Molluscum Medscape

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emedicine.medscape.com
Molluscum Contagiosum
Updated: Aug 09, 2018
Author: Ashish C Bhatia, MD, FAAD, FACMS; Chief Editor: Dirk M Elston, MD
Overview
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 molluscum) in diameter.
The papules are umbilicated and contain a caseous plug. See the images below for examples. (See Presentation and
Workup.)
Note the central umbilication in these classic lesions of molluscum contagiosum.
https://emedicine.medscape.com/article/910570-print Page 1 of 35
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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.
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Molluscum contagiosum on the right axilla.
See 15 Rashes You Need to Know: Common Dermatologic Diagnoses and 20 Signs of Sexually Transmitted
Infections, Critical Images slideshows, to help identify and treat various rashes.
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).
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%).
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.
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.
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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.[2, 3]
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.
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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.
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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).[4, 5, 6]
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
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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. Viral-derived proteins inhibit
mitochondrial-mediated apoptosis.[7]
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 milker’s 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]
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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/µL, 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.
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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.
Presentation
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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).[4,
5, 6]
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.)
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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
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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).
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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:
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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
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. (See Prognosis, Treatment, and Medication.)
Cellulitis is an unusual complication of molluscum contagiosum in patients who are HIV infected.[20] Secondary
infection with Staphylococcus aureus has resulted in abscess formation, whereas Pseudomonas aeruginosa can
cause necrotizing cellulitis.
DDx
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.)
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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.[21, 22] 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:
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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
Differential diagnoses to consider in patients with AIDS include the following:
Cutaneous cryptococcus[23] : Cutaneous cryptococcus presents as molluscumlike eruptions (on the face, it
often has a very dramatic appearance); the patient may have few or no other symptoms associated with
cryptococcal meningitis.
Cutaneous coccidioidomycosis
Cutaneous histoplasmosis
Cutaneous aspergillosis
Differential Diagnoses
Basal Cell Carcinoma
Condyloma Acuminatum (Genital Warts)
Cryptococcosis
Pearly Penile Papules
Pediatric Keratosis Pilaris
Pediatric Milia
Pediatric Pyogenic Granuloma
Surgical Treatment of Basal Cell Carcinoma
Varicella-Zoster Virus (VZV)
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Workup
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.[24]
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.[25] 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.
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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 35µm 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. (See the images below.)
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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.
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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)
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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 body–type,
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
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, antiviral therapy, or a combination of these.[26] 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 four previously recognized treatments for molluscum contagiosum in 124 children.[27] 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 adverse effects. However, it must
be performed with adequate anesthesia and is a time-consuming procedure. Cantharidin is generally well tolerated,
but this study had moderate complications owing to blisters and was slightly less effective. The topical keratolytic used
was too irritating for children. Topical imiquimod has been found to be ineffective in several studies, and combination
therapy may be required.[28, 29, 30, 31, 32, 33]
01/01/19 22.30
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:
Cantharidin: Several studies report that cantharidin, a chemovesicant that has been 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.[34]
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
Dilute povidone iodine
Tretinoin and cantharidin may be dispensed to the patient with application instructions and close follow-up, although
some recommend application in the office. Bichloracetic acid, trichloroacetic acid, salicylic acid, lactic acid, glycolic
acid, potassium hydroxide, and silver nitrate must be applied in the office by the physician.[35]
Topical podophyllotoxin 0.5% cream self-administered twice daily for 3 weeks has been reported effective in a
placebo-controlled, double-blind study.[36] Dilute povidone iodine has also been used.[37]
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.[5] Cidofovir diphosphate was reported to inhibit molluscum contagiosum virus DNA polymerase activity.[38]
Imiquimod cream is an immune response modifier approved for the treatment of external genital and perianal warts in
01/01/19 22.30
adults. In the past, it was used in molluscum contagiosum; however, imiquimod cream has been reported to be
ineffective in the treatment of molluscum contagiosum,[28, 29, 30, 31] particularly in children, in whom adverse effects
have been noted.[30]
Benign Neglect
Leaving mollusca to spontaneously resolve is often reasonable,[39] 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.
(See the image below.)
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.[40] 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[41, 42] may be used. Cantharidin,[34, 43] silver nitrate,[44] trichloroacetic acid, and phenol
also are options. Children may tolerate therapy with these agents better than curettage or cryotherapy. None of these
01/01/19 22.30
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.[45]
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.[46, 47] 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,[48, 49] expression
of the central core with tweezers, rupture of the central core with a needle or a toothpick,[50, 51] electrodesiccation,
shave removal, or duct tape occlusion.[52]
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.
01/01/19 22.30
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.[53, 54, 55, 56, 57]
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

Intralesional interferon-alfa[58] and topical injections of streptococcal antigen[59] 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. The dosing schedule and length of treatment require further evaluation.
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.[60]
Antiviral Therapy
In immunocompromised patients, improvement of lesions has been observed in individual patients treated with
ritonavir, cidofovir (intravenous and topical),[61, 62] and zidovudine. Not surprisingly, patients with AIDS and severe
molluscum contagiosum improve with effective antiretroviral therapy.
Medication
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
01/01/19 22.30
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.[29] One report suggested using a 10% solution of
essential oil of Australian lemon myrtle (Backhousia citriodora).[63]
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.
01/01/19 22.30
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.
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.
Questions & Answers

Overview
What is molluscum contagiosum?
What are the types of molluscum contagiosum viruses and which type causes most infections?
Who discovered molluscum contagiosum disease?
How is molluscum contagiosum infection transmitted?
Which patient groups are at increased risk for molluscum contagiosum infection?
What is the disease pattern of molluscum contagiosum infection in children?
What is the disease pattern of molluscum contagiosum infection in healthy adults?
What is the disease pattern of molluscum contagiosum infection in immunocompromised patients?
What is the pathogenesis and disease progression of molluscum contagiosum infection?
How is molluscum contagiosum virus classified?
01/01/19 22.30
Which types of molluscum contagiosum virus cause infection in humans?
What is the structure of the molluscum contagiosum virus genomes?
How prevalent is molluscum contagiosum infection in the US?
What is the global prevalence of molluscum contagiosum infection?
Does molluscum contagiosum have a racial or sexual predilection?
How does the prevalence of molluscum contagiosum vary among age groups?
What is the prognosis of molluscum contagiosum?
What is the morbidity associated with molluscum contagiosum infection?
What education about molluscum contagiosum should be provided to patients?
Should children with molluscum contagiosum be kept out of school or daycare?
What instructions should a patient be given to prevent transmission of molluscum contagiosum?
Presentation
What are the symptoms of molluscum contagiosum?
Which conditions increase the risk of spreading molluscum contagiosum?
How does comorbid atopic dermatitis affect molluscum contagiosum?
Which factors increase the risk for molluscum contagiosum infection?
What is the duration of molluscum contagiosum infection?
What are the risk factors for molluscum contagiosum in patients with HIV?
How are molluscum contagiosum skin lesions characterized?
Where are molluscum contagiosum skin lesions commonly located?
Which types of skin lesions are comorbidities of molluscum contagiosum?
Which physical findings suggest molluscum contagiosum?
Which comorbidities are associated with disfiguring molluscum contagiosum lesions?
What are the complications of molluscum contagiosum?
DDX
What are the diagnostic considerations if molluscum contagiosum is suspected?
Which conditions should be included in the differential diagnosis of molluscum contagiosum?
Which perforating disorders should be included in the differential diagnosis of molluscum contagiosum?
What conditions should be considered in differential diagnosis of molluscum contagiosum in patients with HIV/AIDS?
What are the differential diagnoses for Molluscum Contagiosum?
Workup
How is molluscum contagiosum diagnosed?
What is the role of squash preparation in the diagnosis of molluscum contagiosum?
01/01/19 22.30
Which histologic findings are characteristic of molluscum contagiosum lesions?
Treatment
When is treatment indicated for molluscum contagiosum?
What are the therapeutic options for molluscum contagiosum?
What is the basis for treatment selection in molluscum contagiosum?
When is repeat exam indicated in molluscum contagiosum?
Which activity restrictions are indicated in the treatment of molluscum contagiosum?
How is molluscum contagiosum prevented?
Which topical agents are effective in the treatment of molluscum contagiosum?
Which drugs may be effective for treatment of molluscum contagiosum?
What are the treatment options for facial molluscum contagiosum legions?
What is the role of caustic agents in the treatment of molluscum contagiosum?
How is tretinoin cream used to treat molluscum contagiosum?
How is potassium hydroxide used to treat molluscum contagiosum?
What is the role of cantharidin in the treatment of molluscum contagiosum?
How is salicylic acid used to treat molluscum contagiosum?
How is therapeutic trauma used to treat molluscum contagiosum?
What is the role of immune response stimulation in the treatment of molluscum contagiosum?
What is the role of antiviral therapy in the treatment of molluscum contagiosum?
Medications
What are the goals for treatment of molluscum contagiosum?
Which medications in the drug class Antivirals, Other are used in the treatment of Molluscum Contagiosum?
Which medications in the drug class Topical Skin Products are used in the treatment of Molluscum Contagiosum?
Which medications in the drug class Keratolytic Agents are used in the treatment of Molluscum Contagiosum?
Contributor Information and Disclosures
Author
Ashish C Bhatia, MD, FAAD, FACMS Associate Professor of Clinical Dermatology, Department of Dermatology,
Northwestern University, The Feinberg School of Medicine; Medical Director for Dermatologic Research, Director of
Dermatologic, Laser and Cosmetic Surgery, Oak Dermatology
Ashish C Bhatia, MD, FAAD, FACMS is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Dermatology, American College of Mohs Surgery, American Medical Association, American Society for
Dermatologic Surgery, American Society for Laser Medicine and Surgery
Disclosure: Nothing to disclose.
Chief Editor
01/01/19 22.30
Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical
University of South Carolina College of Medicine
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Acknowledgements
Carissa N Beatty, MPH Program Manager, Tobacco Technical Assistance Consortium
Carissa N Beatty, MPH is a member of the following medical societies: American Public Health Association
Ashish C Bhatia, MD, FAAD Assistant Professor, Department of Dermatology, Northwestern University, Feinberg
School of Medicine; Director of Clinical Research, Department of Dermatology and Dermatologic Surgery; Director of
Dermatologic Surgery and Dermatology, The Dermatology Institute of DuPage Medical Group
Ashish C Bhatia, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy
of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical
Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, and
Connective Tissue Oncology Society
David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of
Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS
Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Tracy Campbell, MD Staff Physician, Department of Dermatology, Rush Medical Center
Tracy Campbell, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Dermatology, American Medical Association, Chicago Dermatological Society, and Women's Dermatologic Society
Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of
Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American
Society of Dermatopathology, and Society for Investigative Dermatology
Mark W Cobb, MD Consulting Staff, WNC Dermatological Associates
Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Dermatology, and American Society of Dermatopathology
Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and
Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the
Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American
College of Osteopathic Pediatricians, and American Osteopathic Association
01/01/19 22.30
Mark A Crowe, MD Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of
Washington School of Medicine
Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North
American Clinical Dermatologic Society
Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief,
Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American
College of Physicians, and Infectious Diseases Society of America
Seth Forman, MD Private Practice, Tampa, Florida
Seth Forman, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Abbott Laboratories Honoraria Speaking and teaching
Catharine Lisa Kauffman, MD, FACP Georgetown Dermatology and Georgetown Dermpath
Catharine Lisa Kauffman, MD, FACP is a member of the following medical societies: American Academy of
Dermatology, American Medical Association, Royal Society of Medicine, Society for Investigative Dermatology, and
Women's Dermatologic Society
John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for
Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks
Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of
Science, American College of Physicians, American Federation for Medical Research, American Society for
Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: MERCK None Other
Daniel R Lucey, MD, MPH Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious
Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of
the Health Sciences
Daniel R Lucey, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American College
of Physicians
Julia R Nunley, MD Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia
Commonwealth University Medical Center
Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American
College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology
Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, and Women's Dermatologic Society
Disclosure: Novartis Grant/research funds Consulting; Biolex Grant/research funds sub-investigator
Robert Orenstein, DO Associate Professor, Department of Medicine, Medical College of Virginia, Virginia
Commonwealth University; Medical Director, Infectious Disease Clinic, Medical College of Virginia Hospitals
Robert Orenstein, DO is a member of the following medical societies: Infectious Diseases Society of America
01/01/19 22.30
David Rowe, MD Pathologist, Laboratory Medicine, Martha Jefferson Hospital
David Rowe, MD is a member of the following medical societies: United States and Canadian Academy of Pathology
Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and
Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Dermatology, American College of Physicians, and Sigma Xi
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy;
Pharmacy Editor, Medscape Drug Reference
Disclosure: Medscape Salary Employment.
Sung W Yoon, MD, Fellow, Department of Plastic Surgery, Mayo Clinic at Scottsdale
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01/01/19 22.

Note the central umbilication in these classic lesions of molluscum contagiosum.

Molluscum contagiosum on the right axilla.

Multiple papules on the face of a man with HIV.

accompanied by a latent period of as long as 6 months.

Race- and sex-related demographics

Morbidity and mortality

Patients infected with HIV

Other characteristics of molluscum contagiosum to consider include the following:

Disfiguring lesions may occur in patients with the following conditions:

Selective immunoglobulin M (IgM) deficiency

Treatment with prednisone and methotrexate

Refractory atopic dermatitis

Histologic or microscopic confirmation of molluscum contagiosum is indicated in patients who are

Verruca vulgaris (warts)

Foreign body granuloma

Flat warts (verruca plana)

Acquired reactive perforating dermatosis of renal failure

Perforating serpiginous elastoma

Verrucous perforating collagenoma

Perforating granuloma annulare

Differential diagnoses to consider in patients with AIDS include the following:

Condyloma Acuminatum (Genital Warts)

Pearly Penile Papules

Pediatric Keratosis Pilaris

Pediatric Pyogenic Granuloma

Surgical Treatment of Basal Cell Carcinoma

Varicella-Zoster Virus (VZV)

Low-power histopathologic examination reveals an overall cup-shaped appearance.

Viral particles have a dumbbell-shaped appearance. Courtesy of Alvin Zelickson, MD.

Direct lesional trauma

Immune response stimulation

Deterrence and prevention

Dilute povidone iodine

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

Direct Lesional Trauma

Immune Response Stimulation

Salicylic acid (Compound W, Freezone, Wart-Off)

Tretinoin topical (Retin-A, Avita, Tretin-X)

Topical Skin Products

Questions & Answers

What is molluscum contagiosum?

Who discovered molluscum contagiosum disease?

How is molluscum contagiosum infection transmitted?

What is the disease pattern of molluscum contagiosum infection in children?

What is the disease pattern of molluscum contagiosum infection in healthy adults?

What is the disease pattern of molluscum contagiosum infection in immunocompromised patients?

What is the pathogenesis and disease progression of molluscum contagiosum infection?

How is molluscum contagiosum virus classified?

Which types of molluscum contagiosum virus cause infection in humans?

What is the structure of the molluscum contagiosum virus genomes?

How prevalent is molluscum contagiosum infection in the US?

What is the global prevalence of molluscum contagiosum infection?

Does molluscum contagiosum have a racial or sexual predilection?

What is the prognosis of molluscum contagiosum?

What is the morbidity associated with molluscum contagiosum infection?

What education about molluscum contagiosum should be provided to patients?

Should children with molluscum contagiosum be kept out of school or daycare?

What instructions should a patient be given to prevent transmission of molluscum contagiosum?

What are the symptoms of molluscum contagiosum?

Which conditions increase the risk of spreading molluscum contagiosum?

How does comorbid atopic dermatitis affect molluscum contagiosum?

Which factors increase the risk for molluscum contagiosum infection?

What is the duration of molluscum contagiosum infection?