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Molluscum contagiosum

Aetiology.
Molluscum contagiosum virus (MCV); DNA virus
Poxvirus : family
genus: molluscipox
intermediate features between the orthopox and parapox group
infects humans, causing characteristic skin papules
cannot be grown in tissue culture or eggs
not readily transmissible to laboratory animals
produce typical changes on human skin cultured on immunoincompetent mice
Restriction endonuclease and PCR analyses of MCV DNA have identifi ed:
i)two main types, MCV-1 and MCV-2,
ii) two much rarer types, MCV-3 and MCV-4

Epidemiology

The virus occurs throughout the world, most commonly causing disease in
childhood.
Type 1 MCV is found in the majority of infections (7697%), and whilst there is no
relationship
between virus type and lesional morphology or anatomical distribution
there is some evidence to support a relatively higher incidence of MCV-2 type in
adults and HIV infection compared to that in children
The disease is common, but its incidence in most areas is not
reliably known. Infection follows contact with infected persons or
contaminated objects, but the importance of epidermal injury is
unknown.
The disease is rare under the age of 1 year, perhaps due to
maternally transmitted immunity and a long incubation period.
In hot countries where children are lightly dressed and in close
contact with one another, spread within households is not uncommon.
The age of peak incidence is reported as between 2 and 5
years [8,9]. In cooler climates, however, spread within households
is rare and infection may occur at a later age [8,10], perhaps correlated
with use of swimming pools and shared bathing facilities
[11]. A later incidence peak in young adults is attributable to
sexual transmission with lesions more common in the genital
area.
Infection of children through sexual abuse is presumably possible.
However, to a greater extent than warts, molluscum contagiosum
is seen quite commonly on the genital, perineal and
surrounding skin of children, and abuse should not be regarded
as likely unless there are other suspicious features.

There is a clinical impression that molluscum contagiosum is


commoner in patients with atopic eczema [12], and occasional
reports describe widespread infections, possibly based on impaired
immunity [13]. Topical steroids and also topical calcineurin inhibitors
have been suspected as a contributing factor in eczema and
other patients [1416].
Unusually widespread lesions have been reported in immunosuppressed
patients with HIV disease (see Chapter 35), sarcoidosis
[17], and in those receiving immunosuppressive therapy
[1820], suggesting that cell-mediated immunity is signifi cant in
control and elimination of the infection. In spite of profound
immunosuppression following organ transplantation, the incidence
of molluscum contagiosum infection is not greatly increased
in this group and is not as common as other infections such as
warts and herpes simplex [21].

Pathogenesis and pathology.


The molecular pathogenesis of the
lesions is uncertain but an antiapoptotic protein has been postulated
to have a role [22]. The virus seems fi rst to enter the basal
epidermis where an early increase in cell division extends into the
suprabasal layer [23]. The cellular proliferation produces lobulated
epidermal growths which compress the papillae until they
appear as fi brous septa between the lobules, which are pearshaped
with the apex upwards. The basal layer remains intact.
Cells at the core of the lesion show the greatest distortion and are
ultimately destroyed, and appear as large hyaline bodies (molluscum
bodies) some 25 m in diameter, containing cytoplasmic
masses of virus material. These bodies are present in large numbers
in the cavity, which appears near the surface at the centre of the
fully developed lesion.
Infl ammatory changes in the dermis are
absent or slight, but in lesions of long duration there may be a
chronic granulomatous infi ltrate. It has been suggested that the
infl ammatory reaction may be induced by the discharge into the
dermis of the contents of a papule rather than by secondary
infection.
Specifi c antibodies have been found in about 5873% of patients
with molluscum contagiosum, and, perhaps due to unrecognized
infection, in about 616% of controls [25,26], but these have not
been demonstrated to have a role in disease clearance.

Clinical features (Fig. 33.7). The incubation period is variously


estimated at 14 days to 6 months. The individual lesion is a shiny,
pearly white, hemispherical, umbilicated papule which may show
a central pore. It may be identifi ed with a hand lens or dermatoscope
when less than 1 mm in diameter. Enlarging slowly it may
reach a diameter of 510 mm in 612 weeks. Rarely, and usually
when one or very few are present, a lesion may become considerably
larger. Plaques composed of many small lesions (agminate
form or giant molluscum) occur rarely. Lesions frequently spread
and the number of lesions ultimately present is sometimes very
large. After trauma, or spontaneously after several months, infl ammatory
changes result in suppuration, crusting and eventual
destruction of the lesion.
The duration both of the individual lesion and of the attack is
very variable and although most cases are self-limiting within 69
months, it is not unusual for some to persist for 3 or 4 years [12].
Individual lesions are unlikely to persist for more than 2 months, but some lesions,
particularly if solitary, may persist for up to 5
years [27].
The distribution of the lesions is infl uenced by the mode of
infection, and by the type of clothing worn, and hence by the
climate. In temperate regions they are commonly seen on the neck
or on the trunk, particularly around the axillae, except in sexually
transmitted infection, when the anogenital region is usually
involved. In children in the tropics lesions are more common on
the limbs. Widespread and refractory mollusca on the face are
seen most commonly in HIV disease [28] and also with iatrogenic
immunosuppression [29]. In otherwise healthy subjects occasional
facial lesions are seen, particularly on the eyelids. Molluscum may
affect the scalp, lips, tongue and buccal mucous membrane, and
indeed any part of the body surface, including the soles where the
appearance is atypical [30]. Molluscum can occur in scars and in
tattoos [31]. Follicular molluscum contagiosum in four adults produced
atypical, less protuberant pale papules [32].

In at least 10% of cases, particularly in atopic subjects, a patchy


eczema, often very irritable, develops around one or more of the
lesions a month or more after their onset [33] and erythema annulare
centrifugum and erythema multiforme have also been
reported in association with the infection [34,35]. Chronic conjunctivitis
and superfi cial punctate keratitis may similarly complicate
lesions on or near the eyelids [36]. The eczema and the conjunctivitis
subside spontaneously when the lesion is removed.
Depressed scars or anetoderma-like lesions can remain when
mollusca clear [37,38].

Diagnosis. The diagnosis of molluscum contagiosum is usually


obvious when multiple lesions at different stages of evolution are
present and the typical umbilicated papule is evident. The distinctive
umbilication can be seen more easily with a dermatoscope or
after freezing. The diagnosis can be confi rmed by direct microscopy
or electron microscopy of the papule contents, by histopathology
or by molecular analysis [3,39,40]. The solitary molluscum
may resemble a pyogenic granuloma, a keratoacanthoma or a
squamous cell carcinoma and may be diffi cult to identify. Multiple
small lesions can be confused with plane warts. In HIV disease,
molluscum contagiosum may resemble cutaneous cryptococcosis
(see Chapter 35).

Treatment. In many instances, therapy is not necessary and


natural resolution can be awaited. The risk of dissemination of the
infection can be minimized by reducing scratching, which can
both damage adjacent skin and spread virus from mature papules.
Associated dry skin or eczema should be treated with emollients
and possibly a weak topical steroid. Transfer of infection to another
individual may be reduced by avoidance of shared towels, contact
sports and communal bathing.
If spontaneous clearance is slow, lesions are symptomatic, or
associated eczema is troublesome, treatment may be desirable.
The choice of treatment will depend on the age of the patient, and
the number and position of the lesions. Treatments aim to destroy
the infected epidermal cells, stimulate an immunological response
or act directly against the virus.
Surgical removal of molluscum contagiosum by curettage has
been used for many years [41]. Children will usually need prior
application of topical anaesthetic cream with strict observance of
the maximum safe dose [42]. Damage to the lesions by squeezing
the contents or insertion of a pointed cocktail stick may stimulate
infl ammation and clearance.
Cryotherapy is effective and commonly used in older children
and adults, but needs to be repeated at 34 weekly intervals. The
carbon dioxide or pulsed dye lasers have produced useful effects
[43,44] but like curettage, can cause scars. Photodynamic therapy
has also been used with effect [45].
Many topical agents can be used to produce mild to moderate
infl ammation and hence potentially stimulate the development of
an immune response against the virus. Cantharidin, trichloroacetic
acid and diluted liquefi ed phenol are strong irritants which can
both cause pain, blistering and scarring but with careful application
and appropriate dilution can increase lesion clearance
[37,46,47]. Topical salicylic acid preparations [12,41], tretinoin [48],
adapalene [49], nitric oxide cream [50] and potassium hydroxide
solution [51,52] all lead to an irritant reaction but if the strength
of preparation and the frequency of application are adjusted, individuals
can tolerate repeated treatments until resolution occurs

Stimulation of the immune response may occur after destructive


or infl ammatory therapies. Treatment used for molluscum contagiosum
with the explicit aim of enhancing the immune response
and reported effi cacy include induction of allergic contact dermatitis
with topical dyphencyprone [53], imiquimod cream [54],
intralesional interferon [55] and systemic cimetidine [56].

The antiviral agent cidofovir has recently been shown to


effectively resolve molluscum lesions [57,58] (used either intravenously
or topically as a 13% ointment or cream). It should be
considered for treating extensive lesions in, for example, immunoincompetent
patients where eradication has proved diffi cult with
standard treatment regimens.