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Approach to Molluscum Contagiosum

Developed by Aryan Riahi and Dr. M. B. Shokravi, MD, FRCPC for PedsCases.com. December 19, 2020

Introduction:

Hello, and welcome to PedsCases! My name is Aryan Riahi and I am a 4th year medical student at the University of British Columbia. This podcast was developed in collaboration with dermatologist, Dr. M.B.Shokravi, MD, FRCPC in Vancouver, British Columbia. This podcast will review an approach to molluscum contagiosum in paediatric patients. After listening to this podcast, the learner should be able to do the following:

Learning outcomes: 1. Describe the morphology of molluscum contagiosum. 2. Describe how to manage and treat molluscum contagiosum. 3. List indications on when to refer a patient with molluscum contagiosum to a Dermatologist.

Now, let’s talk about how can present in children by first starting out with a case.

Case: Mike is an otherwise healthy 5 year old boy complaining of an “itchy ” that has been spreading for the last 3 months. His family physician provided Mupirocin 2% ointment, and antibiotic cream, and instructed his mother to apply it on the patient’s affected area twice a day for 2 weeks, but the did not help. Family history is unremarkable for atopy or similar . Mike loves to swim. He is a single child who lives at home with his parents.

Developed by Aryan Riahi and Dr. M. B. Shokravi for PedsCases.com. December 19, 2020.

What is on your differential for pedunculated ? 1. Acrochordon ( tag), epidermal inclusion cyst, fibrokeratoma, , , and molluscum contagiosum.

What is the clinical presentation of molluscum contagiosum? 1. The causative agent of molluscum contagiosum is the DNA pox . 2. Molluscum contagiosum is a viral infection of the skin without systemic manifestations (i.e. fever). 3. It presents with small, skin-colored or pink, dome-shaped, umbilicated . Usually multiple. 4. The main demographic is young and school-aged children with history of swimming. 5. In order to characterize the virus' viability in pools, we need more research. One possibility is that softening of the lesions after they become submerged in water promotes transmission via or person-to-person contact. It is still not known if contaminated fomites such as towels and kicking boards have any role or if swimming in contaminated water is a contributing factor for virus transmission. 6. Although it can occur anywhere on the body, lesions are typically seen in areas of high friction where skin rubbing may occur.

Developed by Aryan Riahi and Dr. M. B. Shokravi for PedsCases.com. December 19, 2020.

Are any further investigations required for diagnosing molluscum contagiosum? 1. No, the diagnosis is made clinically. 2. While not routine, a can be taken to confirm the diagnosis but is rarely done in practice. A biopsy is sometimes done in order to rule out carcinoma, but the result may come back as molluscum contagiosum. 3. If a biopsy is completed, histology would show cytoplasmic inclusions in keratinocytes known as molluscum bodies.

What is the therapy of choice for molluscum contagiosum? 1. No single treatment option is effective. 2. If the lesions are not bothering the patient, consider watchful waiting. 3. Watchful waiting is appropriate for the majority of patients given the self-resolving course of molluscum contagiosum. In a study of 269 children, resolution occurred at an average of 13 months. However, in practice, watchful waiting is often not acceptable to parents and families.

When would you consider treating molluscum contagiosum as opposed to watchful waiting? 1. Therapy is indicated based on patient preferences concerning decreasing discomfort and for cosmetic reasons. Others elect for treatment to reduce the risk of autoinoculation, transmission to close contacts such as family members, scarring, and secondary infection. While molluscum contagiosum is benign and resolves without scarring, scratching at the can cause scarring. 2. Lesions in the genitalia are not considered sexually transmitted infections in children. However, it is important to always remain alert and vigilant for possible sexual abuse when genital lesions are present. The primary care physician should cautiously evaluate these scenarios if deemed appropriate.

What are treatment options for molluscum contagiosum? 1. Firstly, no treatment is a reasonable option if the lesions are not bothersome to the child. 2. If treatment is considered, is an odorless fatty substance secreted by beetles, which can be applied topically to lesions. 3. Cantharidin runs the risk of causing blistering, pain, burning, hypopigmentation, or . For this reason, it is used sparingly. Due to the potential for blistering, it is advisable to only treat a few lesions at once to determine how severely the patient . Avoid using it on the face or genital region, and minimize its use in the intertriginous areas. 4. Cantharidin comes in different concentrations, and it is advisable to use the lowest concentration on a few lesions with short contact time (e.g. 30- 45 min) before using in more widespread areas. 5. , which is the use of liquid nitrogen, can also be used, but it can cause pain, scarring, blisters, hypopigmentation, or hyperpigmentation. If liquid nitrogen is used, each spot is frozen for 5-10 seconds to form a layer of ice over the affected area. Several cryotherapy sessions may be needed, with 2 to 3 weeks between each session. Cryotherapy may be difficult for young children. Developed by Aryan Riahi and Dr. M. B. Shokravi for PedsCases.com. December 19, 2020.

6. Curettage, which is a minor procedure to remove the lesions, is generally avoided in small children due to pain. One retrospective study evaluated 2022 children who had molluscum cantagiosum.5 Curettage cured 70% of cases after the first treatment and 26% of patients after the second treatment. However, the authors note the need to perform curettage under topical anesthesia and administer topical gentamycin, an antibiotic, for 1 week after treatment. Other methods of treatment such as cantharidin, and cryotherapy are equally effective and lead to less pain for children. In-office sedation with intravenous or inhaled sedatives is not routinely available in most office settings, and would be more appropriate in a hospital setting. 7. Topical creams such as retinoids have limited evidence of effectiveness. Potential side effects of retinoids include irritation, burning, peeling, and pruritus. 8. Pulsed is an effective in-office treatment, which usually occurs in specialty offices. Side effects include pain, redness, hypopigmentation, and hyperpigmentation. Rarely, ulceration may occur. One small study using a single session of pulsed dye therapy on only 15 children, who were 5 years or younger, reported no pain or discomfort among the patients.6 was seen for all patients after irradiation with the pulsed dye laser, but resolved after 1 week of treatment. No recurrence of molluscum lesions recurred after 3 months of follow- up. 9. However, the most practical therapy for patients and families is over-the-counter solutions, which are the same ones used for warts. Families can apply the solution at home, and minimize the need for multiple office visits.

How is molluscum contagiosum spread? 1. Molluscum contagiosum spreads through fomites, autoinoculation, and skin-to- skin contact. 2. Certain sports are at particularly high risk for exposure to molluscum contagiosum. Wrestlers, for example, experience excessive skin-to-skin contact, and swimmers are regularly exposed to public pools. 3. Autoinoculation is the main cause for anogenital lesions in children, where children spread the virus to other parts of their own body. 4. When sexually active adults transmit molluscum contagiosum, it is classified as a sexually transmitted infection. Unlike children, adults with molluscum contagiosum commonly present with genital lesions.

How to counsel patients on limiting the spread of molluscum contagiosum? 1. Molluscum contagiosum can spread through fomites (e.g. clothes, furniture, utensils), so encourage patients to minimize using shared items such as towels, cutlery and toys. 2. It is important to note that molluscum contagiosum is not a barrier to attend school, daycare or public pools.

Developed by Aryan Riahi and Dr. M. B. Shokravi for PedsCases.com. December 19, 2020.

What if Mike and his mother came back a few months later complaining of changes in the lesions that resemble an infection? 1. While secondary bacterial infection may be on your differential, keep in mind that crusting, pain on palpation and redness are signs that the host’s immune system is responding appropriately to the infection. 2. Reassure parents that is typically followed by regression of the lesions. Sometimes, this means all of the lesions are resolving. 3. It takes approximately 3 months from onset of inflammation to resolution of the disease.

When should you refer a patient with molluscum contagiosum to a dermatologist? 1. Consider referral to a dermatologist if there is diffuse involvement, prominent facial involvement, prolonged cases, or significant discomfort. 2. It is also important to consider the patient’s medical background, including underlying , and moderate or severe . Molluscum contagiosum is more widespread in patients with or who are immunosuppressed.

How is the presentation of molluscum contagiosum different in patients who have underlying atopic dermatitis? 1. Molluscum contagiosum in a patient with atopic dermatitis, is called . It is a relatively common complaint with an incidence of 27% among patients with molluscum contagiosum. The risk of occurrence is higher in patients with atopic dermatitis. 2. Patients with atopic dermatitis often experience pruritus as part of their condition. This is a compounding factor in molluscum contagiosum as scratching can spread the virus in a linear distribution. 3. To minimize scratching and autoinoculation, it is important to control the symptoms of dermatitis, whether from the molluscum contagiosum or from underlying atopic dermatitis.

Before we conclude this podcast, let’s take a moment to summarize and recap the key points: 1. Molluscum contagiosum is a viral infection secondary to pox virus. 2. Three populations are at greatest risk of developing molluscum contagiosum: children, patients who are immunosuppressed, and sexually active adults. 3. While there are numerous treatment options for molluscum contagiosum, watchful waiting is an effective approach as eruptions are self-limiting. 4. If treatment is preferred by families, the most commonly used options are cantharidin, cryotherapy and over-the-counter salicylic acid solutions.

That concludes our PedsCases podcast on molluscum contagiosum! Thanks for listening to PedsCases podcasts!

Developed by Aryan Riahi and Dr. M. B. Shokravi for PedsCases.com. December 19, 2020.

References:

We would like to acknowledge the following sources from which pictures and/or statistics were drawn for this PedsCases podcast. The visual references were solely used for educational purposes.

1. www.dermnetnz.com 2. Cockayne S, Hicks K, Kangombe AR, et al. The effect of patients' preference on outcome in the EVerT cryotherapy versus salicylic acid for the treatment of plantar warts (verruca) trial. J Foot Ankle Res. 2012;5(1):28. Published 2012 Nov 12. doi:10.1186/1757-1146-5-28 3. Coutlee F, Roger M, Franco E, Brassard P., Prevalence and Age Distribution of Human Papillomavirus Infection in a Population of Inuit Women in Nunavik, Quebec, Cancer Epidemiol Biomarkers Prev November 1 2008 (17) (11) 3141- 3149; DOI: 10.1158/1055-9965.EPI-08-0625 4. Society, C. (2020). Human papillomavirus vaccine for children and adolescents | Canadian Paediatric Society. Retrieved 11 June 2020, from https://www.cps.ca/en/documents/position/HPV 5. Harel A, Kutz AM, Hadj-Rabia S, Mashiah J. To Treat Molluscum Contagiosum or Not-Curettage: An Effective, Well-Accepted Treatment Modality. Pediatr Dermatol. 2016;33(6):640‐645. doi:10.1111/pde.12968 6. Omi T, Kawana S. Recalcitrant molluscum contagiosum successfully treated with the pulsed dye laser. Laser Ther. 2013;22(1):51‐54. doi:10.5978/islsm.13-or-07 7. Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Glossary. MedEdPORTAL; 2007. 8. Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for cutaneous warts. Cochrane Database Syst Rev; 2012. 9. Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination — Updated Recommendations of the Advisory Committee on Immunization Practices. 2007;21:260-2. MMWR 65(49)1405-1408. 10. Berger EM, Orlow SJ, Patel RR, Schaffer N. Experience with molluscum contagiosum and associated inflammatory reactions in a pediatric dermatology practice: the bump that rashes. Arch Dermatol. 2012 Nov; 148(11):1257-64 11. Braue A, et al. "Epidemiology and impact of childhood molluscum contagiosum: A case series and critical review of the literature." Ped Derm. 22(4):287-294. 2005. 12. Butala N, et al. "Molluscum BOTE Sign: A Predictor of Imminent Resolution." Pediatrics. 131(5): e1650-e1653. 2013. 13. Cohen BA, et al. "Molluscum Contagiosum: To Treat or Not to Treat? Experience with 170 Children in an Outpatient Clinic Setting in the Northeastern United States." Pediat Dermatol 2015;32:353-357. 14. Katz KA, Swetman GL. ", Molluscum, and the Need for a Better "Best Pharmaceuticals for Children" Act." Pediatrics. 132(1): 1-3. 2013. 15. Olsen JR, et al. "Time to resolution and effect on quality of life of molluscum contagiosum in children in the UK: a prospective community cohort study." Lancet Infect Dis 2015;15:190-95.2004. Developed by Aryan Riahi and Dr. M. B. Shokravi for PedsCases.com. December 19, 2020.

16. van der Wouden JC, et al. "Interventions for cutaneous molluscum contagiosum." Cochrane Rev. Vol 2. 2010.

Developed by Aryan Riahi and Dr. M. B. Shokravi for PedsCases.com. December 19, 2020.