BAGIAN ILMU KESEHATAN JOURNAL READING

KULIT DAN KELAMIN SEPTEMBER 2020

FAKULTAS KEDOKTERAN
UNIVERSITAS PATTIMURA

“Update on the Treatment of Molluscum Contagiosum in Children”

OLEH:

Oleh

Mega R. Bagdad (201984002)

Cynthia Manaha (201984005)

Pembimbing:

dr. Hanny Tannasal Sp.KK

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK

PADA BAGIAN ILMI KESEHATAN KULIT KELAMIN
FAKULTAS KEDOKTERAN UNIVERSITAS PATTIMURA
AMBON
2020

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 Pembaruan tentang Pengobatan Moluskum Kontagiosum pada Anak
P. Gerlero,a Á. Hernández-Martínb

Abstrak
Moluskum Kontagiosum adalah salah satu infeksi virus paling umum terjadi
pada masa kanak-kanak. Infeksi ini biasanya sembuh sendiri, tetapi pengobatannya
pada anak-anak dapat menjadi sebuah tantangan, terutama ketika pasien
menunjukkan banyak lesi atau ketika lesi tersebut menunjukkan gejala atau sangat
terlihat. Ada beberapa pilihan pengobatan. Pilihan pengobatan tergantung pada
jumlah dari lokasi lesi, pengalaman sebelumnya dari dokter yang merawat, dan
preferensi orang tua atau pengasuh anak. Artikel ini memberikan pembaruan tentang
pilihan pengobatan untuk Moluskum Kontagiosum, dengan focus khusus pada pasien
pediatric imunokompeten.

Kata Kunci: Molluscum contagiosum, Children, Treatment, Poxvirus, Curettage,

Cryotherapy

Pengantar
Moluskum Kontagiosum (MK) disebabkan oleh virus DNA dari genus
Moluscipoxvirus, dari keluarga Poxviridae. Saat ini, virusnya dikategorikan menjadi
dua tipe (MCV-1 dan MCV-2) dan empat genotif berbeda. Genotif 1 menyumbang
98% kasus yang tercatat di Amerika Serikat,genotif 2 dan genotif 3 lebih umum
menyebabkan kejadian di Eropa dan Australia dan pada pasien dengan HIV (Human
Immonudefisiensi Virus), dan genotif empat jarang terjadi. MK merupakan salah satu
dari 50 penyakit yang paling sering terjadi di seluruh dunia. Pada anak-anak, kejadian
tahunannya berkisar dari 2% hingga 10% dan prevalensinya dari 5,1% menjadi
11,5%. Namun, angka ini sangat bervariasi tergantung pada populasi yang diteliti.
MK dapat ditularkan melalui kontak langsung, fomites dan suntikan. Masa inkubasi
dari virus ini berkisar dari 14 hari hingga 6 bulan. Tidak seperti virus herpes, MK
tidak menetap sebagai infeksi laten. Tinjauan literature dari survei Australia terhadap
pasien MK mengungkapkan hal itu terutama mempengaruhi anak-anak sekolah yang

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telah mengunjungi kolam renang. Namun, tidak ada bukti terdokumentasi yang
menunjukkan bahwa penularan dapat dicegah secara efektif dengan menjauhkan
anak-anak dari kolam renang. Variabel lain seperti kontak langsung, keberadaan
fomites, dan tinggal di iklim tropis juga dikaitkan dengan tingkat infeksi yang lebih
tinggi. Studi lain menentukan bahwa individu yang berbagi spons mandi atau handuk
dengan orang yang terinfeksi memiliki resiko infeksi relatif tiga kali lipat lebih besar
daripada mereka yang tidak berbagi barang-barang mereka. Tindakan pencegahan
tertentu (misalnya memandikan anak-anak terpisah, menghindari penggunaan spons
dan handuk bersama, dan menutupi lesi MK) mungkin akan efektif.
Secara klinis, MK ditandai dengan papula berwarna kulit dan atau nodul
dengan umbilikasi sentral. Pada beberapa pasien, lesinya mungkin dikelilingi oleh
halo dari eksema, yang dikenal dengan dermatitis moluskum. Ini merupakan hasil
dari reaksi hipersensitivitas terhadap antigen virus dan bisa berkembang menjadi
abses atau lesi yang kurang khas (Gambar 1). Meskipun area kulit atau membran
mukosa manapun dapat terinfeksi, lesi pada telapak kaki, telapak tangan dan
membran mukosa jarang terjadi. Anak-anak sering mengalami dermatitis atopik
(DA). Dalam tinjauan retrospektif bagian medis dari 696 kasus MK pediatric, 259
(37,2%) memiliki riwayat DA dan 38,8% menderita dermatitis moluskum. Pada
pasien dengan DA yang mendasari atau kondisi lain yang berhubungan dengan
kekebalan yang terganggu, lesi cenderung lebih banyak dan bertahan lama.

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 Gambar 1. Manifestasi klinis Moluskum Kontagiosum yang berbeda. A, papula merah muda di
kelopak mata dengan umbilikasi sentral yang khas. B, lesi sesil dengan morfologi yang kurang khas di
samping lesi lain yang khas pada MK. C, reaksi Eczematiform (dermatitis moluskum) di sekitar lesi
MK. D, luka radang dan abses di perut.

Pada pasien dengan imunokompeten, infeksi kulit yang disebabkan oleh MK

bersifat tidak berbahaya dan dapat sembuh sendiri. Ada beberapa pilihan pengobatan
yang tersedia, tidak ada satupun yang secara signifikan lebih efektif daripada yang
lain. Dalam memilih pengobatan untuk pasien anak, prioritasnya harus menghindari
rasa sakit dan meminimalkan resiko jaringan parut. Selain itu, penting untuk
meyakinkan ornag tua dan memberitahu mereka tentang perjalanan penyakit dan hasil
pengobatan yang diharapkan. Sebuah survei terhadap orang tua dari anak-anak
dengan MK menemukan bahwa mereka terutama mengkhawatirkan jaringan parut,
pruritus, kemungkinan penularan, nyeri dan efek dari pengobatan. Bagaimanapun,
kualitas hidup anak tidak terpengaruh.

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Jenis Pengobatan untuk Moluskum Kontagiosum

Tabel 1. Pilihan perawatan untuk Moluskum Kontagiosum

Pengobatan Pengobatan Imunoterap Terapi Pengobatan Pengobatan
topikal, topikal, i destruktif, tradisional lainnya
Rawat jalan Rumah Rawat jalan
 Nitrat silver  Krim  Cimetidin Krioterapi  Minyak  Perekat adesif
 Asam Imiquimod  Cidofovir,  Kuretase esensial  Hipertermia
trikloroaseti 5% IV  Ekstrusi asutralian  Tunggu dan
k  Peroksid  Interferon-α manual (Blackhousia lihat
 Podofilin benzoil  Candidin  Laser citriodora)
 Kantaridin  Peroksid kasrbondiksid  Tea tree oil
 Asam hydrogen  Laser pulsed
salisilik  Hidroksid dye
potasium

Pilihan pengobatan untuk MK tercantum pada tabel 1. Pengobatan yang

digunakan pada pasien anak-anak adalah sebagai berikut.

Metode Destruktif
Metode destruktif merupakan metode yang paling umum digunakan dalam
praktik rutin dan dapat merusak keratinosit yang terinfeksi oleh virus MK. Ini
prosedur sederhana yang tidak mahal, akan sangat efektif jika dilakukan oleh orang
sesuai yang berkualifikasi.
Kuretase
Kuretase adalah prosedur yang sederhana dan relative murah, dengan
keuntungan tambahan bahwa jaringan yang diangkat dapat disimpan untuk analisis
histopatologi jika ada keraguan diagnostik. Krim EMLA (campuran anestesi lokal
eutetik 2,5% lidokaindan 2,5% prilokain), sering digunakan pada anak-anak untuk
meredakan nyeri yang disebabkan oleh prosedur kuretase, meskipun aplikasinya pada
lesi MK dapat menyebabkan reaksi purpura lokal yang akan sembuh sendiri (Gambar
2).

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 Gambar 2. Reaksi purpura terhadap pengaplikasian topikal krim EMLA (campuran anestesi lokal
eutektik) dan oklusi selama 1 jam.

Resiko toksisitas juga harus dipertimbangkan jika krim EMLA diterapkan di

area yang luas, terutama pada bayi yang berusia kurang dari 3 bulan (Tabel 2).
Kuretase mungkin salah satu metode yang paling efektif. Sebuah studi retrospektif
klinis terhadap 1879 pasien anak-anak menemukan bahwa 70% anak sembuh setelah
pengobatan tunggal, 26% membutuhkan 2 jenis pengobatan, dan hanya 4% yang
membutuhkan 3 jenis pengobatan. Kepuasannya sangat tinggi (97% pada anak-anak
dan orang tua). Sebuah uji coba terkontrol secara acak yang membandingkan
kemapuhan kuretase, kantaridin, asam salisilat dengan asam glikolat dan imiquimod
menemukan bahwa kuretase adalah terapi yang paling efektif, menunjukkan 80,6%
pasien tanpa kekambuhan setelah 6 bulan dari masa follow up. Kekurangan kuretase
termasuk memerlukan anestesi lokal, adanya potensi nyeri dan perdarahan, dan resiko
terbentunknya jaringan parut.

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 Tabel 2. Dosis maksimum yang direkomendasikan dan area pengaplikasian campuran anestesi
lokal eutetik.
Usia dan atau berat Dosis maksimum Maksimal area Maksimal jam
badan total pengaplikasian, cm2 pengaplikasian, Jam
0-3 bulan atau < 5 kg 1 10 1
3-12 bulan dan > 5 kg 2 20 4
1-6 tahun dan > 10 kg 10 100 4
7-12 tahun dan > 20 20 200 4
kg

Ekstrusi Manual
Inti lesi umbilikasi dapat diangkat secara manual menggunakan tangan atau
salah satu dari berbagai instrument, termasuk pisau bedah, lancet, jarum insulin, slide
atau forsep (Gambar 3). Bekas luka yang dihasilkan mirip dengan yang disebabkan
oleh kuretase. Teknik ini sangat menarik karena sederhana dan cepat serta dapat
dipelajari oleh pasien, anggot keluarga dan pengasuh, maka dari itu ini dapat
dilakukan di rumah.

Gambar 3. Tindakan manusal pada moluskum dengan jari-jari. A, lesi terjepit di antara 2 jari. B dan
C, bagian putih dari moluskum diesktrusi. C, Kerusakan jaringan minimal.

Asam Trikloroasetat
Asam trikloroasetat menyebabkan kerusakan jaringan dengankoagulasi kimiawi
langsung dan nekrosis superfisial. Ini digunakan pada konsentrasi 25% dam 35%
kemudian dioleskan berulang kali ditengah lesi sampai terbentuk penampakan seperti

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embun beku. Dalam tinjauan kasus pediatrik, MK pada wajah yang diobati dengan
asam trikloroasetat topikal, tidak ada iritasi atau perubahan pigmen dan pasien hanya
melaporkan rasa perih ringan selama pengaplikasian, ini menghasilkan hasil klinis
yang baik. Efek samping termasuk pruritus di daerah yang dirawat, iritasi pada kulit
sekitar, ulserasi dan jaringan parut.

Asam salisilat
Asam salisilat adalah agen keratolitik yang dijual dengan konsentrasi 10%
hingga 30%. Sebuah uji coba terkontrol acak dari pengobatan dengan 10% kalium
hidroksida (KOH) atau kombinasi asam salisilat dan asam laktat pada 16,7% pada 26
pasien MK berusia 2 tahun sampai 12 tahun tidak menemukan perbedaan yang
signifikan antara kelompok setelah 6 minggu. Efek sampingnya antara lain iritasi,
pruritus, sensasi terbakar dan pengelupasan kulit.

Hidrogen peroksida
Hidrogen peroksida (HP) adalah agen pengoksidasi dan antiseptic yang kuat
yang dapat menonaktifkan poxvirus in vitro. Pengobatan dengan HP yang dijual di
luar spanyol dalam krim 1%, menghasilkan lesi sembuh total pada pasien berusia 8
bulan dengan MK genital saat diterapkan pada setiap penggantian popok selama 1
minggu. Dalam studi lain dari 12 pasien MK yang diobati dengan krim HP 1% yang
dioleskan dua kali sehari selama 21 hari berturut-turut, 67% mengalami kesembuhan
tanpa kekambuhan setelah 6 bulan masa follow up. Uji klinis yang tepat diperlukan
untuk memastikan kemanjuran dan keamanan HP untuk pengobatan MK pada anak-
anak.

Chantaridin
Cantharidin adalah agen vesicant yang diproduksi oleh kumbang Lytta
vesicatoria. Ketika dioleskan pada kulit, penghambat fosfodiesterase ini
menghasilkan lepuh intraepidermal yang jarang meninggalkan bekas luka karena

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lokasinya yang superfisial. Chantaridin digunakan pada konsentrasi 0,7% hingga
0,9%, dan setelah aplikasi harus dibiarkan di tempat selama 2 hingga 4 jam tanpa
penyumbatan dan kemudian dihilangkan dengan sabun dan air. Penulis lain telah
mengusulkan bahwa dalam kasus lesi resisten cantharidin harus dibiarkan mengering
selama 5 sampai 10 menit dan kemudian ditutup dengan pita perekat. Perawatan
dapat diulang dengan interval 1 hingga 4 minggu. Dalam penelitian retrospektif
terhadap 300 anak dengan MC yang diobati dengan cantharidin, angka kesembuhan
90% dicapai dengan rata-rata 2,1 pengobatan.
Perawatannya sendiri tidak menimbulkan rasa sakit, tetapi dalam 24 hingga 48
jam bentuk lepuhan yang menyakitkan, membawa risiko tambahan superinfeksi
sekunder. Kasus limfangitis dengan limfedema setelah pengobatan cantharidin juga
telah dilaporkan Mengingat risiko ini, cantharidin tidak dianjurkan untuk MC pada
wajah atau daerah anogenital.

Potasium Hidroksida
Potasium hidroksida (KOH) adalah alkali yang menembus dan menghancurkan
kulit dengan melarutkan keratin. Ini digunakan dalam larutan air pada konsentrasi 5%
sampai 20%, dan diterapkan pada lesi MC sekali atau dua kali sehari. Dalam uji coba
prospektif di mana 35 anak dengan lesi MC menerima perawatan dua kali sehari
dengan larutan air KOH 10%, resolusi lesi lengkap diamati pada 32 pasien. Aplikasi
dihentikan pada 3 pasien karena sengatan parah dan infeksi sekunder. Kemanjuran
KOH telah dibandingkan dengan perawatan MC lainnya. Tidak ada perbedaan
signifikan yang dilaporkan dalam percobaan yang membandingkan kemanjuran
cryotherapy dengan 10% KOH dalam larutan untuk pengobatan MC. Namun, biaya
yang lebih tinggi dan efek lokal sekunder dari cryotherapy cenderung mendukung
penggunaan KOH. Studi lain menemukan bahwa 10% KOH dan krim imiquimod 5%
sama efektifnya, tetapi KOH memiliki onset kerja yang lebih cepat. Akhirnya,
penelitian ketiga membandingkan 10% KOH yang diberikan sekali sehari dengan
kombinasi asam salisilat dan asam laktat, menemukan bahwa keduanya sama-sama

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efektif dalam pengobatan MC. Karena pengobatan 10% KOH tidak invasif, efektif,
dan dapat diterapkan di rumah, banyak penulis menganggapnya sebagai terapi lini
pertama.

Cryoterapi
Penerapan nitrogen cair pada 196◦C menginduksi pembentukan kristal es
intraseluler dan ekstraseluler, yang menyebabkan kerusakan jaringan dan perubahan
pada membran sel dan sirkulasi di kulit. Nitrogen cair diaplikasikan dengan kapas
atau penyemprot portabel selama 10 hingga 20 detik dalam 1 atau 2 siklus perawatan
dengan interval 1 hingga 3 minggu. Dalam sebuah studi prospektif yang merekrut 74
anak dengan MC, kemanjuran klinis dari cryotherapy mingguan dibandingkan dengan
5% imiquimod yang diberikan 5 kali per minggu. Setelah 16 minggu pengobatan,
resolusi lengkap diamati pada 100% pasien yang diobati dengan cryotherapy dan
91,8% dari mereka yang diobati dengan imiquimod, tetapi perbedaannya tidak
signifikan secara statistik. Meskipun krioterapi dapat dengan mudah dan cepat
diberikan, terapi ini sangat tidak dapat ditoleransi pada anak kecil. Kerugian lain
termasuk pembentukan lepuh, kemungkinan jaringan parut, dan hiperatau
hipopigmentasi residual

Terapi Laser
Beberapa penulis menganggap karbon dioksida (CO2) terapi laser menjadi
pendekatan yang lebih cepat dan tidak terlalu traumatis dibandingkan kuretase.
Namun, dalam sebuah penelitian terhadap 6 pasien yang diobati dengan CO2 laser,
bekas luka hipertrofik dan keloid diamati pada 70% pasien pasien yang dirawat, dan
oleh karena itu penggunaannya pada anak-anak tidak dianjurkan. Beberapa penulis
menganggap terapi laser pulsed dye sangat berguna pada anak-anak dengan lesi
resisten. Karena hanya diperlukan satu siklus pengobatan dalam banyak kasus,
kecemasan yang terkait dengan pengobatan berulang diminimalkan. Namun,
modalitas perawatan ini mahal dan terkadang membutuhkan anestesi lokal. Efek

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merugikan dari jenis terapi laser ini termasuk rasa sakit dan ketidaknyamanan lokal,
edema, dan perubahan pigmen

Imunoterapi
Metode imunoterapi didasarkan pada stimulasi respon imun seluler dan / atau
Potasium hidroksida humoral yang dapat menghilangkan infeksi virus.

Imiquimod
Imiquimod, agonis dari reseptor 7, mengikat reseptor ini, mengaktifkan respon
imun bawaan dan menginduksi sintesis interferon-, interleukin (IL) -1, IL-5, IL-6, IL-
8, IL-10, dan IL-12, dan antagonis reseptor IL-1, di antara faktor-faktor lainnya. Efek
antivirus dan antitumor Imiquimod dimediasi oleh sistem kekebalan adaptif dan
bawaan. Ini tersedia dalam krim 5% untuk dioleskan pada malam hari, dibiarkan
selama 8 jam, dan dibilas di pagi hari. Beberapa penulis merekomendasikan aplikasi
harian sementara yang lain menyarankan 3 perawatan per minggu. Dalam satu studi
di mana anak-anak dengan MC diobati 3 kali per minggu selama 16 minggu dengan
krim imiquimod 5%, resolusi lengkap MC diamati pada 69%. Efek samping lokal
yang paling sering adalah eritema, pruritus, perih, dan nyeri, yang dalam beberapa
kasus sangat intens

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 Gambar 4. Iritasi yang disebabkan oleh penerapan imiquimod topikal di lengan bawah kanan.

Simetidin
Simetidin oral adalah antagonis reseptor histamin H2. Ini memberikan efek
imunomodulator dengan merangsang hipersensitivitas tertunda. Dalam sebuah studi
klinis terhadap 13 anak berusia kurang dari 10 tahun yang diobati dengan 40 mg/kg
simetidin oral sekali sehari selama 2 bulan, resolusi lesi lengkap diamati pada 9 dari
13 pasien. Para penulis menyimpulkan bahwa simetidin adalah alternatif yang mudah
diaplikasikan, efektif, dan tanpa rasa sakit untuk mengobati MC di wajah, meluas,
atau berulang pada anak-anak yang imunokompeten. Namun, dalam uji coba tersamar
ganda yang membandingkan pengobatan plasebo dengan simetidin oral (35 mg/kg)
yang diberikan sekali sehari selama 12 minggu pada pasien MC yang berusia 1
sampai 16 tahun, tidak ada perbedaan yang signifikan secara statistik yang diamati
antara kelompok plasebo dan kelompok pengobatan. Berdasarkan temuan ini, penulis
mengusulkan bahwa kemanjuran yang diamati dalam penelitian lain sebenarnya

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mungkin merupakan hasil dari resolusi lesi secara spontan. Efek samping simetidin
oral jarang terjadi, tetapi termasuk mual, diare, ruam, dan pusing

Candidin
Candidin, zat yang berasal dari ekstrak yang dimurnikan Candida albicans,
biasanya digunakan untuk mengobati kutil tetapi telah diusulkan sebagai pilihan
pengobatan untuk MC. Ini diberikan secara intralesi baik yang tidak diencerkan atau
pada konsentrasi 50% dalam lidokain. Dosis yang diberikan sesuai dengan 0,2 sampai
0,3mL antigen. Dalam satu penelitian retrospektif terhadap 29 pasien MC di bawah
usia 17 tahun yang dirawat dengan 0,3mL candidin intralesi, tingkat respons global
adalah 93%, dan respons lengkap dan parsial diamati masing-masing pada 55% dan
37,9% pasien. Kebanyakan efek sampingnya minimal, tetapi nyeri di tempat suntikan
dialami oleh 4 pasien. Dalam tinjauan retrospektif lain dari 25 kasus MC yang diobati
dengan Update tentang Pengobatan Moluskum Kontagiosum pada Anak candidin
intralesi, resolusi lengkap diamati pada 14 (56%) kasus, respon parsial pada 7 (28%),
dan tidak ada perbaikan klinis pada 4 (16%). Keuntungan imunoterapi dalam
pengobatan MC termasuk induksi respon imun memori terhadap MC, potensi untuk
menginduksi respon umum yang mengarah pada resolusi lesi yang tidak diobati di
tempat yang jauh secara anatomis, dan kurangnya efek samping. Namun, candidin,
yang tidak tersedia secara komersial di Spanyol, jarang digunakan dalam praktik
klinis.

Perak Nitrat
Perak nitrat dibuat dengan 0,2 ml larutan perak nitrat 40% dan 0,05 g larutan
kami. Campuran semitransparan ini ditempatkan di tengah lesi. Setelah 24 jam, kulit
hitam mulai muncul, dan setelah sekitar 14 hari lesi MC lepas. Pengobatan 389
pasien MC berturut-turut dengan perak nitrat 40% menghasilkan angka kesembuhan
97,7% dan tidak menimbulkan jaringan parut. 41 Prosedur sederhana dan murah ini

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tidak menimbulkan rasa sakit dan menyebabkan beberapa reaksi merugikan seperti
nyeri, perih, eritema, luka bakar kimiawi, atau sisa hiperpigmentasi

Terapi Antimitotik
Cidovir
Cidofovir adalah analog nukleotida dari deoxycytidine monophosphate.
Meskipun mekanisme kerjanya masih belum jelas, ia diketahui menghambat
polimerase DNA virus, oleh karena itu menghalangi sintesis DNA virus. Cidofovir
dapat diberikan secara intravena (5mg / kg / minggu selama 2 minggu diikuti dengan
5mg / kg sekali setiap 2 minggu) atau secara topikal (krim atau gel 1%- 3%,
dioleskan setiap hari). Beberapa penelitian telah menggambarkan keberhasilan
penggunaan intravena atau topikal cidofovir untuk MC resisten terhadap pengobatan
lain. Namun, obat ini mahal dan penelitian lebih lanjut diperlukan untuk menentukan
kemanjuran dan keamanannya pada anak-anak

Perawatan Lainnya
Basis bukti yang mendukung beberapa pengobatan dengan efektivitas langka
lemah, tetapi tidak berbahaya dan secara umum diterima dengan baik oleh orang tua
dan pengasuh. Perawatan semacam itu mungkin berguna pada pasien dengan lesi
resisten multipel yang membutuhkan pengobatan aktif. Perawatan ini termasuk
hipertermia lokal, oklusi dengan pita perekat, dan aplikasi topikal Leucotomos
polipodium ekstrak, immunoferon, seng oksida, asam azelaic, dan produk alami
tertentu seperti minyak esensial dari daun myrtle lemon Australia.

Tunggu dan lihat

Karena MC bersifat jinak dan membatasi diri, pendekatan menunggu dan
melihat masuk akal. Waktu penyelesaian MC bervariasi. Dalam studi kohort
komunitas prospektif waktu rata-rata untuk resolusi lesi MC pada 306 pasien MC
Inggris berusia 4 sampai 15 tahun adalah 13,3 bulan. Tiga puluh persen tidak

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terselesaikan pada 18 bulan, dan 13% tetap tidak terselesaikan pada 24 bulan. Namun,
banyak orang tua tidak akan menerima perkiraan waktu yang tidak pasti untuk
penyelesaian dan takut potensi risiko penyebaran atau penularan ke anak-anak lain.
Selain itu, dalam beberapa kasus penyakit ini dapat menimbulkan ketidaknyamanan
atau menstigmatisasi. Satu survei menemukan bahwa orang tua dua kali lebih
mungkin dibandingkan anak-anak mereka dengan MC untuk mengungkapkan
kekhawatiran yang signifikan tentang penyakit tersebut. Kekhawatiran orang tua
terkait dengan manifestasi klinis MC (jaringan parut, menyebar, gatal, dan nyeri) dan
ketidaknyamanan yang disebabkan oleh metode pengobatan yang tersedia. Namun,
penelitian yang sama menemukan bahwa infeksi tidak terjadi secara signifikan
memengaruhi aktivitas sehari-hari, kualitas hidup, atau produktivitas individu di
sekolah

Pendekatan kami untuk perawatan MC

Karena MC cenderung sembuh secara spontan, kita sering memilih untuk
menunggu dan melihat, terutama jika lesi tidak bergejala dan orang tua, karena alasan
apa pun, lebih memilih untuk membiarkan penyakit berjalan dengan sendirinya. Jika
lesi menyebabkan ketidaknyamanan, terletak di area yang sangat terlihat, atau
menyebabkan anak dikeluarkan dari kegiatan sekolah, kami memilih pengobatan aktif
Pilihan pengobatan tergantung pada jumlah lesi, lokasinya, potensi efek
samping, preferensi orang tua, dan pengalaman dokter. Secara umum, kami
menghindari prosedur apa pun yang menyebabkan nyeri hebat atau terkait dengan
risiko jaringan parut yang signifikan (misalnya, cryotherapy atau terapi laser)
Ekstrusi tubuh moluskum secara manual dengan menggunakan jari merupakan
teknik yang sederhana dan murah, dan sangat ideal bila anak yang terkena memiliki
sedikit lesi dan takut pada instrumen bedah seperti kuret, pisau bedah, atau klem.
Kuretase mungkin merupakan teknik yang paling efektif, tetapi membutuhkan
keterampilan dan kolaborasi pasien, yang seringkali kurang (terutama dalam kasus
yang memerlukan perawatan berulang atau melibatkan lesi wajah). EMLA topikal

15
dapat meminimalkan rasa sakit, tetapi tidak melakukan apa pun untuk mengurangi
rasa takut pada anak-anak. Selain itu, anestesi topikal sulit diterapkan di lokasi
tertentu seperti kelopak mata. Meskipun sedasi pada pasien dimungkinkan, opsi ini
disediakan untuk keadaan yang sangat spesifik
Di Spanyol, KOH dijual dengan konsentrasi 5% dan 10% dan dapat diterapkan
di rumah. Kedua formulasi tersebut cocok untuk pengobatan pasien dengan banyak
lesi atau lesi pada batang tubuh dan ekstremitas. KOH juga berguna saat anak tidak
bekerja sama dengan diam selama pengobatan atau saat orang tua enggan
mengizinkan kuretase. Kami cenderung tidak menggunakan produk topikal lain yang
tersedia di Spanyol karena menurut pengalaman kami, produk tersebut menyebabkan
iritasi lokal yang cukup besar dan menunjukkan efektivitas yang relative buruk.
Selain itu, sangat sedikit yang secara resmi diindikasikan untuk pengobatan MC pada
anak-anak.

Kesimpulan
Meskipun MC adalah salah satu penyakit kulit akibat virus yang paling umum
pada anak-anak, tidak ada kesepakatan mengenai pilihan pengobatan atau apakah
pasien harus dirawat. Tidak ada bukti ilmiah yang secara jelas mendukung
pengobatan khusus untuk MC. Menurut Strength of Recommendation Taxonomy yang
baru dikembangkan untuk menilai kualitas, kuantitas, dan konsistensi bukti untuk
terapi, dukungan untuk opsi manajemen MC akan berada pada level B paling baik,
menunjukkan kurangnya bukti yang konsisten dan berkualitas tinggi yang tersedia
Pada prinsipnya, MC harus dirawat dengan menggunakan modalitas yang
menyebabkan nyeri dan jaringan parut minimal. Penting juga untuk menentukan
pengobatan yang paling tepat untuk setiap kasus tertentu.

16
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/324880317

Update on the Treatment of Molluscum Contagiosum in Children

Article · May 2018

DOI: 10.1016/j.adengl.2018.04.016

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Actas Dermosifiliogr. 2018;109(5):408---415

REVIEW

Update on the Treatment of Molluscum Contagiosum in

Children夽
P. Gerlero,a Á. Hernández-Martínb,∗

a
Servicio de Dermatología, Hospital Sirio Libanés, Buenos Aires, Argentina
b
Servicio de Dermatología, Hospital Infantil del Niño Jesús, Madrid, Spain

Received 30 October 2017; accepted 18 January 2018

Available online 1 May 2018

KEYWORDS Abstract Molluscum contagiosum is one of the most common viral infections in childhood. It
Molluscum is a benign and usually self-limiting infection, but its treatment in children can be challenging,
contagiosum; particularly when the patient presents multiple lesions or when lesions are symptomatic or
Children; highly visible. Several treatment options exist. Choice of treatment depends on the number
Treatment; and location of lesions, the prior experience of the treating physician, and the preferences of
Poxvirus; the child’s parents or carers. This article provides an update on treatment options for molluscum
Curettage; contagiosum, with a particular focus on immunocompetent pediatric patients.
Cryotherapy © 2018 Elsevier España, S.L.U. and AEDV. All rights reserved.

PALABRAS CLAVE Actualización sobre el tratamiento de moluscos contagiosos en los niños

Moluscos contagiosos;
Niños; Resumen El molusco contagioso es una de las infecciones virales más frecuente en los niños.
Tratamiento; Aunque se trata de una infección de curso benigno y generalmente autolimitada, el tratamiento
Poxvirus; puede resultar complicado en la edad pediátrica cuando las lesiones son muy numerosas, están
Curetaje; en áreas visibles, o producen molestias. Existen diversos tratamientos disponibles, cuya selec-
Crioterapia ción depende del número y localización de las lesiones, de la experiencia del médico que las
trata, y de las preferencias de los padres o cuidadores. Este artículo proporciona una actual-
ización sobre las diferentes terapias contra los moluscos contagiosos particularmente enfocadas
a los pacientes pediátricos.
© 2018 Elsevier España, S.L.U. y AEDV. Todos los derechos reservados.

夽 Please cite this article as: Gerlero P, Hernández-Martín Á. Actualización sobre el tratamiento de moluscos contagiosos en los niños. Actas

Dermosifiliogr. 2018;109:408---415.
∗ Corresponding author.

E-mail address: ahernandez@aedv.es (Á. Hernández-Martín).

1578-2190/© 2018 Elsevier España, S.L.U. and AEDV. All rights reserved.
Update on the Treatment of Molluscum Contagiosum in Children
Introduction
Molluscum contagiosum (MC) is caused by a DNA virus of
the genus Molluscipoxvirus, family Poxviridae. Currently,
this virus is categorized into 2 types (MCV-1 and MCV-2)
and 4 distinct genotypes.1 Genotype 1 accounts for 98% of
cases recorded in the United States, genotypes 2 and 3 are
more prevalent in Europe and Australia and in patients with
human immunodeficiency virus 1, and genotype 4 is rare.2
MC is one of the 50 most frequent diseases worldwide.3 In
children its annual incidence ranges from 2% to 10%4 and
its prevalence from 5.1% to 11.5%.5 However, these rates
vary significantly depending on the population studied. MC
can be transmitted by direct contact, fomites, and self-
inoculation.1 The incubation period ranges from 14 days
to 6 months. Unlike herpesvirus, MC does not persist as a
latent infection. The review of the literature of an Australian
survey of MC patients revealed that it mainly affects school-
aged children who have visited a swimming pool.6 However,
there is no documented evidence demonstrating that trans-
mission can be effectively prevented by keeping children
out of pools.7 Other variables such as direct contact, the
presence of fomites, and living in tropical climates are also
associated with higher rates of infection.6 Another study
determined that individuals who share a bath sponge or
towel with an infected patient have a 3-fold greater relative
risk of infection than those who do not share these items.8
Certain preventive measures (eg, bathing children alone,
avoiding shared use of sponges and towels, and covering MC
lesions) may therefore be effective.
Clinically, MC is characterized by skin-colored papules
and/or nodules with central umbilication. In some patients,
these lesions may be surrounded by a halo of eczema, known
as molluscum dermatitis.9 This is the result of a hypersen-
sitivity reaction to the viral antigen2 and can evolve into
Figure 1 Different clinical manifestations of molluscum contagiosum (MC). A, Pink papules on the eyelids with typical central
umbilication. B, Sessile lesion of less typical morphology next to other lesions more characteristic of MC. C, Eczematiform reaction
(molluscum dermatitis) surrounding MC lesions. D, Inflamed and abscessed lesions on the abdomen.
409
an abscess or a less morphologically typical lesion (Fig. 1).
While any area of the skin or mucous membranes can be
infected, lesions on the soles, palms, and mucous mem-
branes are rare.6 Children often develop associated atopic
dermatitis (AD). In a retrospective medical chart review of
696 pediatric MC cases, 259 (37.2%) had a history of AD and
38.8% had molluscum dermatitis.9 In patients with under-
lying AD or other conditions associated with compromised
immunity, lesions tend to be more numerous and longer
lasting.2
In immunocompetent patients, skin infections caused by
MC are benign and self-limiting. There are multiple treat-
ment options available, none of which is significantly more
effective than the other.10 In selecting a treatment for pedi-
atric patients, the priorities should be to avoid pain and
minimize the risk of scarring. Furthermore, it is essential to
reassure parents and inform them as to the expected course
of the disease and treatment outcome. A survey of parents
of children with MC found that they were mainly concerned
about scarring, pruritus, the possibility of contagion, pain,
and the effects of treatments.6 However, children’s quality
of life was not affected.
Types of Treatment for MC
Treatment options for MC lesions are listed in Table 1. Those
that have been used in pediatric patients are described
below.
Destructive Methods
Destructive methods are the most commonly used meth-
ods in routine practice and result in the destruction of
keratinocytes infected by the MC virus. These simple and
410 P. Gerlero, Á. Hernández-Martín

Table 1 Treatment Options for Molluscum Contagiosum and Corresponding Degree of Evidence.

Topical Treatment, Topical Treatment, Immunotherapy Destructive Homeopathic/ Other

Outpatient Home Treatment, Natural Treatments
Outpatient
---Silver nitrate ---Imiquimod cream ---Cimetidinea Cryotherapya ---Australian ---Adhesive
---Trichloroacetic 5%a,b ---Cidofovir, IVb ---Curettageb essential oil tape
acid ---Benzoyl ---Interferon-␣b ---Manual extrusion (Backhousia ---Hyperthermia
---Podofilin peroxidea,b ---Candidin ---Carbon dioxide citriodora)a ---Wait and see
---Cantharidina,b ---Hydrogen laser --- Tea tree oil
---Salicylic acida,b peroxideb ---Pulsed dye
---Potassium lasera,b
hydroxidea,b

Abbreviations: IV, intravenous.

a Based on inconsistent or limited quality patient-oriented evidence, according to the SORT.
b Based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention,

or screening, according to the SORT. Adapted from Forbat et al42 and Ebell et al.51

inexpensive procedures, when carried out by a suitably qual-

ified health care professional, are very effective.2

Curettage

Curettage is a simple and relatively inexpensive procedure,

with the added advantage that the tissue removed can
be kept for histopathological analysis in case of diagnostic
doubt.11 EMLA cream, a eutectic mixture of local anesthet-
ics (2.5% lidocaine and 2.5% prilocaine), is frequently used
in children to ameliorate the pain caused by the procedure,
although its application on MC lesions can cause local, self-
resolving purpuric reactions12,13 (Fig. 2). The risk of systemic
toxicity should also be considered if EMLA is applied to a
large area, particularly in infants less than 3 months old14
(Table 2). Curettage is probably one of the most effective
methods. A retrospective clinical study of 1879 pediatric
patients found that 70% were cured after a single treat-
ment, 26% required 2 treatments, and only 4% required 3
treatments.15 Satisfaction was high (97% in children and par-
ents). A randomized, controlled trial comparing the efficacy
of curettage, cantharidin, salicylic acid with glycolic acid,
and imiquimod found that curettage was the most effective
therapy, resulting in complete resolution in 80.6% of patients
with no recurrences after 6 months of follow-up.16 Disad- Figure 2 Purpuric reaction to topical application of EMLA
vantages of curettage include the need for local anesthesia, (eutectic mixture of local anesthetics) cream and occlusion for
potential pain and bleeding, and the risk of scarring.17 1 hour.

Manual Extrusion
The umbilicated nucleus of the lesion can be manually
removed using the hands or any one of a variety of instru-
ments, including a scalpel, lancet, insulin needle, slide, or
forceps (Fig. 3). The resulting scarring is similar to that
caused by curettage. This technique is of particular inter-
est as it is simple and fast and can be learned by patients,
family members, and caregivers and therefore performed at
home.11
Trichloroacetic Acid
Trichloroacetic acid causes tissue destruction by immediate
chemical coagulation and superficial necrosis.18 It is used
at concentrations of 20% and 35% and applied repeatedly
on the center of the lesion until a white, frost-like cover-
ing forms. In a review of pediatric cases of facial MC treated
with topical trichloroacetic acid, no irritation or marked pig-
mentary alterations were described, and patients reported
only mild stinging during applications, which produced good
clinical results.19 Adverse effects include pruritus in the
Update on the Treatment of Molluscum Contagiosum in Children 411

Table 2 Maximum Recommended Dose and Area of Application of Eutectic Mixture of Local Anesthetics.

Age and/or Body Weight Total Maximum Maximum Area of Maximum Application
Dose, g Application, cm2 Time, h
0---3 mo or < 5 kg 1 10 1
3---12 mo and > 5 kg 2 20 4
1---6 y and > 10 kg 10 100 4
7---12 y and > 20 kg 20 200 4

Figure 3 Manual expression of molluscum bodies with the fingers. A, The lesion is squeezed between 2 fingers. B and C, A whitish
molluscum body is extruded. C, Tissue damage is minimal.

treated area, irritation of the surrounding skin, ulceration, consecutive days, 67% attained full resolution without recur-
and scarring.18 rence after 6 months of follow-up. Appropriate clinical trials
are required to confirm the efficacy and safety of HP for the
treatment of MC in children.
Salicylic Acid

Salicylic acid is a keratolytic agent sold at concentrations

of 10% to 30%. A randomized controlled trial of treatment
with 10% potassium hydroxide (KOH) or the combination of
salicylic acid and lactic acid at 16.7% in 26 MC patients aged
2 to 12 years found no significant differences between groups
after 6 weeks.20 Side effects included irritation, pruritus, a
burning sensation, and peeling of the skin.
Hydrogen Peroxide
Hydrogen peroxide (HP) is a powerful oxidizing agent and
antiseptic that can inactivate poxvirus in vitro.21 Treatment
with HP, which is sold outside of Spain in a 1% cream, resulted
in complete resolution of lesions in an 8-month-old patient
with genital MC when applied at every diaper change for
1 week.22 The authors attributed the rapid resolution to
greater exposure of the virus to HP because the skin was
occluded by the diaper. In another study of 12 MC patients
treated with 1% HP cream applied twice per day for 21
Cantharidin
Cantharidin is a vesicant agent produced by the beetle Lytta
vesicatoria.23 When applied to the skin, this phosphodieste-
rase inhibitor produces an intraepidermal blister that rarely
leaves a scar owing to its superficial location.17 It is used at
concentrations of 0.7% to 0.9%, and after application should
be left in place for 2 to 4 hours without occlusion and subse-
quently removed with soap and water.17 Other authors have
proposed that in cases of resistant lesions cantharidin should
be allowed to dry for 5 to 10 minutes and then occluded with
adhesive tape.24 The treatment can be repeated at intervals
of 1 to 4 weeks. In a retrospective study of 300 children
with MC who were treated with cantharidin, a cure rate
of 90% was achieved with an average of 2.1 treatments.18
The treatment itself is painless, but within 24 to 48 hours
painful blisters form, bringing the added risk of secondary
superinfection. Cases of lymphangitis with lymphedema fol-
lowing cantharidin treatment have also been reported.25
412
Given these risks, cantharidin is not recommended for MC
of the face or anogenital region.16
Potassium Hydroxide
Potassium hydroxide (KOH) is an alkali that penetrates and
destroys the skin by dissolving keratin. It is used in aque-
ous solution at concentrations of 5% to 20%, and applied to
MC lesions once or twice per day.20,26 In a prospective trial
in which 35 children with MC lesions received twice-daily
treatments with 10% KOH aqueous solution, complete lesion
resolution was observed in 32 of the patients.27 Applications
were discontinued in 3 patients due to severe stinging and
secondary infection. The efficacy of KOH has been compared
with that of other MC treatments. No significant differ-
ences were reported in a trial comparing the efficacy of
cryotherapy with that of 10% KOH in solution for the treat-
ment of MC.26 However, the higher cost and secondary local
effects of cryotherapy would tend to favor the use of KOH.
Another study found that 10% KOH and 5% imiquimod cream
were equally effective, but that KOH had a faster onset of
action.28 Finally, a third study compared 10% KOH admin-
istered once per day with salicylic acid and lactic acid
in combination, finding they were equally effective in the
treatment of MC.20 Because 10% KOH treatment is noninva-
sive, efficacious, and can be applied at home, many authors
consider it to be the first line of therapy.29
Cryotherapy
The application of liquid nitrogen at ---196 ◦ C induces the for-
mation of intracellular and extracellular ice crystals, which
cause tissue destruction and changes in the cell membrane
and circulation in the skin.18 Liquid nitrogen is applied with
a cotton swab or a portable sprayer for 10 to 20 seconds
in 1 or 2 treatment cycles at intervals of 1 to 3 weeks. In
a prospective study that recruited 74 children with MC the
clinical efficacy of weekly cryotherapy was compared with
that of 5% imiquimod administered 5 times per week.30 After
16 weeks of treatment, complete resolution was observed in
100% of patients treated with cryotherapy and 91.8% of those
treated with imiquimod, but the difference was not statisti-
cally significant. While cryotherapy can be easily and rapidly
administered, it is very poorly tolerated in young children.
Other disadvantages include the formation of blisters, the
possibility of scarring, and residual hyper- or hypopigmen-
tation.
Laser Therapy
Some authors consider carbon-dioxide (CO2 ) laser therapy
to be a faster and less traumatic approach than curettage.
However, in a study of 6 patients treated with CO2 laser,
hypertrophic scars and keloids were observed in 70% of
treated patients, and therefore its use in children is not
recommended.31 Some authors consider pulsed dye laser
therapy to be particularly useful in children with resistant
lesions. Because only a single treatment cycle is required
in most cases, anxiety associated with repeated treatments
is minimized.32 However, this treatment modality is expen-
sive and sometimes requires local anesthesia. The adverse
effects of this type of laser therapy include localized pain
and discomfort, edema, and pigmentary changes.
P. Gerlero, Á. Hernández-Martín
Immunotherapy
Immunotherapeutic methods are based on the stimulation of
a cellular and/or humoral immune response that can elimi-
nate the viral infection.
Imiquimod
Imiquimod, an agonist of toll-like receptor 7, binds to this
receptor, activating the innate immune response and induc-
ing the synthesis of interferon-␣, interleukin (IL)-1, IL-5,
IL-6, IL-8, IL-10, and IL-12, and IL-1 receptor antagonist,
among other factors. Imiquimod’s antiviral and antitumor
effects are mediated by both the adaptive and innate
immune systems.33 It is available in a 5% cream to be applied
at night, left for 8 hours, and rinsed off in the morning. Some
authors recommend daily application while others suggest 3
treatments per week.34 In one study in which children with
MC were treated 3 times per week for 16 weeks with 5%
imiquimod cream, complete resolution of MC was observed
in 69%.35 The most frequent local adverse effects were ery-
thema, pruritus, stinging, and pain, which in some cases was
intense (Fig. 4).
Cimetidine
Oral cimetidine is an antagonist of H2 histamine receptors.
It exerts immunomodulatory effects by stimulating delayed
hypersensitivity. In a clinical study of 13 children of less
than 10 years of age who were treated with 40 mg/kg of
oral cimetidine once per day for 2 months, complete lesion
resolution was observed in 9 of 13 patients.36 The authors
concluded that cimetidine was an easy to apply, effective,
and painless alternative for treating facial, widespread, or
recurrent MC in immunocompetent children. However, in a
double-blind trial comparing placebo treatment with oral
cimetidine (35 mg/kg) administered once per day for 12
weeks in MC patients aged 1 to 16 years, no statistically sig-
nificant differences were observed between the placebo and
treatment groups.37 Based on this finding, the authors pro-
posed that the efficacy observed in other studies may in fact
be the result of spontaneous lesion resolution. Side effects
of oral cimetidine are rare but include nausea, diarrhea,
rash, and dizziness.36
Candidin
Candidin, a substance derived from the purified extract
of Candida albicans, is usually used to treat warts38 but
has been proposed as a treatment option for MC.39 It
is administered intralesionally either undiluted or at a
concentration of 50% in lidocaine. The dose administered
corresponds to 0.2 to 0.3 mL of the antigen. In one ret-
rospective study of 29 MC patients under the age of 17
who were treated with 0.3 mL of intralesional candidin the
global response rate was 93%, and complete and partial
responses were observed in 55% and 37.9% of patients,
respectively.40 Most side effects were minimal, but pain
at the site of injection was experienced by 4 patients. In
another retrospective review of 25 MC cases treated with
Update on the Treatment of Molluscum Contagiosum in Children
Figure 4 Irritation caused by the application of topical imiquimod on the right forearm.
intralesional candidin, complete resolution was observed
in 14 (56%) cases, a partial response in 7 (28%), and
no clinical improvement in 4 (16%).39 The advantages of
immunotherapy in the treatment of MC include the induc-
tion of a memory immune response to MC, the potential
to induce a generalized response that leads to resolution
of untreated lesions in anatomically distant sites, and the
lack of adverse effects.40 However, candidin, which is not
commercially available in Spain, is scarcely used in clinical
practice.
Silver Nitrate
Silver nitrate is prepared with 0.2 mL of a 40% aqueous
solution of silver nitrate and 0.05 g of flour. This semitrans-
parent mixture is placed in the center of the lesion. After
24 hours a dark crust begins to appear, and after about 14
days the MC lesion falls off. Treatment of 389 consecutive
MC patients with 40% silver nitrate resulted in a cure rate
of 97.7% and caused no scarring.41 This simple, inexpen-
sive procedure is painless and causes few adverse reactions
such as pain, stinging, erythema, chemical burns, or residual
hyperpigmentation.42
Antimitotic Therapies
Cidofovir
Cidofovir is a nucleotide analogue of deoxycytidine
monophosphate. Although its mechanism of action remains
unclear, it is known to inhibit viral DNA polymerase,
therefore blocking the synthesis of viral DNA. Cidofovir can
be administered intravenously (5 mg/kg/wk for 2 weeks
followed by 5 mg/kg once every 2 weeks) or topically
(1%---3% cream or gel, applied daily).43 Several studies
have described the successful use of intravenous or topical
413
cidofovir for MC resistant to other treatments.44 However,
this drug is expensive and further studies are required to
determine its efficacy and safety in children.
Other Treatments
The evidence base supporting several treatments of scarce
efficacy is weak, but they are harmless and generally well
accepted by parents and caregivers. Such treatments may
be useful in patients with multiple resistant lesions for
whom active treatment is sought. These treatments include
local hyperthermia,45 occlusion with adhesive tape,46 and
the topical application of Polypodium leucotomos extract,
immunoferon,47 zinc oxide,48 azelaic acid, and certain natu-
ral products such as essential oil of Australian lemon myrtle
leaves.49
Wait and See
Because MC is benign and self-limiting, a wait-and-see
approach is reasonable. The time to resolution of MC varies.
In a prospective community cohort study the average time
to resolution of MC lesions in 306 British MC patients aged
4 to 15 years was 13.3 months.50 Thirty percent had not
resolved at 18 months, and 13% remained unresolved at 24
months. However, many parents will not accept an indeter-
minate estimate of time to resolution and fear the potential
risk of spread or transmission to other children.23 More-
over, in some cases the disease can be uncomfortable or
stigmatizing. One survey found that parents were twice as
likely as their children with MC to express significant concern
about the disease.6 Parents’ concerns related to the clinical
manifestations of MC (scarring, spread, itching, and pain)
and the discomfort caused by available treatment meth-
ods. However, the same study found that infection did not
414
significantly affect daily activities, quality of life, or indi-
vidual productivity in school.
Our Approach to the Treatment of MC
Because MC tends to resolve spontaneously, we often choose
to wait and see, especially if the lesions are asymptomatic
and the parents, for whatever reason, prefer to let the dis-
ease run its natural course. If the lesions cause discomfort,
are located in very visible areas, or lead to the child’s exclu-
sion from school activities, we choose active treatment.
The choice of treatment depends on the number of
lesions, their location, potential adverse effects, parental
preferences, and the physician’s experience. In general, we
avoid any procedures that cause intense pain or are associ-
ated with a significant risk of scarring (eg, cryotherapy or
laser therapy).
Manual extrusion of the molluscum body using the fingers
is a simple and inexpensive technique, and is ideal when
the affected child has few lesions and is afraid of surgical
instruments like curettes, scalpels, or clamps. Curettage is
probably the most effective technique, but requires skill and
patient collaboration, which is often lacking (particularly
in cases that require repeated treatments or involve facial
lesions). Topical EMLA can minimize the pain, but does noth-
ing to diminish fear in children. Moreover, topical anesthesia
is difficult to apply in certain locations such as the eyelids.
Although sedation of the patient is a possibility, this option
is reserved for very specific circumstances.
In Spain, KOH is sold at concentrations of 5% and 10% and
can be applied at home. Both formulations are suitable for
the treatment of patients with a large number of lesions
or lesions on the trunk and extremities. KOH is also useful
when children do not collaborate by staying still for treat-
ment or when parents are reluctant to allow curettage. We
tend not to use any of the other topical products available
in Spain because in our experience they cause considerable
local irritation and show relatively poor efficacy. Further-
more, very few are formally indicated for treating MC in
children.
Conclusion
Although MC is one of the most common viral skin diseases in
children, there is no consensus as to the treatment of choice
or whether patients should even be treated. No scientific
evidence clearly favors a specific treatment for MC. Accord-
ing to the newly developed Strength of Recommendation
Taxonomy for rating the quality, quantity, and consistency of
evidence for therapies, support for MC management options
would fall at level B at best, indicating a lack of consistent,
high quality evidence available.42,51
In principle, MC should be treated using modalities that
cause minimal pain and scarring. It is also important to
determine the most appropriate treatment for each partic-
ular case.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
P. Gerlero, Á. Hernández-Martín
References
1. Molino AC, Fleischer AB, Feldman SR. Patient demographics and
utilization of health care services for molluscum contagiosum.
Pediatr Dermatol. 2004;21:628---32.
2. Larralde M, Angles V. Actualizaciones sobre Molusco conta-
gioso [cited 2017 April 5]. Available from: http://www.sap.org.
ar/docs/publicaciones/molusco.pdf
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Journal Reading

Update on the Treatment of Molluscum

Contagiosum in Children

OLEH:
Mega R. Bagdad ( 201984002)
Cynthia Manaha (201984005)

Pembimbing
dr. Hanny Tannasal Sp,KK

BAGIAN ILMU KESEHATAN KULIT DAN

KELAMIN
FAKULTAS KEDOKTERAN
UNIVERSITAS PATTIMURA
AMBON
2020
• Molluscum contagiosum (CM) is caused by a DNA virus of genus
Molluscipoxvirus, family Poxviridae
• This virus is categorized into 2 type (MCV-1 and MCV-2) and 4
distinct genotypes.
• MC can be transmitted by direct contact, fomites, and self
inoculation.
• MC is characterized by skin-colored papules and/or nodul with
central umbilication.
• The lession may be surrounded by a halo of eczema 
molluscum dermatitis
• In immunocompetent patients, skin infection caused by MC are
benign and self-limiting.
Different Clinical Manifestation of Molluscum Contagiosum
Types of Treatment for MC
The most commonly These simple and
used methods in routine inexpensive procedure
practice.

01 02
 2. 3.
Use EMLA cream Disadvantages of curratage
for the procedure include the need for local
 Risk of systemic anesthesia, potential pain and
toxicity bleeding, and the risk of
scarring
Curretage

1.
Is a simple and
relatively
inexpensive
procedure
Purpuric reaction to topical
application of EMLA
Maximum Recommended Dose and Area of Application of
Eutetic Mixture of Local Anesthetics
 Manual Extrusion
The umbilicated nucleus This technique is of
of the lession can be particular interest as it is
manually removed using simple and fast.
the hands or any of
instruments.

01 02 03

The result is similar to

that caused bu curettage
 Trichloroacetic Acid
Causes tissue Applied repeatedly on
destruction by the center of the lesion
immediate chemical until a white, frost-like
coagulation and covering forms  20%
superficial necrosis dan 35%

Adverse effect include

pruritus in the treated
area, irritation of the
surrounding skin,
ulceration, and
scarring.
Is a keratolytic agent  Side effects included
10%-30% irritation, pruritus, a
concentrations burning sensation and
peeling of the skin.

Salicylic Acid
 Hydrogen Peroxide

Is a powerful oxidizing
agent andantiseptic.
Treatment HP  1%
cream

Appropriate cliical
trials are required to
confirm the efficacy
and safety of HP for
the treatment of MC
in Children.
 Cantharidin

• Cantharidin is a It is used at
in cases of resistant
vesicant agent concentrations of 0.7%
lesions cantharidin
produced by the to 0.9%, and after
should be allowed to
beetle application should be left
dry for 5 to 10 minutes
Lyttavesicatoria. in place for 2 to 4 hours
and then occluded with
• Cantharidin is a without occlusion and
adhesive tape.
phosphodiesterase subsequently removed
inhibitor with soap and water

The treatment can cantharidin is not

be repeated at recommended for MC
intervals of 1 to 4 of the face or
weeks. anogenital region
 Potassium Hydroxide

Potassium It is used in aqueous 10% KOH treatment is

The efficacy of KOH
hydroxide (KOH) is solution at noninvasive, efficacious,
has been compared
an alkali that concentrations of 5% and can be applied at
with that of other MC
penetrates and to 20%, and applied home, many authors
treatments. No
destroys the skin by to MC lesions once or consider it to be the
significant differ-
dissolving keratin twice per day. first line of therapy
ences
 The application of liquid nitrogen at 196◦C induces the
formation of intracellular and extracellular ice crystals,
which cause tissue destruction and changes in the cell
membrane and circulation in the skin

Cryotherapy
Liquid nitrogen is applied with a cotton swab or a portable
sprayer for 10 to 20 seconds in 1 or 2 treatment cycles at
intervals of 1 to 3 weeks.

• While cryotherapy can be easily and rapidly

administered, it is very poorly tolerated in young
children.
• Other disadvantages include the formation of
blisters, the possibility of scarring, and residual
hyper or hypo pigmentation.
 Some authors consider carbondioxide (CO2) laser
therapy to be a faster and less traumatic approach than
curettage.

Laser Therapy
However, in a study of 6 patients treated with CO2
laser,hypertrophic scars and keloids were observed in
70% oftreated patients, and therefore its use in children is
not recommended.

this treatment modality is expensive and sometimes

requires local anesthesia. The adverse effects of this
type of laser therapy include localized painand
discomfort, edema, and pigmentary changes
 Immunotherapy
Immunotherapeutic methods are based on the
stimulation ofa cellular and/or humoral immune
response that can eliminate the viral infection

Laser Therapy
 Imiquimod, an agonist of toll-like receptor 7, binds to thisr eceptor,
activating the innate immune response and inducing the synthesis of
interferon , interleukin (IL)-1, IL-5,IL-6, IL-8, IL-10, and IL-12, and IL-1
receptor antagonist, among other factors.

 It is available in a 5% cream to be applied at night, left for 8 hours, and

rinsed off in the morning. Some authors recommend daily application
while others suggest 3 treatments per week.

 The most frequent local adverse effects were erythema, pruritus,

stinging, and pain, which in some cases was intense Irritation caused by the application of
topical imiquimod on the right forearm
 Cimetidine
• Oral cimetidine is an antagonist of H2 histamine
receptors.
• It exerts immunomodulatory effects by
stimulating delayed hypersensitivity

In a clinical study of 13 children of lessthan 10 years of

The authorsconcluded that cimetidine was an easy to apply,
age who were treated with 40 mg/kg of oral cimetidine
effective,and painless alternative for treating facial,
once per day for 2 months, complete lesion resolution
widespread, orrecurrent MC in immunocompetent children
was observed in 9 of 13 patients

In adouble-blind trial comparing placebo treatment with

oralcimetidine (35 mg/kg) administered once per day for the authors proposed that the efficacy observed in other
12 weeks in MC patients aged 1 to 16 years, no studies may in factbe the result of spontaneous lesion
statistically significant differences were observed resolution.
between the placebo andtreatment groups

Side effectsof oral cimetidine are rare but include nausea,

diarrhea,rash, and dizziness
 Candidin

Candidin, a substance derived from the purified

But has been proposed as a treatment
extractof Candida albicans, is usually used to
option for MC
treat warts

It is administered intralesionally either undiluted or The dose administeredcorresponds to 0.2 to 0.3 mL of

at aconcentration of 50% in lidocaine. the antigen

20
 Silver Nitrate

This semitransparent mixture is placed in the center of

Silver nitrate is prepared with 0.2 mL of a 40%
the lesion. After 24 hours a dark crust begins to
aqueoussolution of silver nitrate and 0.05 g of
appear, and after about 14days the MC lesion falls off
flour

Treatment of 389 consecutive MC patients with This simple, inexpen-sive procedure is painless and
40% silver nitrate resulted in a cure rateof 97.7% causes few adverse reactions such as pain, stinging,
and caused no scarring. erythema, chemical burns, or residual
hyperpigmentation

21
 Antimitotic Therapies
(CIDOFOVIR)

Although its mechanism of action remainsunclear, it is

known to inhibit viral DNA polymerase,therefore blocking
the synthesis of viral DNA

Cidofovir is a nucleotide analogue of Cidofovir canbe administered intravenously (5 mg/kg/wk

deoxycytidinemonophosphate for 2 weeks followed by 5 mg/kg once every 2 weeks) or
Topically (1%---3% cream or gel, applied daily

this drug is expensive and further studies are required

todetermine its efficacy and safety in children

22
 Other Treatments
These treatments include
o local hyperthermia,
o occlusion with adhesive tape
o the topical application of Polypodium leucotomos extract,
o immunoferon,
o zinc oxide,
o azelaic acid,
o and certain natural products such as essential oil of Australian lemon
myrtleleaves

23
 Wait and See

• Because MC is benign and self-limiting, a wait and-
see approach is reasonable
• The time to resolution of MC varies
• In a prospective community cohort study the
average time to resolution of MC lesions in 306
British MC patients aged4 to 15 years was 13.3
months.
• More-over, in some cases the disease can be uncomfortable
or stigmatizing
• One survey found that parents were twice as likely as their
children with MC to express significant concern about the
disease
• Parents’ concerns related to the clinical manifestations of
MC (scarring, spread, itching, and pain) and the discomfort
caused by available treatment methods
 Our Approach to the Treatment
of MC

• Because MC tends to resolve spontaneously, we often

choose to wait and see, especially if the lesions are
asymptomatic and the parents, for whatever reason,
prefer to let the dis-ease run its natural course

• If the lesions cause discomfort,are located in very

visible areas, or lead to the child’s exclusion from
school activities, we choose active treatment

• The choice of treatment depends on the number oflesions, their

location, potential adverse effects, parental preferences, and the
physician’s experience

• In general, weavoid any procedures that cause intense pain or are

associated with a significant risk of scarring (eg, cryotherapy orlaser
therapy)
 Cont ...

• Manual extrusion of the molluscum body using the

fingers is a simple and inexpensive technique, and
is ideal when the affected child has few lesions
and is afraid of surgical instruments like curettes,
scalpels, or clamps.

• Curettage is probably the most effective technique,

but requires skill and patient collaboration, which is
often lacking (particularly in cases that require
repeated treatments or involve facial lesions)

• Topical EMLA can minimize the pain, but does nothing to

diminish fear in children

• Moreover, topical anesthesia is difficult to apply in certain

locations such as the eyelids. Although sedation of the
patient is a possibility, this optionis reserved for very
specific circumstances
o Although MC is one of the most common viral skin diseases
inchildren, there is no consensus as to the treatment of choice or
whether patients should even be treated.

o No scientific evidence clearly favors a specific treatment for MC.

o According to the newly developed Strength of Recommendation

Taxonomy for rating the quality, quantity, and consistency CONCLUSIONS
ofevidence for therapies, support for MC management options
would fall at level B at best, indicating a lack of consistent,high
quality evidence available.

o In principle, MC should be treated using modalities thatcause

minimal pain and scarring. It is also important to determine the most
appropriate treatment for each partic-ular case.
THANKS