Tuesday, April 07, 2009
The therapy of molluscum contagiosum is divided into three
treatment groups: children, adults, and the immunosuppressed.
Molluscum contagiosum limited to the genital area in children
should raise the possibility of child abuse.
Children may have a few lesions or many lesions (50 to
More than 50 lesions
- For children with many lesions, no therapy is an acceptable
approach. These lesions eventually will disappear spontaneously
without sequelae. Parents are reluctant to accept this option, but
heroic measures are unnecessary and potentially scarring both
physically and emotionally.
- In the cooperative child, cantharidin applied for 2-6 hours may
cause enough irritation to cause lesions to involute.
Less than 50 lesions
If the number of lesions is manageable and the child is at least
in part cooperative, multiple topical therapies may work.
- Administer cryotherapy with liquid nitrogen to the individual
- Apply 1 tiny drop of cantharidin to the tip of each lesion and
wash off in 2-6 hours. Do not occlude. Before allowing the patient
to move around, be sure the medication is dry to the touch so that
it does not spread to normal skin. Lesions will crust and fall off
in less than 1 week. This medication must be applied by the doctor
in the office. It cannot be used in occluded areas (axillae, groin,
inner thighs) or around the eyes.
- Pricking the surface of a lesion with a #11 blade will often
lead to inflammation and resolution of that lesion. Pressing out
the central core of the lesion with a comedone extractor will
- Cooperative children may occasionally be able to tolerate the
pain of curetting individual lesions.
Molluscum contagiosum in normal adults is usually an STD and is
found in the genital area. Adults with extensive lesions outside
the genital area must be evaluated for immunosuppression,
especially HIV infection.
- Cryotherapy with liquid nitrogen is quick and effective.
- Evaluate for other STDs.
- Examine and treat the patient's sexual partner(s).
- Advise the patient that the lesions are sexually
- Destruction of each lesion by pricking with a large (18-guage)
needle or a #11 blade. Removal of the core with a comedone
extractor will enhance resolution.
- Adults will usually tolerate curettage of individual
- Electrocautery may be used to destroy smaller lesions.
Anesthesia with topical EMLA may allow this form of treatment
without injected anesthesia.
One treatment is usually inadequate to eradicate all lesions.
See the patient at biweekly intervals until no lesions are present,
then 4-6 weeks after the last visit for a final check.
- The most common error is diagnosing molluscum as genital warts.
If there is any question, refer the patient.
- Avoid cantharidin in the genital area.
In severe immunosuppression, especially in advanced AIDS,
extensive facial or genital molluscum are very common. Total cure
is almost impossible. (Individual lesions, in general, do not
spontaneously resolve as in healthy adults and children.) Lesions
are treated for cosmesis at the patient's request.
Molluscum contagiosum in the setting of HIV infection is a
direct consequence of significant immunosuppression. The treatment
of choice is institution of Highly Active Antiretroviral Therapy
(HAART). Once the helper T-cell count exceeds 100, the molluscum
begin to resolve, leaving no scars. This takes several months.
Aggressive therapy that potentially would scar should not be
undertaken until the full beneficial effects of immune
reconstitution have been realized.
- Liquid nitrogen cryotherapy (preferably by spray rather than a
swab) is effective and well tolerated for smaller lesions.
- For facial or truncal molluscum, cantharidin applied for 2-6
hours and then washed off will also resolve lesions. This has the
advantage of usually being painless.
- Instruct the patient to use only an electric razor (preferably
with floating heads) to shave. This type of shaving is less likely
to spread the lesions.
- Pricking and curetting lesions, although also effective, have
disadvantages. First, this approach is potentially hazardous to the
care provider because he or she may be exposed to blood. Second,
this may provide a portal of entry for infection. If these methods
are used, appropriate precautions are necessary.
- 5-Fluorouracil 5% cream may cause inflammation of lesions and
their gradual resolution. Treatment should be used at the frequency
tolerated by the patient in order to maintain mild inflammation of
the lesions. This is usually once or twice weekly in fair-skinned
persons, but up to once daily in persons of color. Several months
of treatment may be required.
- In severe cases, trichloroacetic acid peels, up to 50%
concentration, may be considered.
In the setting of immunosuppression, other infectious agents
(eg, herpes simplex, Cryptococcus neoformans) may produce
lesions mimicking molluscum contagiosum. If there is any question
as to the correct diagnosis, a biopsy should be performed.