Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of "Major Recommendations" field.
General Recommendations
- Stress benign but contagious nature of disease.
- Limit physical contact with infected areas of skin and good hygiene.
- Instruct patient to avoid scratching of lesions.
- In small children keep infected areas covered with clothing.
- In adolescent and adult patients, this disease is usually sexually transmitted, so encourage safe sex and abstinence. It is unclear whether condoms or other barrier methods provide adequate protection. (Crowe, 2007) (Recommendation A, Good).
Diagnosis
- Diagnosis is usually made by the characteristic appearance of the lesions.
- If necessary, electron microscopic (EM) examination can confirm the clinical diagnosis. EM examination would show the typical brick-shaped poxvirus particles, similar to those of smallpox.
- Molluscum contagiosum virus (MCV) cannot be grown in tissue culture.
- The thick white central core can be smeared on a slide and stained or unstained, large brick shaped bodies will be observed. (Crowe, 2007) (Recommendation A, Good).
Management/Considerations
- Management of molluscum should be based on a case-by-case basis including: the extent and site of lesions, patient discomfort and patient preference of treatment.
- The infection is generally self limiting but may take 6 months to 5 years to resolve (Tyring, 2003). Most patients are rarely satisfied with non-intervention.
- Choosing non-intervention can allow the lesions to multiply by autoinoculation, increasing contagion, increasing occurrence of scarring, and causing discomfort from dermatitis that may lead to secondary bacterial infections.
- Some patients may have psychological distress including anxiety/depression regarding appearance and fear of transmission. (Recommendation A, Good).
Treatment Options
- None
- Monitor and educate on minimizing transmission and autoinoculation. Molluscum virus transmission occurs during close physical contact, by contact with a fomite on objects touched by infected child, and by autoinoculation. (Recommendation A, Good).
- Educate the patient not to scratch/play with lesions, avoid sharing towels, bathtubs, and limit direct physical contacts. (Recommendation A, Good).
- Alleviating dermatological symptoms/preventing secondary infection (pruritus, erythema)
- Reduce atopic irritants: use fragrance-free soaps and lotions, lukewarm baths, prevent skin from over-drying, reduce other causes of dermatitis to prevent skin susceptibility to molluscum. (Recommendation B, Good).
- Antihistamines: Prevention of pruritus, reducing inflammation, and reducing autoinoculation by scratching. (Recommendation B, Good).
- Topical corticosteroids: Management of atopic symptoms. May consider short-term use of topical corticosteroids. Class 3 or 4 corticosteroid ointment is appropriate for the body, class 6 or 7 for the face. May be helpful for reversing infections by removing underlying atopic dermatitis (Brown et al., 2006). Although intermittent topical corticosteroid use is a common therapy for atopic dermatitis, maintenance topical corticosteroid use should be avoided due to concerns about potential side effects such as skin atrophy and immunosuppression. (Sanfilippo et al., 2003) (Recommendation B, Fair).
- Direct lesion trauma
- Curettage: performed by experienced provider under local or topical anesthesia. Limited use of EMLA (eutectic mixture of local anesthetics) topical cream can relieve local discomfort with therapy. Care should be taken not to use topical lidocaine mixtures over a body surface area in excess of the maximum recommended to avoid central nervous system (CNS) toxicity (Brown et al., 2006). (Recommendation B, Good).
- Cantharidin solution 0.7%-0.9%: apply to lesions 1 time per week until lesions resolve (in office treatment). Alternate dosing schedule: apply monthly to visible lesions and wash off after 2 to 6 hours. Avoid treating >20 lesions at one session to prevent id (the same) reaction (Brown et al., 2006). Cantharidin should not be used on the face. It should be applied sparingly, avoiding contact with surrounding healthy skin. Patients should be advised to rinse the treated areas with copious amounts of water 2-4 hours after treatment or if discomfort or vesiculation occurs (Silverberg, Sidbury, & Mancini, 2000). (Recommendation B, Good).
- Immune response stimulation
- Imiquimod topical 1% or 5% cream to be applied to molluscum contagiosum lesions three times per week for <16 weeks and washed off after 6 to 10 hours. Imiquimod stimulates cell-mediated immunity to aid in the regression of mollusca. (Recommendation B, Fair).
- Cimetidine 800 mg by mouth 3 times a day or 30 to 50 mg/kg/day for children in divided doses for 3 months. There has been some evidence to support the use of high dose cimetidine in patients with viral warts including molluscum contagiosum. It is projected that cimetidine stimulates cell-mediated immunity by increasing the number of CD4 lymphocytes which assists in wart regression. (Recommendation C, Fair).
- Follow up: Follow up as specific therapies or treatments indicate.
- Referral: for cases outside of provider's professional experience, numerous lesions >50, lesions around eyes, or for cases not responding to treatments. (Recommendation A, Good).
Considerations
- Molluscum may serve as a cutaneous marker of severe immunodeficiency and sometimes is the first indication of human immunodeficiency virus (HIV) infection-typically a more extensive, disfiguring infection that is not self-limiting (Stulberg & Hutchinson, 2003).
- Children who are febrile, have more than 50 lesions, or whose response to therapy is limited may have disseminated fungal infections or immunodeficiency (Silverberg, 2007).
Complications
- Secondary inflammation
- Bacterial infections
- Scarring
- Emotional and psychological discomfort
- Infectivity
- Autoinoculation
Prognosis
Generally excellent because the disease is self limited and benign. In healthy patients, treatments are usually effective.
Definitions:
Quality of Evidence (Based on U.S. Preventive Services Task Force [USPSTF] Ratings)
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence of health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number of power of studies, important flaws in their designs or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
Grading of Recommendations (Based on USPSTF Ratings)
A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.
B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.
C. There is at least fair evidence that the service can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.
D. There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.
I. Evidence that the service is effective is lacking, of poor quality or conflicting and the balance of benefits and harms cannot be determined.
