6/12/2017 Molluscumcontagiosum[eScholarship]

DermatologyOnlineJournal
UCDavis

MolluscumContagiosum
DanielHansonandDaynaG.Diven
DermatologyOnlineJournal9(2):2

PrimaryHealth,Boise,IdahoUSA

Abstract
MolluscumcontagiosumisadiseasecausedbyapoxvirusoftheMolluscipoxvirusgenusthatproducesabenign
selflimitedpapulareruptionofmultipleumbilicatedcutaneoustumors.Thiscommonviraldiseaseisconfinedtothe
skinandmucousmembranes.Transmissionrequiresdirectcontactwithinfectedhostsorcontaminatedfomites.Itis
generallythoughttoinfecthumansexclusively,butthereareafewisolatedreportsofMolluscumcontagiosum
occurringinchickens,sparrows,pigeons,chimpanzees,kangaroos,adog,andahorse.Theinfectionisfound
worldwideandhasahigherincidenceinchildren,sexuallyactiveadults,andthosewhoareimmunodeficent.

Introduction
Molluscumcontagiosum,acutaneousandmucosaleruptioncausedbyaMolluscipoxvirus,wasfirstdescribedand
laterassigneditsnamebyBatemaninthebeginningofthenineteenthcentury.[1]In1841HendersonandPaterson
describedtheintracytoplasmicinclusionbodiesnowknownasmolluscumorHendersonPatersonbodies.[2]Inthe
earlytwentiethcentury,Juliusberg,Wile,andKingerywereabletoextractfilterablevirusfromlesionsandshow
transmissibility.[3,4]Goodpasturelaterdescribedthesimilaritiesofmolluscumandvaccinia.[5]Thoughgenerally
thoughttoinfectonlyhumans,casereportsofthevirusoccurringinotheranimalshavebeenpublished.[6,7,8,9]

Incidence
Molluscumcontagiosumvirus(MCV)canbefoundworldwidewithahigherdistributioninthetropicalareas.The
diseaseismoreprevalentinchildrenwiththelesionsinvolvingtheface,trunk,andextremities.Inadultsthelesions
aremostoftenfoundnearthegenitalregion.Thediseaseisendemicwithahigherincidencewithininstitutionsand
communitieswhereovercrowding,poorhygiene,andpovertypotentiateitsspread.[10]Overthelast30yearsits
incidencehasbeenincreasing,mainlyasasexuallytransmitteddisease,anditisparticularlyrampantasaresultof
concurrenthumanimmunodeficiencyvirus(HIV)infection.[11]Theworldwideincidenceisestimatedtobebetween
2%and8%.[12]Lessthen5%ofthechildrenintheUnitedStatesarebelievedtobeinfected.Between5%and20%
ofpatientswithHIVhavesymptomaticMCV.[13,14]Therearefourmainsubtypesofmolluscumcontagiosum:MCV
I,MCVII,MCVIII,andMCVIV.[15,16]Allsubtypescausesimilarclinicallesionsingenitalandnongenitalregions.
StudiesshowMCVItobemoreprevalent(75%90%)thanMCVII,MCVIII,andMCVIV,exceptin
immunocompromisedindividuals.[17,18]Thereare,however,regionalvariationsinthepredominanceofagiven
subtypeanddifferencesbetweenindividualsubtypesindifferentcountries.[19]

Pathogenesis
Thisdiseaseistransmittedprimarilythroughdirectskincontactwithaninfectedindividual.Fomiteshavebeen
suggestedasanothersourceofinfection,withmolluscumcontagiosumreportedlyacquiredfrombathtowels,tattoo
instruments,andinbeautyparlorsandTurkishbaths.[10]Theaverageincubationtimeisbetween2and7weeks
witharangeextendingoutto6months.Infectionwiththeviruscauseshyperplasiaandhypertrophyoftheepidermis.
[12]Freeviruscoreshavebeenfoundinalllayersoftheepidermis.Socalledviralfactoriesarelocatedinthe
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[12]Freeviruscoreshavebeenfoundinalllayersoftheepidermis.Socalledviralfactoriesarelocatedinthe

malpighianandgranularcelllayers.[12]Themolluscumbodiescontainlargenumbersofmaturingvirions.Theseare
containedintracellularlyinacollagenlipidrichsaclikestructurethatisthoughttodeterimmunologicalrecognitionby
thehost.[20]Ruptureanddischargeoftheinfectiousviruspackedcellsoccurinthecenterofthelesion.MCV
inducesabenigntumorinsteadoftheusualnecroticpoxlesionassociatedwithotherpoxviruses.[21]

Clinicalmanifestations
MCVproducesapapulareruptionofmultipleumbilicatedlesions.Theindividuallesionsarediscrete,smooth,and
domeshaped.Theyaregenerallyskincoloredwithanopalescentcharacter.Thecentraldepressionorumbilication
containsawhite,waxycurdlikecore.Thesizeofthepapuleisvariable,dependinguponthestageofdevelopment,
usuallyaveraging26mm.Papulesmayexceed1cminsizeinimmunosuppressedhosts.Thepapulesmay
becomeinflamedspontaneouslyoraftertraumaandpresentatypicallyinsize,shape,andcolor.Thelesionsare
oftengroupedinsmallareasbutmayalsobecomewidelydisseminated.

Anycutaneoussurfacemaybeinvolved,butfavoredsitesincludetheaxillae,theantecubitalandpoplitealfossae,
andthecruralfolds.Rarely,MCVlesionsoccurinthemouthorconjunctivae.[22,23,24]Autoinoculationiscommon.
Childrenusuallyacquiremolluscumnonsexuallyatbothgenitalandnongenitalareas.MCVinadultsaffectsthe
groin,genitalarea,thighs,andlowerabdomenandisoftenacquiredsexually.Around10%ofcasesdevelopan
eczematousdermatitisaroundthelesions,butthisdisappearsastheinfectionresolves.[25]Patientswithatopic
dermatitiscanhaveadisseminatederuption.Eruptionsinimmunocompromisedindiviualsareveryresistantto
treatment.[13,26]

Dermatopathology
Histologically,molluscumcontagiosumexhibitsintraepidermallobuleswithcentralcellularandviraldebris.Inthe
basallayer,enlargedbasophilicnucleiandmitoticfiguresareseen.Progressingupward,thecellsshowcytoplasmic
vacuolizationandtheneosinophilicglobules.Thenucleusbecomescompressedatthelevelofthegranularcell
layer,andthemolluscumbodieslosetheirinternalstructuralmarkings.Undisruptedlesionsshowanabsenceof
inflammation,butdermalchangescanincludeaninfiltratethatislymphohistiocytic,neutrophilic,orgranulomatous.
Thelatterhasbeenseeninsolitarylesions.AntibodytoMCVbyindirectimmunofluorescencehasbeenfoundin
69%ofpatientswithvisiblelesions.[27]PolymerasechainreactioncandetectMCVinskinlesions.[28]Currently,
thereisnoinvitrooranimalmodelforMCV.MCVcanundergoanabortiveinfectioninsomecelllines,whichcan
causeconfusionwithherpessimplexvirusbylaboratories.[29]Twosetsofinvestigatorshaveinfectedhumanskin
withmolluscumcontagiosumandgrafteditontoathymicmice,althoughtherewasnocontinuedviralreplication.
[30,31]

Diagnosis
Theclinicalappearanceofmolluscumcontagiosumisinmostcasesdiagnostic.Thoughmolluscumcannotbe
culturedinthelaboratory,histologicalexaminationofacurettedorbiopsiedlesioncanalsoaidinthediagnosisin
casesthatarenotclinicallyobvious.Thethickwhitecentralcorecanbeexpressedandsmearedonaslideandleft
unstainedorstainedwithGeimsa,Gram,Wright,orPapanicolaoustainstodemononstratethelargebrickshaped
inclusionbodies.Electronmicroscopyhasalsobeenusedtodemonstratethepoxivirusstructures.
Immunohistochemicalmethodsusingapolyclonalantibodyallowsrecognitionofmolluscumcontagiosuminfixed
tissue.[32]InsituhybridizationforMCVDNAhasalsobeenutilized.[33]Molluscumcontagiosumlesionsmustbe
differentiatedfromverrucavulgaris,condylomaaccuminata,varicella,herpessimplex,papillomas,epitheliomas,
pyoderma,cutaneuoscyptococcosis,epidermalinclusioncyst,basalcellcarcinoma,papulargranulomaannulare,
keratoacanthoma,lichenplanus,andsyringomaorotheradenexaltumors.

Treatment
Molluscumcantagiosumisaselflimiteddisease,which,leftuntreated,willeventuallyresolveinimmunocompetent
hostsbutmaybeprotractedinatopicandimmunocompromisedindividuals.Somepatientspickandscratchatthe
lesions,ahabitthatmayleadtoscarring.Inaddition,someschoolsanddaycarecenterswillnotadmitchildrenwith
visiblemolluscumpapules.Whenpatientsseekmedicalattentionanddesiretoridthemselvesofthepapules,there
areseveralmeansoftherapeuticdestructiontohelpspeedresolution.Thedecisionwhethertreatmentisnecessary
dependsontheneedsofthepatient,therecalcitranceoftheirdisease,andthelikelihoodoftreatmentstoleave
pigmentaryalterationorscarring.Mostofthecommontreatmentsconsistofvariousmeanstotraumatizethe
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lesions.Antiviralandimmunemodulatingtreatmentshaverecentlybeenaddedtotheoptions.Thefollowingisabrief
summaryofsomeofthemorecommontreatments.

Cryosurgery
Oneofthemostcommon,quick,efficientmethodsoftreatmentiscryotherapy.Liquidnitrogen,dryice,orFrigiderm
areappliedtoeachindividuallesionforafewseconds.Repeattreatmentsin23weekintervalsmayberequired.[34]
Hyperorhypopigmentationandscarringmaybecausedbythistreatment.

Evisceration
Aneasymethodtoremovethelesionsisevisceratingthecorewithaninstrumentsuchasascalpel,sharptooth
pick,edgeofaglassslide,oranyotherinstrumentcapableofremovingtheumbilicatedcore.Becauseofits
simplicity,patients,parents,andcaregiversmaybetaughtthismethodsonewlesionscanbetreatedathome.
[35,36]Thismethodissimplebutmaynotbetoleratedbysmallchildren.

Curettage
Curettageisanothermethodofremoval.Itcanbeusedwithandwithoutlightelectrodessication.Thismethodis
morepainful,anditisrecommendedthatatopicalanestheticcreambeappliedtothelesionsbeforetheprocedureto
decreasethepain.Thismethodhastheadvantageofprovidingareliabletissuesampletoconfirmthediagnosis.
[35,37]

Tapestripping
Anotherreportedtreatmentinvolvestheuseofadhesivetape.Theadhesivesideofthetapeisrepeatedlyappliedto
andremovedfromthelesionfor1020cycles.Thisactioneffectivelyremovesthesuperficialepidermisfromthetop
ofthelesion.[38]However,repeateduseofthesamestriphasthepotentialtospreadthevirustoadjacent,
uninvolvedskin.

Podophyllinandpodofilox
A25%suspensioninatinctureofbenzoinoralcoholmaybeappliedonceaweek.Thistreatmentrequiressome
precautions.Itcontainstwomutagens,quercetinandkaempherol.Someofthelistedsideeffectsincludesevere
erosivedamageinadjacentnormalskinthatmaycausescarringandsystemiceffectssuchasperipheral
neuropathy,renaldamage,adynamicilleus,leucopenia,andthrombocytopenia,especiallyifusedgenerouslyon
mucosalsurfaces.Podofiloxisasaferalternativetopodophyllinandmaybeusedbythepatientathome.The
recommendeduseusuallyconsistsofapplicationof0.05mlof5%podofiloxinlactatebufferedethanoltwiceaday
for3days.[35,38]Theactiveagentisabsolutelycontraindicatedinpregnancy.

Cantharidin
Cantharidin(0.9%solutionofcollodianandacetone)hasbeenusedwithsuccessinthetreatmentofMCV.This
blisterinducingagentisappliedcarefullyandsparinglytothedomeofthelesionwithorwithoutocclusionandleftin
placeforatleast4hoursbeforebeingwashedoff.Cantharidincancausesevereblistering.Itshouldbetestedon
individuallesionsbeforetreatinglargenumbersoflesions.Itshouldnotbeusedontheface.Whentolerated,this
treatmentisrepeatedeveryweekuntilthelesionsclear.Usually13treatmentsarenecessary.[39]

Iodinesolutionandsalicylicacidplaster
A10%iodinesolutionisplacedonthemolluscumpapulesand,whendry,thesiteiscoveredwithsmallpiecesof
50%salicylicacidplasterandtape.Theprocessisrepeateddailyafterbathing.Afterthelesionshavebecome
erythematousin37days,onlytheiodinesolutionisapplied.Resolutionhasbeenreportedinameanof26days.[40]
Macerationanderosioncanresult.

Tretinoin
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Tretinion0.1%creamhasbeenusedinthetreatmentofMCV.Itisappliedtwicedailytothelesions.Resolutionwas
reportedbyday11.Traceerythemaatthesiteofpriorlesionswasanotedsideeffect.[41]Tretinion0.05%cream
hasalsobeenusedwithsuccessanddecreasedirritation.[35]

Cimetdine
Oralcimetidinehassuccessfullybeenusedinextensiveinfections.[42]Thehistamine2receptorantagonist
stimulatesdelayedtypehypersensivity.Oneuncontrolledstudyshowedresolutionin9of13patients.Inthisstudy,
thedosagewas40mg/kg/dayintwodivideddosesfor2months.[43]Theauthorsrecommendedfurtherplacebo
controlled,doubleblindstudiesbecompletedtodeterminetheefficacyofcimetidineintreatingMCV.Because
cimetadineinteractswithmanysystemicmedications,areviewofthepatient'sothermedicationsisrecommended.

Potassiumhydroxide

Anothertreatmentoptionistheuseofpotassiumhydroxide.Inonestudy,anaqueoussolutionof10%KOHwas
appliedtopicallytwicedailytoalllesionswithaswab.Thetreatmentwasdiscontinuedwhenaninflammatory
responseorsuperficialulcerbecameevident.Resolutionoccurredinameanof30days.[44]Thistreatmenthad
somecomplicationsincludinghypertrophicscarformationandpersistentortransitoryhyperandhypopigmentation.
Asubsequentstudyinpediatricpatientsrecommendedtheuseof5%KOHandfounditequallyeffectivewithmany
fewersideeffects.[45]

Pulseddyelaser

TheuseofpulseddyelaserforthetreatmentofMChasalsobeendocumentedwithexcellentresults.Thetherapy
waswelltolerated,withoutscarsorpigmentanomalies.Thelesionsresolvedwithoutscarringat2weeks.Studies
show96%99%ofthelesionsresolvedwithonetreatment.[46,47]Thepulseddyelaserisquickandefficient,butits
expensemakesitlesscosteffectivethanotheroptions.

Imiquimod
Imiquimod5%creamhasbeenusedtopicallytotreatMCVbyinducinghighlevelsofIFNandothercytokines
locally.[48,49]Thispotentimmunomodulatoryagentiswelltolerated,althoughapplicationsiteirritationiscommon.It
hashadnoknownsystemicortoxiceffectsinchildren.[50]Itisappliedtotheareanightlyfor4weeks.Clearingcan
takeupto3months.

Cidofovir

Cidofovirisanucleosideanalogthathaspotentantiviralproperties.Severalsmallstudiesandcasereportsdescribe
thesuccessfuluseofcidofovirappliedtopicallyoradministeredbyintralesionalinjectioninseveralvirallyinduced
cutaneousdiseases.[51]Cidofovircream3%hasbeenusedsuccessfullytotreatMCVinstudies,withclearingin2
6weeks.[52]Itshighcost,needforextemporaneouspreparation,andcarcinogenicityinsomestudieshavelimited
itsuse.[51]

Conclusion
MolluscumContagiosumisacommon,generallybenign,viralinfectionoftheskin.Itiscommoninchildren,sexually
activeadults,andimmunodeficientpatients.Itiscausedbythemolluscipoxvirus,amemberofthepoxviridae
family.Thisvirusdiffersfromotherpoxvirusesinthatitcausesspontaneouslyregressing,umbilicatedtumorsofthe
skinratherthanpoxlikevesicularlesions.Inimmunocompetent,nonatopicpatientsmolluscumcontagiosumis
usuallyaselflimiteddiseaseforwhichtreatmentisnotmandatory.However,whentreatmentisdeemedappropriate,
multiplelocaltherapeuticoptionsareavailable.Forpatientswithimpairedimmunefunctionswithwidespreadand
potentiallydisfiguringeruptions,theusuallocaldestructivetherapiesareineffectiveantiviralandimmunomodulatory
medicationshavebeenmoresuccessful.

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