes of 185
kilobases (kb) and 195 kb, respectively. Molluscum contagiosum virus III and IV are
very rare.
No relationship between virus type and lesional morphology or anatomical distribution is
known. Molluscum contagiosum virus encodes an antioxidant protein (MC066L),
selenoprotein, which functions as a scavenger of reactive oxygen metabolites and
protects cells from damage from ultraviolet (UV) light and peroxide. The particular role
of this protein is not known.
In one study, type I caused 96.6% and type II caused 3.4% of infections in 147 patients,
but no relationship was observed between virus type and lesional morphology or
anatomic distribution. [1]
Epidemiology
Occurrence in the United States
Molluscum contagiosum is a common infection throughout the United States and
accounts for approximately 1% of all skin disorders diagnosed. Data reported from
1969-1983 by the National Disease and Therapeutic Index Survey show an increasing
number of patient visits. The prevalence rate in patients with HIV is reported to be 5-
18%, and, if the CD4 cell counts are less than 100 cells/L, the prevalence of
molluscum contagiosum is reported to be as high as 33%.
International occurrence
The molluscum contagiosum virus occurs throughout the world, and its incidence in
most areas is not reliably known. It is more prevalent in tropical areas. In Mali,
molluscum contagiosum is among the most frequent dermatoses in children, with an
incidence of 3.6%. [9] In Australia, an overall seropositivity rate of 23% is reported. [10]The
lowest antibody prevalence was in children aged 6 months to 2 years (3%), and
seropositivity increased with age to reach 39% in persons aged 50 years or older.
Childhood molluscum contagiosum is common in Papua New Guinea, Fiji, and certain
parts of Africa. During a regional outbreak in East Africa, it was estimated that 17% of
the village population and as many as 52% of children older than age 2 years
developed lesions. Epidemiologic studies suggest that transmission may be related to
poor hygiene and climatic factors such as warmth and humidity.
Race- and sex-related demographics
During a US longitudinal study performed from 1977-1981, 2-4 times as many cases
were found in whites than in persons of other races. [11] Whether the noted difference
was secondary to differences in access to medical care, other socioeconomic factors, or
genetic predisposition is unclear. [12]
Several studies have shown that males are affected by molluscum contagiosum more
commonly than are females. Data from STD clinics in England and Wales revealed that
more than twice as many men as women were diagnosed with the infection.
Age-related demographics
Molluscum contagiosum is rare in children younger than age 1 year, perhaps because
of maternally transmitted immunity and a long incubation period; otherwise, incidence
seems to reflect exposure to others. The greatest incidence is in children younger than
age 5 years and in young adults. The peak among the pediatric age group correlates
with casual contact, whereas the peak in young adults correlates with sexual
contact. [13, 14]
Spread of the virus among households is common in warm climate countries where
children are lightly dressed and in close contact with one another and where personal
hygiene may be poor. The age of peak incidence is reported to be 2-3 years in Fiji and
1-4 years in the Congo (formerly Zaire). In New Guinea, the annual infection rate for
children younger than age 10 years was found to be 6%.
In cooler climates, spread within households is less common, and infection is more
common at a later age. Use of school swimming pools is correlated with childhood
infections, with a peak incidence in children aged 10-12 years in Scotland and 8 years
in Japan. Prevalence appears to be increasing in all age groups.

Prognosis
The prognosis in molluscum contagiosum is generally excellent because the disease is
usually benign and self-limited. Spontaneous resolution generally occurs by 18 months
in immunocompetent individuals; however, lesions have been reported to persist for as
long as 5 years. In healthy patients, treatments are usually effective, although lesions
can be disfiguring and may produce anxiety in the patient, family, and daycare facility or
school.
Recurrences occur in as many as 35% of patients after initial clearing. The significance
of these recurrences is unknown. They may represent reinfection, exacerbation of
ongoing disease, or new lesions arising after a prolonged latent period.
The disease often becomes generalized in patients who are infected with HIV or are
otherwise immunocompromised. A direct correlation has been found between
increasing severity of the disease and lower CD4 counts. The duration of infection is
uncertain in populations with HIV infection and in populations that are otherwise
immunocompromised (eg, patients who have undergone renal transplant), because
molluscum contagiosum may not be self-limiting in these cases.
Morbidity and mortality
Molluscum contagiosum is generally a benign and self-limited infection. For the most
part, morbidity is caused by temporary adverse cosmetic results. Morbidity is higher in
immunocompromised patients because they tend to have more lesions and more
widespread infection. Most lesions resolve with no permanent residual skin defect;
however, occasional lesions may produce a slightly depressed scar. This may represent
deeper skin damage in lesions that were particularly inflammatory or secondarily
infected. Involvement of the margin of the eyelids may produce keratoconjunctivitis. No
mortality has been associated directly with the molluscum contagiosum virus.

Patient Education
Before attempting any therapy, educate the patient or parents in-depth about the
diagnosis, prognosis, risk of autoinoculation or infection of others, therapeutic options,
and risks of therapy. [15, 16] More than 1 treatment session is frequently required.
Providing this information at the first clinical visit is particularly important when treating
benign lesions, such as those of molluscum contagiosum and common warts. A few
extra minutes of explanation at this stage can prevent or mitigate numerous problems
and questions during later visits. [17]
When lesions fail to respond to initial therapy, a temptation to be overzealous in
treatment may occur. Patients and families are more understanding and less likely to
demand aggressive therapy when reasonable goals and limitations of therapy are
thoroughly discussed.
Stress the benign nature of this ubiquitous disease to the patient and his or her parents.
Limiting physical contact with infected areas of skin and good handwashing may reduce
transmission. Instruct the patient to avoid scratching, which may result in
autoinoculation.
Keeping children out of school is not necessary; however, discourage physical contact
and sharing of clothes and towels. In smaller children in whom physical contact is more
difficult to prevent, keeping infected areas covered with clothing is reasonable. Cover
exposed lesions with tape or an adhesive bandage. Infection of other children cannot be
completely prevented. Because the disease is extremely common and of very little
clinical significance, the decision to limit infected children from daycare centers must be
approached on a case-by-case basis.
In adolescent and adult patient populations, this disease is usually sexually transmitted.
Encourage safe sex and abstinence; however, whether condoms and other barrier
methods provide adequate protection against transmission is unclear.
Emphasize that not all STDs are as benign as molluscum contagiosum virus (eg,
herpes simplex, gonorrhea, chlamydia, HIV). Stress adherence to abstinence until
lesions resolve. In the patient with multiple sexual partners or other risk factors, HIV
testing is strongly recommended. Note that not all cases in adults are sexually
transmitted. This diagnosis can cause significant relationship stress.
For patient education information, see the Skin Conditions and Beauty Center, as well
as Molluscum Contagiosum.

Clinical Presentation

History
Molluscum contagiosum is usually asymptomatic; however, individual lesions may be
tender or pruritic. In general, the patient does not experience systemic symptoms, such
as fever, nausea, or malaise.
The patient may recall contact with an infected sexual partner, family member, or other
person. Patients who report having multiple sexual partners or unprotected sex have an
increased risk of infection. Contact may be reported in children sharing a bath or in
athletes sharing gymnasium equipment and benches. Parents may report recent
exposure to other children affected with molluscum contagiosum at school, camp, or
public recreational facilities (eg, gymnasiums, swimming pools).
If the patient has skin conditions that disrupt the epidermal layer, molluscum tends to
spread more rapidly.
The patient may notice new lesions developing along a scratch in areas of involved
skin. Patients with atopic dermatitis may have more extensive disease and may have a
positive family history of atopy (eg, eczema, asthma, hayfever). Children frequently
have active atopic dermatitis.
A report detailed an eruption of molluscum contagiosum in a patient who had
undergone a renal transplant. [18] Case reports have detailed molluscum contagiosum
eruptions in areas that were treated with tacrolimus 0.1% (Protopic). [5, 6,7]
Duration of the individual lesion and of the attack varies. Although most cases resolve
without therapy within 6-9 months, some persist for 3-4 years. Individual lesions seldom
persist more than 2 months.
Patients with HIV or those receiving prednisone, methotrexate, or other
immunosuppressive medications may have more extensive and resistant infections.
Patients infected with HIV
Patients generally have a low CD4 count, with the severity of infection being inversely
related to the count.
Patients who are poorly compliant or noncompliant with highly active antiretroviral
therapy (HAART) for the treatment of HIV are at an increased risk, as are patients who
have multiple sexual partners. The frequency of unprotected sex also increases the risk
of transmission.

Physical Examination
Lesions are discrete, nontender, flesh-colored, dome-shaped papules that show a
central umbilication (which is more apparent when the lesion is frosted with liquid
nitrogen). (See the image below.)
Presented here are the classic umbilicated papules of molluscum contagiosum lesions
on the cheek of a child. Facial lesions occur frequently in children, although lesions
generally are few.
Lesions are usually 2-5 mm (rarely up to 1.5 cm in
the case of giant molluscus) in diameter and may be
present in groups or widely disseminated.
Immunocompetent children and adults usually have
fewer than 20 lesions. Larger lesions may have
several distinct clumps of molluscum bodies (see the
image below). Beneath the umbilicated center is a
white, curdlike core that contains molluscum bodies.
Some lesions become confluent to form a plaque
(agminate form).

Larger lesions may have several clumps of molluscum bodies rather than the more
common single central umbilication. This may make them difficult to recognize as
molluscum contagiosum.
Lesions may be located anywhere; however, a predilection for the face, trunk, and
extremities is observed in children and a predilection for the groin and genitalia is
observed in adults. Lesions are seldom found on the palms and are rarely documented
on the soles, oral mucosa, or conjunctiva.
Distribution is influenced by the mode of infection, type of clothing worn, and climate. In
sexually active individuals, the lesions may be confined to the penis, pubis, and inner
thighs (see the image below). Widespread and persistent molluscum contagiosum may
occur in patients with AIDS and may be the presenting complaint.
Molluscum contagiosum on the shaft of the penis.
Molluscum contagiosum in the genital region of
adults is most commonly acquired as a sexually
transmitted disease.
Molluscum contagiosum may be randomly
associated with other lesions, such as epidermal
cysts, nevocellular nevi, sebaceous hyperplasias,
and Kaposi sarcoma. Pseudocystic molluscum
contagiosum, giant molluscum contagiosum, and
molluscum contagiosum associated with other
lesions are responsible for frequent clinical
misdiagnosis.
Other characteristics of molluscum contagiosum
to consider include the following:
Intertriginous areas - Hundreds of lesions
may develop in intertriginous areas, such
as the axillae and intercrural region
Atopic dermatitis - Patients with atopic
dermatitis occasionally develop large
numbers of lesions, which are confined to
areas of lichenified skin
Eczema - Approximately 10% of patients develop eczema around the lesions, with
this being attributed to toxic substances produced by the virus or to a
hypersensitivity reaction to the virus; eczema that is associated with molluscum
lesions subsides spontaneously following removal (see the first image below)
Inflammatory changes - These result in suppuration, crusting, and eventual
resolution of the lesion; this inflammatory stage does not usually represent
secondary infection and seldom requires antibiotic therapy (see the second image
below)
Approximately 10% of patients develop eczema around lesions. Eczema
associated with molluscum lesions spontaneously subsides following removal.
After trauma, or spontaneously after several months,
inflammatory changes result in suppuration, crusting and
eventual resolution of the lesion. This inflammatory stage
does not usually represent secondary infection and
seldom requires antibiotic therapy.
Disfiguring lesions may occur in patients with the following
conditions:
AIDS - Facial and perioral molluscum contagiosum
are most commonly observed as a manifestation of HIV
 infection, particularly in homosexual men with HIV [19] ; at the time of molluscum
contagiosum diagnosis, the CD4 count is low
Immunocompromise - Lesions are especially common and extensive on the face
and neck
Sarcoidosis
Lymphocytic leukemia
Congenital immunodeficiency
Selective immunoglobulin M (IgM) deficiency
Thymoma
Treatment with prednisone and methotrexate
Disseminated malignancy
Refractory atopic dermatitis

Molluscum contagiosum virus is an unclassified member of the Poxviridae family. It

cannot be grown in tissue culture or eggs; it has been grown in human foreskin grafted
to athymic mice but has not been transmitted to other laboratory animals. (See Etiology
below.)
Through restrictive endonuclease analysis of the genomes of isolates, molluscum
contagiosum virus types I-IV have been identified. In a study of 147 patients, molluscum
contagiosum virus I caused 96.6% of infections, and molluscum contagiosum virus II
caused 3.4%; however, no relationship was observed between virus type and lesional
morphology or anatomical distribution. [1] Molluscum contagiosum viruses III and IV are
rare. In patients with human immunodeficiency virus (HIV) infection, molluscum
contagiosum virus II causes most infections (60%).

Diagnostic Considerations
The cutaneous manifestations of other opportunistic infections, such as cutaneous
cryptococcosis, histoplasmosis, and aspergillosis, may mimic molluscum contagiosum
and must be ruled out in immunocompromised hosts. (See the images below.)
This lesion of cutaneous coccidioidomycosis could
be included among the differential diagnoses of
molluscum contagiosum.

This keratoacanthoma could be

included among the differential
diagnoses of molluscum contagiosum.
Molluscum contagiosum may be randomly associated with other lesions, such as
epidermal cysts, nevocellular nevi, sebaceous hyperplasias, and Kaposi sarcoma.
Pseudocystic molluscum contagiosum, giant molluscum contagiosum, and molluscum
contagiosum associated with other lesions are responsible for frequent clinical
misdiagnoses.
Infection of children through sexual abuse is possible; however, to a greater extent than
warts, molluscum contagiosum virus is quite common on the genital, perineal, and
surrounding skin of children. [20, 21] Regard abuse as unlikely, unless other suspicious
features are present.
Histologic or microscopic confirmation of molluscum contagiosum is indicated in
patients who are immunocompromised because several life-threatening opportunistic
infections may clinically mimic molluscum contagiosum.
Conditions to consider in the differential diagnosis of molluscum contagiosum include
the following:
Keratoacanthoma
Verruca vulgaris (warts)
Eccrine poroma
Epidermal cyst
Foreign body granuloma
Lichen planus
Flat warts (verruca plana)
Pyoderma
Perforating disorders (all very rare in children) to consider in the differential diagnosis of
molluscum contagiosum include the following:
Acquired reactive perforating dermatosis of renal failure
Kyrle disease
Perforating serpiginous elastoma
Perforating folliculitis
Verrucous perforating collagenoma
Perforating granuloma annulare

Workup
Approach Considerations
In most instances, a diagnosis is easily established because of the distinctive, central
umbilication of the dome-shaped lesion. Pseudocystic molluscum contagiosum, giant
molluscum contagiosum, and molluscum contagiosum associated with other lesions
may be more difficult to diagnose clinically.
If diagnosis is uncertain, lesions may be biopsied. Characteristic intracytoplasmic
inclusion bodies (molluscum bodies, or Henderson-Paterson bodies) are seen on
histologic examination findings.
Express the pasty core of a lesion by crushing the lesion between 2 microscope slides
and staining it to reveal the particulate virions, which are present in abundance. Firm
compression between the slides is required to release the virions with the stain in place.
The use of crystal violet, safranin, and ammonium oxalate in 10% ethanol; the
Papanicolaou test; or Wright, Giemsa, or Gram stains can reveal the virions that make
up the Henderson-Paterson bodies.
Measure serum antibodies by complement fixation, tissue culture neutralization,
fluorescent antibody, and gel agar diffusion techniques; however, they are not well
standardized and are seldom used except in research protocols.
Polymerase chain reaction (PCR) assay can be used to detect and categorize
molluscum contagiosum virus in skin lesions.
Molluscum contagiosum virus cannot be grown in tissue culture; however, Buller et al
demonstrated molluscum contagiosum virus replication in an experimental system using
human foreskin grafted to athymic mice. [23]
Evaluate the patient for other sexually transmitted diseases (STDs) because sexually
active patients may acquire other concomitant venereal diseases, such as syphilis and
gonorrhea. Always consider testing for HIV infection in patients with facial lesions.
Squash preparation
Squash preparation is microscopic examination of cellular exudate. The cellular material
contained within the central umbilication may be extracted manually, flattened between
2 microscope slides, and stained. Microscopic examination of this preparation reveals
the Henderson-Paterson bodies.
Histologic Findings
Lesions in molluscum contagiosum have a characteristic histopathology. [24] The
prototypical hematoxylin and eosin (H&E)stained histologic section in this disease
reveals a cup-shaped indentation of the epidermis into the dermis (as seen in the
images below). Downward proliferation of the rete ridges with envelopment by the
connective tissue forms the crater.
This low-power view of a molluscum
contagiosum lesion shows the classic cup-
shaped invagination of the epidermis into
dermis. The Henderson-Paterson bodies are
identified readily and stained purple to red in
this image.
Low-power histopathologic examination reveals
an overall cup-shaped appearance.

Within the region of the indentation, the

epidermis appears thickened (acanthosis),
possibly measuring up to 6 times the thickness
of the surrounding, uninvolved skin, and the
cornified layer typically is disintegrated. The
striking feature is the presence of
intracytoplasmic, eosinophilic, granular
inclusions within the keratinocytes of the basal,
spinous, and granular layers of the epidermis.
These inclusions, the Henderson-Paterson
bodies, can measure 35m in diameter. Ultrastructural studies have shown that these
bodies are membrane-bound sacs that contain numerous molluscum contagiosum
virions. The viral particles increase in size as
they progress up toward the granular layer,
causing compression of the nucleus to the
periphery of the infected keratinocytes. The
surrounding dermis is relatively unremarkable.
Intact lesions show little or no inflammatory
change.
This is a medium-power view of a molluscum
contagiosum lesion. Magnification allows better
demonstration of the intracytoplasmic molluscum
bodies (staining purple-pink) within the
keratinocytes.
Lesions of molluscum contagiosum have a
characteristic histopathology. Lobules containing
hyalinized molluscum bodies, also known as
Henderson-Paterson bodies, are diagnostic.

This molluscum contagiosum body is an

intracytoplasmic inclusion body. Notice in the
image that the keratinocyte nuclei are displaced
to the periphery of the cell and that the
intracytoplasmic inclusions have a granular
quality.

Cytoplasmic viral inclusions become

progressively larger toward the epidermal
surface (hematoxylin and eosin, 200X)
 Viral particles have a dumbbell-shaped
appearance. Courtesy of Alvin Zelickson, MD.

In nonprototypical cases of molluscum contagiosum, in which intradermal rupture of

molluscum bodies occurs, an intense, inflammatory dermal infiltrate consisting of
lymphocytes, histiocytes, and occasional foreign bodytype, multinucleated giant cells
may be observed. Rarely, metaplastic ossification may occur. Exceptionally, the
inflammatory dermal infiltrate may be intense enough to simulate a cutaneous
lymphoma (pseudolymphoma).

Treatment & Management

Approach Considerations
In healthy patients, molluscum contagiosum is generally self-limited and heals
spontaneously after several months. Individual lesions are seldom present for more
than 2 months. Although treatment is not required, it may help to reduce autoinoculation
or transmission to close contacts and improve clinical appearance.
Intervention may also be indicated if lesions persist. Therapeutic modalities include
topical application of various medications, radiation therapy, and/or surgery. Each
technique may result in scarring or postinflammatory pigmentary changes. Frequently,
multiple treatment sessions are necessary because of the recurrence of treated lesions
and/or the appearance of new lesions.
Therapeutic options for molluscum contagiosum can be divided into broad categories,
including the following:
Benign neglect
Direct lesional trauma
Antiviral therapy
Immune response stimulation

Choice of therapy
The most appropriate therapeutic approach largely depends on the clinical situation. In
healthy children, a major goal is to limit discomfort, and benign neglect or minor, direct
lesional trauma is appropriate. In adults who are more motivated to have their lesions
treated, cryotherapy or curettage of individual lesions is effective and well tolerated.
In immunocompromised individuals, molluscum contagiosum may be very extensive
and difficult to treat. The goal may be to treat the most troublesome lesions only. In
severe cases, these patients may warrant more aggressive therapy with lasers,
imiquimod, antiviral therapy, or a combination of these. [25] Of course, effective
antiretroviral therapy in patients with AIDS makes therapy of molluscum contagiosum
much more effective.
The US Food and Drug Administration (FDA) has approved none of the topical or
intralesional agents for treatment of molluscum contagiosum.
In a study of the treatment of molluscum contagiosum in children, Hanna et al
determined that curettage was the most efficacious therapy. The investigators
conducted a prospective, randomized trial that compared the efficacy and adverse
effects of 4 recognized treatments of molluscum contagiosum in 124 children. [26]One
group was treated with curettage, a second with cantharidin, a third with a combination
of salicylic acid and lactic acid, and a fourth with imiquimod.
Curettage was found to be the most efficacious treatment and had the lowest rate of
side effects. However, it must be performed with adequate anesthesia and is a time-
consuming procedure. Cantharidin had moderate complications due to blisters and was
slightly less effective. The topical keratolytic used was too irritating for children. Topical
imiquimod was more effective than cantharidin but is expensive, and an optimum
treatment schedule has yet to be reported.
Follow-up
Repeat examination is recommended 2-4 weeks after treatment. Retreatment often is
necessary. Consider combination therapy in patients whose lesions respond poorly.
Activity
Instruct the patient to avoid activities or sports involving physical contact between
infected areas of skin and exposed skin of other participants.
Deterrence and prevention
Most cases in adolescents and adults are secondary to sexual contact. Abstinence and
careful selection of sexual partners are important. Whether condoms are effective in
preventing spread is unclear. Good personal hygiene is important in limiting
transmission. Autoinoculation may result from trauma, such as shaving or the
manipulation of lesions by the patient.
Pharmacologic Therapy
Clinical success has been reported with the use of the following topical agents, which
may act as irritants, stimulating an immunologic response:
Imiquimod cream - An immune response modifier approved for the treatment of
external genital and perianal warts in adults, imiquimod cream has been reported
to be effective in the treatment of molluscum contagiosum [27, 28] ; imiquimod cream
may be used in conjunction with cantharidin [29]
Cantharidin - Several studies report that cantharidin, a chemovesicant that can be
used in combination with imiquimod, is effective in treating molluscum
contagiosum; to test the patient's response to therapy, treat only a few lesions on
the initial visit [29]
Tretinoin - This agent has reportedly been successful in the treatment of small
molluscum contagiosum lesions
Bichloracetic acid
Trichloroacetic acid
 Salicylic acid
Lactic acid
Glycolic acid
Silver nitrate
Potassium hydroxide
Tretinoin, cantharidin, and imiquimod may be dispensed to the patient with application
instructions and close follow-up, although some recommend application in the office.
Data regarding the efficacy of imiquimod cream for molluscum
[28, 30]
are mixed. Bichloracetic acid, trichloroacetic acid, salicylic acid, lactic acid,
glycolic acid, potassium hydroxide, and silver nitrate must be applied in the office by the
physician. [31]
Topical podophyllotoxin 0.5% cream self-administered twice daily for 3 weeks has been
reported effective in a placebo-controlled, double-blind study. [32]
Reports have suggested that subcutaneous interferon alfa administered intralesionally
may be useful in immunocompromised children.
A case report noted the efficacy of topical cidofovir in the treatment of disseminated
molluscum in immunodepressed patients. [6] Cidofovir diphosphate was reported to
inhibit molluscum contagiosum virus DNA polymerase activity. [33]

Benign Neglect
Leaving mollusca to spontaneously resolve is often reasonable, [34] especially in young
children for whom freezing or curettage may be painful and frightening. The
dictum primum non nocere (first do no harm) has a special significance in children with
minor, self-limited conditions. Many physicians refuse to treat children with small
numbers of mollusca.
Lesions on the eyelids and central face may be particularly distressing to parents and
patients. When possible, treat lesions at other locations first, with the hope that the
treatment may stimulate the facial lesions to spontaneously resolve. When facial lesions
require treatment, the best option is to treat them frequently with minor physical trauma.

Lesions on the upper eyelid of a 3-year-old

child.
More aggressive therapy may be required in
patients in whom the extent of disease is
intolerable and in patients who are
immunocompromised.

Direct Lesional Trauma

Takematsu et al reported that disruption of the epidermal wall of Henderson-Paterson
bodies induces acute inflammatory changes by activation of the alternative complement
pathway on exposure to the tissue fluids; furthermore, the Henderson-Paterson bodies
release proinflammatory cytokines and other neutrophil chemotactic factors upon
decomposition. [35] This supports the observation that minor trauma to molluscum lesions
frequently produces an inflammatory response and resolution of the lesion. The
Henderson-Paterson bodies can be ruptured and a local inflammatory response created
by various forms of physical trauma and caustic topical agents.
Various caustic agents have been shown to be effective in treating molluscum
contagiosum. Tretinoin, salicylic acid, and potassium hydroxide [36, 37] may be used.
Cantharidin, [29, 38] silver nitrate, [39] trichloroacetic acid, and phenol also are options.
Children may tolerate therapy with these agents better than curettage or cryotherapy.
None of these caustic agents has been approved by the FDA for treatment of
molluscum contagiosum.
Tretinoin cream
Tretinoin cream 0.1% or gel 0.025% is applied daily. Apply it to a region of skin with
scattered lesions. It may produce eczema and may increase the number of lesions
through autoinoculation; however, a small amount of tretinoin may be applied to
individual lesions with the rough end of a broken toothpick. Rotate the toothpick, gently
abrading the lesion and increasing the inflammatory response produced by the tretinoin.
Treat lesions every few days until significant inflammation or resolution occurs.
Potassium hydroxide
Potassium hydroxide is a strong alkali that has long been known to digest proteins,
lipids, and most other epithelial debris of skin scrapings to identify fungal infections.
Topical 10% potassium hydroxide aqueous solution applied twice daily on each
molluscum contagiosum lesion until all lesions undergo inflammation and superficial
ulceration may be effective in clearing molluscum contagiosum in children.
Cantharidin
Cantharidin is a chemovesicant that is highly effective in treating molluscum
contagiosum; however, this agent has lost favor with some physicians because of
concerns regarding its safety. However, if cantharidin is used properly, it is very
effective, safe, and well tolerated by children.
In a study by Silverberg et al in which 300 patients were treated with cantharidin, 90% of
patients experienced complete clearing after an average of 2.1 visits. Blisters occurred
at sites of application in 92% of patients. Temporary burning, pain, erythema, or pruritus
was reported in 6-37% of patients. No major adverse effects were reported, and no
patients experienced secondary bacterial infection. A total of 95% of parents reported
that they would proceed with cantharidin therapy again. [40]
Cantharidin is not approved by the FDA for treatment of any condition; however, it has
been used safely and effectively by dermatologists for many years. [41, 42] It is listed as
acceptable therapy in the American Academy of Dermatology treatment guidelines for
warts; however, because it has never been approved by the FDA for use in humans, it
is no longer marketed as medical therapy in the United States. Cantharidin crystals and
diluent can be purchased in the United States, and many dermatologists continue to use
it. Cantharidin solution for the treatment of warts and molluscum is available in Canada
and many other countries.
Salicylic acid
Seventeen percent salicylic acid in collodion (Compound W, Freezone, Wart-Off,
Occlusal) is commonly used in treating verruca vulgaris. In most patients, repeated
application to individual molluscum contagiosum lesions until an inflammatory response
is generated is effective therapy.
Physical trauma
Varying degrees of physical trauma to individual lesions are used and are frequently
quite successful. Physical trauma to individual molluscum contagiosum lesions can be
performed with cryotherapy, lasers, curettage, [43, 44] expression of the central core with
tweezers, rupture of the central core with a needle or a
toothpick, [45, 46]electrodesiccation, shave removal, or duct tape occlusion. [47]
Instruct the parents to tease out the firm, white core at the center of lesions using a
clean needle or a toothpick. The process of irritating the lesion usually causes it to
inflame and resolve within 1-2 weeks. This safe and easy approach can be performed
by the patient's parent, limiting the need for follow-up visits.
In an office setting, curettage of individual lesions is easy and very effective. With a
sharp curette and a quick firm motion, small, individual lesions can be removed
completely, with little or no bleeding. With practice and a sharp curette, the provider
may perform this procedure with little or no discomfort. Older children, adolescents, and
adults usually tolerate this procedure better.
Other simple mechanical methods, such as expression of the contents in the papule by
squeezing it with forceps held parallel to the skin surface or shaving off the lesions with
a sharp scalpel, are effective.
Lesions may also be treated with light electrodesiccation. At very low voltage settings,
anesthesia may not be required.
Cryotherapy is the first-line treatment for many physicians, particularly in adolescents
and adults. A brief freeze, which causes icing of the lesion and a thin rim of surrounding
skin, is usually adequate. Treatment is repeated at intervals of 2-3 weeks until all
lesions resolve. Achieve accurate spray of liquid nitrogen by using a disposable ear
speculum. The small end is placed against the skin, and liquid nitrogen is sprayed into
the funnel created. Lesions also may be treated with cotton-tip applicators chilled in
liquid nitrogen and held against the lesion until a small amount of frosting occurs.
Cryotherapy is painful and the smoke that rises off the cold applicator or the noise of the
liquid nitrogen sprayer may be quite frightening to younger children.
Pulsed dye laser (PDL) therapy has been shown to be more than 95% successful in
treating individual lesions with 1 treatment. PDL treatment of molluscum contagiosum
has been used successfully in patients with AIDS. A significant reduction in the number
of molluscum contagiosum lesions following a single treatment with the PDL can be
attained. Treated areas may remain disease-free for months. Although cost and
availability are major limiting factors for routine use, PDL therapy may be considered for
treatment of extensive or resistant lesions. It may also be valuable in
immunocompromised individuals with extensive disease. [48, 49,50, 51, 52]
Treatment of molluscum contagiosum in patients with AIDS remains a challenge. The
combination of 2 or more therapeutic modalities, such as carbon dioxide laser, PDL,
and trichloroacetic acid, can be of much help to improve the quality of life of these
patients.
The discomfort of curettage or other mechanical removal may be reduced. Lesions may
be sprayed with ethyl chloride until frosting has occurred and then scraped away with a
curette. The application of local anesthetic cream, EMLA (a eutectic mixture of 5%
lignocaine and prilocaine) or its equivalent, may permit painless treatment. The cream is
best applied under occlusion 1-2 hours before the planned procedure.

Immune Response Stimulation

Imiquimod cream, intralesional interferon alfa, [53] and topical injections of streptococcal
antigen [54] have been shown to be effective in treating patients with resistant molluscum
contagiosum. The high cost of these products limits their use to more extensive or
resistant infections. Imiquimod cream applied 3 times per week for 16 weeks is an
option in severe cases. The dosing schedule and length of treatment require further
evaluation. [26, 28, 55, 56, 57, 58, 59, 60]
Imiquimod is a novel topical immune response modifier that is a potent inducer of
interferons. Various treatment regimens have been effective in treating molluscum
contagiosum. In children [61, 62] and in some patients with AIDS-associated molluscum
contagiosum, [63, 27] 1% cream applied 3 times daily or 5% cream applied at every
bedtime for 4 weeks appears to be effective treatment.
A newer compound, Veregen, is a sinecatechin. Its true mechanism of action is
unknown. It is a botanical extract from green tea. The 15% ointment is applied topically
3 times a day. It is FDA approved for topical therapy for external genital warts and
perianal warts, but it is used off label for molluscum as well as verruca plana. [64]

Antiviral Therapy
In immunocompromised patients, improvement of lesions has been observed in
individual patients treated with ritonavir, cidofovir (intravenous and topical), [65, 66]and
zidovudine. Not surprisingly, patients with AIDS and severe molluscum contagiosum
improve with effective antiretroviral therapy.

Medication Summary
Molluscum contagiosum usually resolves within months in people with a normal immune
system. Many treatments have been promoted for molluscum contagiosum. The
common goal of most treatment methods is the destruction of lesions and the
development of a localized inflammatory reaction. Extensive controlled studies have not
been performed and all treatments have advantages and disadvantages. A review for
the Cochrane Database examined the effects of several topical, systemic, and
homeopathic interventions. [67] One report suggested using a 10% solution of essential
oil of Australian lemon myrtle (Backhousia citriodora). [68]
Among the findings, the investigators determined that there was limited evidence for the
efficacy of sodium nitrite coapplied with salicylic acid compared with salicylic acid alone.
In addition, no statistically significant differences were found for topical povidone iodine
plus salicylic acid compared with either povidone iodine or salicylic acid alone
The investigators also found no statistically significant differences between treatment
with placebo and therapy with potassium hydroxide or between placebo treatment and
systemic treatment with cimetidine or calcarea carbonica, a homeopathic drug.
The authors concluded no single intervention has been shown to be convincingly
effective in treating molluscum contagiosum. However, various limitations were found in
the studies reviewed, and the investigators cautioned that small study sizes may have
caused some important treatment differences to be missed. None of the evaluated
treatment options were associated with serious adverse effects.

Keratolytic Agents
Class Summary
These agents inhibit cell growth and destroy infected cells. They are applied directly to
lesions. To decrease discomfort, treat a small number of lesions at each visit.
Salicylic acid (Compound W, Freezone, Wart-Off)
Salicylic acid produces desquamation and inflammation. Various liquid products that
contain 17% salicylic acid as the caustic agent or as part of a mix of caustic agents
used to treat molluscum contagiosum and warts are available. Most of these products
include an adhesive such as collodion or a clear nail-polishlike material, which dries
within seconds of application. This helps to concentrate the caustic agent on the lesion
and minimize spread to the surrounding skin.
Tretinoin topical (Retin-A, Avita, Tretin-X)
Tretinoin is available in various bases and concentrations (0.025%, 0.05%, 0.1% cream;
0.01%, 0.025%, 0.1% gel; 0.05% solution). Applied to a region of skin with scattered
lesions, tretinoin may produce eczema and increase the number of lesions through
autoinoculation. However, a small amount of tretinoin may be applied to individual
lesions with good effect.
Cantharidin
Cantharidin is a strong vesicant. It has not been approved by the FDA for the treatment
of any condition but has been safely and effectively used by dermatologists for years. In
the American Academy of Dermatology treatment guidelines for warts, it is listed as the
second-line therapy following liquid nitrogen. However, because cantharidin has never
been approved by the FDA for use in humans, it is no longer marketed in the United
States.
Cantharidin crystals and diluent can be purchased in the United States, and numerous
dermatologists continue to use it. Cantharidin solution for the treatment of warts and
molluscum is available in Canada and many other countries. The effectiveness results
from the exfoliation of the lesion as a consequence of cantharidin's vesicant action. The
lytic action does not go below the basement membrane of epidermal cells. As a result,
unless the area becomes secondarily traumatized or infected, no scarring from topical
application occurs.
Topical Skin Products
Class Summary
These agents induce cytokines, including interferon. They are typically reserved for use
in patients with molluscum contagiosum that is refractory to cryotherapy or tretinoin.
Imiquimod 5% cream (Aldara, Zyclara)
Imiquimod induces the secretion of interferon alfa and other cytokines; its mechanisms
of action are unknown.

Antivirals, Other
Class Summary
Presumably, antiviral drugs may interfere with the ability of the molluscum contagiosum
virus to replicate. Because of their expense and adverse effect potential, consider these
products for use only in immunocompromised patients.
Cidofovir (Vistide)
Cidofovir is a selective inhibitor of viral DNA production in cytomegalovirus and other
herpes viruses. One case report showed improvement in 3 out of 3 patients with HIV
and extensive co-infection with molluscum contagiosum virus.
Ritonavir (Norvir)
Ritonavir is an antiretroviral protease inhibitor. In one case report, a patient with HIV
and intractable molluscum contagiosum had resolution of lesions after treatment.