MOLLUSCIPOXVIRUS INFECTION: MOLLUSCUM CONTAGIOSUM

Molluscum contagiosum (MC) is a benign but nonetheless frequently troublesome viral infection that
most often affects young children. It is characterized by smooth, dome-shaped, discrete, opalescent
papules with a central core that occasionally develops surrounding areas of scale and erythema
(molluscum dermatitis). Patients and families are bothered by this infection because of its often
prolonged course, as it may persist for months to years. MC is a greater concern in
immunocompromised individuals and those with atopic dermatitis, in whom the extent and duration
of infection may be more extreme. Sexually transmitted disease occurs in adults but is extremely
unlikely in children.

EPIDEMIOLOGY

MC virus (MCV) infection occurs worldwide and appears specific to humans. The prevalence of MCV
infection has risen significantly in the past several decades, with an 11-fold increase noted in one US
study of patient visits for this disorder over a twodecade span.75 This rise appears to parallel the
overall increase in sexually transmitted diseases. Although a prevalence rate of less than 5% in US
children is often cited,76 the rate varies by location, and it is thought that subclinical infection may be
more common than overt disease. A representative Australian study documented an overall
seropositivity rate of 23%, which supports the view that subclinical or mild unrecognized disease exists
in the population. HIVinfected individuals are at higher risk for extensive prolonged disease, and
individuals with atopic conditions appear more likely to have increased numbers of lesions and
experience a more prolonged disease course.76 Transmission may occur via direct skin or mucous
membrane contact, or via fomites. Bath towels, swimming pools, and Turkish baths have all been
reported as sources of infection, and individuals involved in close contact sports (e.g., wrestling) also
appear at higher risk.77,78 Autoinoculation and koebnerization also play a role in the spread of
lesions. Recent reports also document the possibility of vertical transmission from mother to neonate
during the intrapartum period.79

ETIOLOGY AND PATHOGENESIS

MCV is a large, brick-shaped poxvirus that replicates within the cytoplasm of cells. It shares a number
of genomic similarities with other poxviruses, and approximately two-thirds of the viral genes are
similar to those of vaccinia and variola virus.80 There are four subtypes of MCV, but they all appear
identical clinically. Ninety-eight percent of disease in the United States is caused by MCV genotype 1
and it is the main cause of MC in children.80,81 MCV-2 is primarily seen in adults and
immunocompromised individuals, with sexual contact being the most common mode of transmission.
Serial transmission of the virus has not yet been achieved in culture. An incubation period of 2–7
weeks has been observed. Virus replicates within the cytoplasm of epithelial cells, and infected cells
replicate at twice the baseline rate. There are many MCV genes that may contribute to an impaired
immune response to this virus, including (1) a homolog of a major histocompatibility class 1 heavy
chain, which may interfere with antigen presentation; (2) a chemokine homolog that may inhibit
inflammation; and (3) a glutathione peroxidase homolog that may protect the virus from oxidative
damage by peroxides.82,83

CLINICAL FINDINGS CUTANEOUS LESIONS. MC often presents with extremely small pink, pearly, or
flesh-colored papules that then enlarge, occasionally reaching sizes of up to 3 cm (“giant molluscum”).
As they enlarge, a dome-shaped, opalescent morphology may become more apparent. The lesions
may have a central dell or umbilication (Fig. 195-12), within which a white curdlike substance can be
seen that can be expressed with pressure. Most patients develop multiple papules, often in
intertriginous sites, such as the axillae, popliteal fossae, and groin. Genital and perianal lesions can
develop in children and are only rarely associated with sexual transmission in this population.75
Lesions may be grouped in clusters or appear in a linear array. The latter often results from
koebnerization or development of lesions at sites of trauma. Erythema and eczematous changes may
occur around lesions; this is termed molluscum dermatitis. Papules may become erythematous (Fig.
195-12B), which is believed to be an immune response to the infection. Patients with acquired
immunodeficiency syndrome may develop large and extensive lesions involving both genital and
extragenital sites.82 (see Chapter 198)

SPECIAL TESTS

Diagnosis is usually straightforward. Evaluation of the central contents using a crush preparation and
Giemsa staining can be carried out when necessary (eFig. 19512.1 in online edition), and
histopathologic evaluation can be performed as needed. Some clinicians recommend that an adult
with new-onset MC infection undergo evaluation for HIV infection and/or other causes of an
immunocompromised state.84 Histopathologic examination reveals a hypertrophied and hyperplastic
epidermis. Above the basal layer, enlarged cells containing large intracytoplasmic inclusions
(Henderson-Paterson bodies) can be seen (Fig. 195-13). These increase in size as the cells reach the
horny layer.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis includes verrucae, pyogenic granulomas, amelanotic melanoma, basal cell
carcinomas, and appendageal tumors. Fungal infections caused by Cryptococcus, histoplasmosis, and
Penicillium must be considered in immunocompromised hosts (Box 195-5).

COMPLICATIONS

Although many patients are asymptomatic, pruritus is sometimes a significant problem, particularly in
those patients with underlying atopic dermatitis. Chronic conjunctivitis and punctate keratitis may
develop in patients with eyelid lesions. Secondary bacterial infection can occur, particularly if patients
scratch their lesions.

PROGNOSIS AND CLINICAL COURSE

Spontaneous clearance occurs, but often over a prolonged period of months to years. Most families
prefer treatment if lesions persist more than a month or two TREATMENT

It is important to discuss the risks and benefits of individual therapies with families before embarking
on treatment for this essentially benign condition, which will generally resolve without complication
in the immunocompetent individual (Table 195-3). For some children, no treatment is the best option
as the child’s native immune response may clear the MC without additional intervention. Many
experts use cantharidin 0.7% or 0.9% liquid for treatment of MC. This extract of the blister beetle,
Cantharis vesicatoria, induces vesiculation at the dermoepidermal junction when applied topically to
the skin. It must be applied with care and washed off 2–6 hours later. Use on the face or genital areas
is not recommended, and families must be counseled regarding the small risk of extreme reaction or
scarring. Other traditional therapies have included curettage and cryotherapy; however, both of these
treatments are painful. The use of topical anesthetic agents may ameliorate some of the associated
pain, but patients generally find topical cantharidin treatment the most efficient and least painful.
Other topical therapeutic modalities include retinoid creams, imiquimod cream, salicylic acid,
trichloroacetic acid, cidofovir, and silver nitrate paste and tape stripping. Oral cimetidine has also been
used with some success.85 However, a 2009 Cochrane Database analysis of treatments for MC, which
identified only 11 therapeutic studies of high quality, found that no single intervention is convincingly
effective for the treatment of MC.86

PREVENTION

Prevention of spread may be enhanced by avoiding trauma to the sites of involvement as well as
avoiding scratching, with the use of antipruritics as necessary. Autoinoculation may be decreased by
treating all existing lesions.

Watchful waiting Spontaneous resolution occurs over months to years in immunocompetent

individuals.

Risk of autoinoculation, associated dermatitis, secondary bacterial infection

Topical therapies Cantharidin (0.7% or 0.9%) Rarely severe blistering and scarring of concern

2, 3

Podophyllin (10%–25% resin) (0.3% or 0.5% cream) Cryotherapy/liquid nitrogen Curettage Imiquimod
cream (5%) Topical retinoids Silver nitrate paste Trichloroacetic acid (25%–35%) Topical cidofovir (1%,
3% gel; 1%, 3% cream)

Rarely severe blistering and scarring of concern Rarely severe blistering and scarring of concern Painful
Painful, scarring possible Irritation common Irritation common Rarely severe blistering and scarring of
concern Expensive

1, 2, 3

3 1, 2, 3 3 2 2, 3

2, 3

Systemic therapies Oral cimetidine (40 mg/kg/day) Oral cidofovir Subcutaneous interferon-α

Recommended only for immunocompromised individuals, expensive

2, 3 3

Recommended only for immunocompromised individuals