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DermatologyOnlineJournal
UCDavis

MolluscumContagiosum
DanielHansonandDaynaG.Diven
DermatologyOnlineJournal9(2):2

PrimaryHealth,Boise,IdahoUSA

Abstract
MolluscumcontagiosumisadiseasecausedbyapoxvirusoftheMolluscipoxvirusgenusthatproducesabenignselflimitedpapular
eruptionofmultipleumbilicatedcutaneoustumors.Thiscommonviraldiseaseisconfinedtotheskinandmucousmembranes.
Transmissionrequiresdirectcontactwithinfectedhostsorcontaminatedfomites.Itisgenerallythoughttoinfecthumans
exclusively,butthereareafewisolatedreportsofMolluscumcontagiosumoccurringinchickens,sparrows,pigeons,chimpanzees,
kangaroos,adog,andahorse.Theinfectionisfoundworldwideandhasahigherincidenceinchildren,sexuallyactiveadults,and
thosewhoareimmunodeficent.

Introduction
Molluscumcontagiosum,acutaneousandmucosaleruptioncausedbyaMolluscipoxvirus,wasfirstdescribedandlaterassignedits
namebyBatemaninthebeginningofthenineteenthcentury.[1]In1841HendersonandPatersondescribedtheintracytoplasmic
inclusionbodiesnowknownasmolluscumorHendersonPatersonbodies.[2]Intheearlytwentiethcentury,Juliusberg,Wile,and
Kingerywereabletoextractfilterablevirusfromlesionsandshowtransmissibility.[3,4]Goodpasturelaterdescribedthesimilaritiesof
molluscumandvaccinia.[5]Thoughgenerallythoughttoinfectonlyhumans,casereportsofthevirusoccurringinotheranimalshave
beenpublished.[6,7,8,9]

Incidence
Molluscumcontagiosumvirus(MCV)canbefoundworldwidewithahigherdistributioninthetropicalareas.Thediseaseismore
prevalentinchildrenwiththelesionsinvolvingtheface,trunk,andextremities.Inadultsthelesionsaremostoftenfoundnearthe
genitalregion.Thediseaseisendemicwithahigherincidencewithininstitutionsandcommunitieswhereovercrowding,poorhygiene,
andpovertypotentiateitsspread.[10]Overthelast30yearsitsincidencehasbeenincreasing,mainlyasasexuallytransmitted
disease,anditisparticularlyrampantasaresultofconcurrenthumanimmunodeficiencyvirus(HIV)infection.[11]Theworldwide
incidenceisestimatedtobebetween2%and8%.[12]Lessthen5%ofthechildrenintheUnitedStatesarebelievedtobeinfected.
Between5%and20%ofpatientswithHIVhavesymptomaticMCV.[13,14]Therearefourmainsubtypesofmolluscumcontagiosum:
MCVI,MCVII,MCVIII,andMCVIV.[15,16]Allsubtypescausesimilarclinicallesionsingenitalandnongenitalregions.Studies
showMCVItobemoreprevalent(75%90%)thanMCVII,MCVIII,andMCVIV,exceptinimmunocompromisedindividuals.[17,18]
Thereare,however,regionalvariationsinthepredominanceofagivensubtypeanddifferencesbetweenindividualsubtypesin
differentcountries.[19]

Pathogenesis
Thisdiseaseistransmittedprimarilythroughdirectskincontactwithaninfectedindividual.Fomiteshavebeensuggestedasanother
sourceofinfection,withmolluscumcontagiosumreportedlyacquiredfrombathtowels,tattooinstruments,andinbeautyparlorsand
Turkishbaths.[10]Theaverageincubationtimeisbetween2and7weekswitharangeextendingoutto6months.Infectionwiththe
viruscauseshyperplasiaandhypertrophyoftheepidermis.[12]Freeviruscoreshavebeenfoundinalllayersoftheepidermis.So
calledviralfactoriesarelocatedinthemalpighianandgranularcelllayers.[12]Themolluscumbodiescontainlargenumbersof
maturingvirions.Thesearecontainedintracellularlyinacollagenlipidrichsaclikestructurethatisthoughttodeterimmunological
recognitionbythehost.[20]Ruptureanddischargeoftheinfectiousviruspackedcellsoccurinthecenterofthelesion.MCVinduces
abenigntumorinsteadoftheusualnecroticpoxlesionassociatedwithotherpoxviruses.[21]

Clinicalmanifestations
MCVproducesapapulareruptionofmultipleumbilicatedlesions.Theindividuallesionsarediscrete,smooth,anddomeshaped.
Theyaregenerallyskincoloredwithanopalescentcharacter.Thecentraldepressionorumbilicationcontainsawhite,waxycurdlike
core.Thesizeofthepapuleisvariable,dependinguponthestageofdevelopment,usuallyaveraging26mm.Papulesmayexceed
1cminsizeinimmunosuppressedhosts.Thepapulesmaybecomeinflamedspontaneouslyoraftertraumaandpresentatypicallyin
size,shape,andcolor.Thelesionsareoftengroupedinsmallareasbutmayalsobecomewidelydisseminated.

Anycutaneoussurfacemaybeinvolved,butfavoredsitesincludetheaxillae,theantecubitalandpoplitealfossae,andthecrural
folds.Rarely,MCVlesionsoccurinthemouthorconjunctivae.[22,23,24]Autoinoculationiscommon.Childrenusuallyacquire
molluscumnonsexuallyatbothgenitalandnongenitalareas.MCVinadultsaffectsthegroin,genitalarea,thighs,andlowerabdomen
andisoftenacquiredsexually.Around10%ofcasesdevelopaneczematousdermatitisaroundthelesions,butthisdisappearsas
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andisoftenacquiredsexually.Around10%ofcasesdevelopaneczematousdermatitisaroundthelesions,butthisdisappearsas
theinfectionresolves.[25]Patientswithatopicdermatitiscanhaveadisseminatederuption.Eruptionsinimmunocompromised
indiviualsareveryresistanttotreatment.[13,26]

Dermatopathology
Histologically,molluscumcontagiosumexhibitsintraepidermallobuleswithcentralcellularandviraldebris.Inthebasallayer,
enlargedbasophilicnucleiandmitoticfiguresareseen.Progressingupward,thecellsshowcytoplasmicvacuolizationandthen
eosinophilicglobules.Thenucleusbecomescompressedatthelevelofthegranularcelllayer,andthemolluscumbodieslosetheir
internalstructuralmarkings.Undisruptedlesionsshowanabsenceofinflammation,butdermalchangescanincludeaninfiltratethat
islymphohistiocytic,neutrophilic,orgranulomatous.Thelatterhasbeenseeninsolitarylesions.AntibodytoMCVbyindirect
immunofluorescencehasbeenfoundin69%ofpatientswithvisiblelesions.[27]PolymerasechainreactioncandetectMCVinskin
lesions.[28]Currently,thereisnoinvitrooranimalmodelforMCV.MCVcanundergoanabortiveinfectioninsomecelllines,which
cancauseconfusionwithherpessimplexvirusbylaboratories.[29]Twosetsofinvestigatorshaveinfectedhumanskinwith
molluscumcontagiosumandgrafteditontoathymicmice,althoughtherewasnocontinuedviralreplication.[30,31]

Diagnosis
Theclinicalappearanceofmolluscumcontagiosumisinmostcasesdiagnostic.Thoughmolluscumcannotbeculturedinthe
laboratory,histologicalexaminationofacurettedorbiopsiedlesioncanalsoaidinthediagnosisincasesthatarenotclinically
obvious.ThethickwhitecentralcorecanbeexpressedandsmearedonaslideandleftunstainedorstainedwithGeimsa,Gram,
Wright,orPapanicolaoustainstodemononstratethelargebrickshapedinclusionbodies.Electronmicroscopyhasalsobeenusedto
demonstratethepoxivirusstructures.Immunohistochemicalmethodsusingapolyclonalantibodyallowsrecognitionofmolluscum
contagiosuminfixedtissue.[32]InsituhybridizationforMCVDNAhasalsobeenutilized.[33]Molluscumcontagiosumlesionsmust
bedifferentiatedfromverrucavulgaris,condylomaaccuminata,varicella,herpessimplex,papillomas,epitheliomas,pyoderma,
cutaneuoscyptococcosis,epidermalinclusioncyst,basalcellcarcinoma,papulargranulomaannulare,keratoacanthoma,lichen
planus,andsyringomaorotheradenexaltumors.

Treatment
Molluscumcantagiosumisaselflimiteddisease,which,leftuntreated,willeventuallyresolveinimmunocompetenthostsbutmaybe
protractedinatopicandimmunocompromisedindividuals.Somepatientspickandscratchatthelesions,ahabitthatmayleadto
scarring.Inaddition,someschoolsanddaycarecenterswillnotadmitchildrenwithvisiblemolluscumpapules.Whenpatientsseek
medicalattentionanddesiretoridthemselvesofthepapules,thereareseveralmeansoftherapeuticdestructiontohelpspeed
resolution.Thedecisionwhethertreatmentisnecessarydependsontheneedsofthepatient,therecalcitranceoftheirdisease,and
thelikelihoodoftreatmentstoleavepigmentaryalterationorscarring.Mostofthecommontreatmentsconsistofvariousmeansto
traumatizethelesions.Antiviralandimmunemodulatingtreatmentshaverecentlybeenaddedtotheoptions.Thefollowingisabrief
summaryofsomeofthemorecommontreatments.

Cryosurgery
Oneofthemostcommon,quick,efficientmethodsoftreatmentiscryotherapy.Liquidnitrogen,dryice,orFrigidermareappliedto
eachindividuallesionforafewseconds.Repeattreatmentsin23weekintervalsmayberequired.[34]Hyperorhypopigmentation
andscarringmaybecausedbythistreatment.

Evisceration
Aneasymethodtoremovethelesionsisevisceratingthecorewithaninstrumentsuchasascalpel,sharptoothpick,edgeofa
glassslide,oranyotherinstrumentcapableofremovingtheumbilicatedcore.Becauseofitssimplicity,patients,parents,and
caregiversmaybetaughtthismethodsonewlesionscanbetreatedathome.[35,36]Thismethodissimplebutmaynotbetolerated
bysmallchildren.

Curettage
Curettageisanothermethodofremoval.Itcanbeusedwithandwithoutlightelectrodessication.Thismethodismorepainful,andit
isrecommendedthatatopicalanestheticcreambeappliedtothelesionsbeforetheproceduretodecreasethepain.Thismethod
hastheadvantageofprovidingareliabletissuesampletoconfirmthediagnosis.[35,37]

Tapestripping
Anotherreportedtreatmentinvolvestheuseofadhesivetape.Theadhesivesideofthetapeisrepeatedlyappliedtoandremoved
fromthelesionfor1020cycles.Thisactioneffectivelyremovesthesuperficialepidermisfromthetopofthelesion.[38]However,
repeateduseofthesamestriphasthepotentialtospreadthevirustoadjacent,uninvolvedskin.

Podophyllinandpodofilox
A25%suspensioninatinctureofbenzoinoralcoholmaybeappliedonceaweek.Thistreatmentrequiressomeprecautions.It
containstwomutagens,quercetinandkaempherol.Someofthelistedsideeffectsincludesevereerosivedamageinadjacentnormal
skinthatmaycausescarringandsystemiceffectssuchasperipheralneuropathy,renaldamage,adynamicilleus,leucopenia,and
thrombocytopenia,especiallyifusedgenerouslyonmucosalsurfaces.Podofiloxisasaferalternativetopodophyllinandmaybe
usedbythepatientathome.Therecommendeduseusuallyconsistsofapplicationof0.05mlof5%podofiloxinlactatebuffered
ethanoltwiceadayfor3days.[35,38]Theactiveagentisabsolutelycontraindicatedinpregnancy.
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Cantharidin
Cantharidin(0.9%solutionofcollodianandacetone)hasbeenusedwithsuccessinthetreatmentofMCV.Thisblisterinducingagent
isappliedcarefullyandsparinglytothedomeofthelesionwithorwithoutocclusionandleftinplaceforatleast4hoursbeforebeing
washedoff.Cantharidincancausesevereblistering.Itshouldbetestedonindividuallesionsbeforetreatinglargenumbersoflesions.
Itshouldnotbeusedontheface.Whentolerated,thistreatmentisrepeatedeveryweekuntilthelesionsclear.Usually13
treatmentsarenecessary.[39]

Iodinesolutionandsalicylicacidplaster
A10%iodinesolutionisplacedonthemolluscumpapulesand,whendry,thesiteiscoveredwithsmallpiecesof50%salicylicacid
plasterandtape.Theprocessisrepeateddailyafterbathing.Afterthelesionshavebecomeerythematousin37days,onlythe
iodinesolutionisapplied.Resolutionhasbeenreportedinameanof26days.[40]Macerationanderosioncanresult.

Tretinoin
Tretinion0.1%creamhasbeenusedinthetreatmentofMCV.Itisappliedtwicedailytothelesions.Resolutionwasreportedbyday
11.Traceerythemaatthesiteofpriorlesionswasanotedsideeffect.[41]Tretinion0.05%creamhasalsobeenusedwithsuccess
anddecreasedirritation.[35]

Cimetdine
Oralcimetidinehassuccessfullybeenusedinextensiveinfections.[42]Thehistamine2receptorantagoniststimulatesdelayedtype
hypersensivity.Oneuncontrolledstudyshowedresolutionin9of13patients.Inthisstudy,thedosagewas40mg/kg/dayintwo
divideddosesfor2months.[43]Theauthorsrecommendedfurtherplacebocontrolled,doubleblindstudiesbecompletedtodetermine
theefficacyofcimetidineintreatingMCV.Becausecimetadineinteractswithmanysystemicmedications,areviewofthepatient's
othermedicationsisrecommended.

Potassiumhydroxide
Anothertreatmentoptionistheuseofpotassiumhydroxide.Inonestudy,anaqueoussolutionof10%KOHwasappliedtopically
twicedailytoalllesionswithaswab.Thetreatmentwasdiscontinuedwhenaninflammatoryresponseorsuperficialulcerbecame
evident.Resolutionoccurredinameanof30days.[44]Thistreatmenthadsomecomplicationsincludinghypertrophicscarformation
andpersistentortransitoryhyperandhypopigmentation.Asubsequentstudyinpediatricpatientsrecommendedtheuseof5%KOH
andfounditequallyeffectivewithmanyfewersideeffects.[45]

Pulseddyelaser
TheuseofpulseddyelaserforthetreatmentofMChasalsobeendocumentedwithexcellentresults.Thetherapywaswell
tolerated,withoutscarsorpigmentanomalies.Thelesionsresolvedwithoutscarringat2weeks.Studiesshow96%99%ofthe
lesionsresolvedwithonetreatment.[46,47]Thepulseddyelaserisquickandefficient,butitsexpensemakesitlesscosteffective
thanotheroptions.

Imiquimod

Imiquimod5%creamhasbeenusedtopicallytotreatMCVbyinducinghighlevelsofIFNandothercytokineslocally.[48,49]This
potentimmunomodulatoryagentiswelltolerated,althoughapplicationsiteirritationiscommon.Ithashadnoknownsystemicor
toxiceffectsinchildren.[50]Itisappliedtotheareanightlyfor4weeks.Clearingcantakeupto3months.

Cidofovir
Cidofovirisanucleosideanalogthathaspotentantiviralproperties.Severalsmallstudiesandcasereportsdescribethesuccessful
useofcidofovirappliedtopicallyoradministeredbyintralesionalinjectioninseveralvirallyinducedcutaneousdiseases.[51]Cidofovir
cream3%hasbeenusedsuccessfullytotreatMCVinstudies,withclearingin26weeks.[52]Itshighcost,needfor
extemporaneouspreparation,andcarcinogenicityinsomestudieshavelimiteditsuse.[51]

Conclusion
MolluscumContagiosumisacommon,generallybenign,viralinfectionoftheskin.Itiscommoninchildren,sexuallyactiveadults,
andimmunodeficientpatients.Itiscausedbythemolluscipoxvirus,amemberofthepoxviridaefamily.Thisvirusdiffersfromother
poxvirusesinthatitcausesspontaneouslyregressing,umbilicatedtumorsoftheskinratherthanpoxlikevesicularlesions.In
immunocompetent,nonatopicpatientsmolluscumcontagiosumisusuallyaselflimiteddiseaseforwhichtreatmentisnotmandatory.
However,whentreatmentisdeemedappropriate,multiplelocaltherapeuticoptionsareavailable.Forpatientswithimpairedimmune
functionswithwidespreadandpotentiallydisfiguringeruptions,theusuallocaldestructivetherapiesareineffectiveantiviraland
immunomodulatorymedicationshavebeenmoresuccessful.

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