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Molluscum-contagiosum cfuk
Molluscum contagiosum (MC) is a viral skin infection caused by the molluscum contagiosum virus, affecting primarily children, sexually active adults, and immunocompromised individuals. The virus spreads through skin-to-skin contact and can cause flesh-colored, dome-shaped papules that may last up to 18 months if untreated, with various treatment options available ranging from cryotherapy to antiviral therapies. Although treatment is often unnecessary as lesions can resolve on their own, it may be sought for comfort, cosmetic reasons, and to prevent further spread or complications.
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Molluscum-contagiosum cfuk
- 1. Common dermatologic disorders Molluscumcontagiosum Dr.FaramarzDidar CosmeticFacialUKLimited www.cosmeticfacial.co.uk
- 2. Molluscum contagiosum (MC)is a viral infection of the skin or occasionally of the mucous membranes. It is caused by a DNA poxvirus called the molluscum contagiosum virus . MCV has no animal reservoir, infecting only humans. There are four types of MCV, MCV-1 to -4; MCV-1 is the most prevalent and MCV-2 is seen usually in adults and often sexually transmitted. This common viral disease has a higher incidence in children, sexually active adults, and those who are immunodeficient. MC can affect any area of the skin but is most common on the trunk of the body, arms, and legs. The virus commonly spreads through skin-to-skin contact. This includes sexual contact or touching or scratching the bumps and then touching the skin. The virus can spread from one part of the body to another or to other people. Molluscum contagiosum is contagious until the bumps are gone (which, if untreated, may last up to 6 months or longer). average incubation period between 2 and 7 weeks. Diagnosis is made on the clinical appearance; the virus cannot routinely be cultured. Molluscum contagiosum lesions are flesh-colored, dome-shaped, and pearly in appearance. They are often 1–5 millimeters in diameter, with a dimpled center. They are generally not painful, but they may itch or become irritated. Picking or scratching the bumps may lead to further infection or scarring. They may occasionally be complicated by secondary bacterial infections.
- 3. 1. Histologically, molluscumcontagiosum is characterized by molluscume bodies in the epidermis above the stratum basale, which consist of large cells with: – abundant granular eosinophilic cytoplasm (accumulated virons), – a small peripheral nucleus. 2. The viral infection is limited to a localized area on the topmost layer of the epidermis. 3. In a process called autoinoculation, the virus may spread to neighboring skin areas
- 4. CLINICAL APPEARANCE Characteristiclesions Smooth, umbilicated, symmetrical papules, usually 1-20mm in diameter Can be white, flesh coloured, translucent, yellow, pink or red. Central umbilication sits atop a white, waxy curd-like core. Solitary or in groups In children mostly found in chest, arms, trunk, legs and face In adults, usually in genitalia, lower abdomen or buttocks Self limiting disease – spontanous resolution within 18months – longer in immunocompromised Infection can recur after initial clearance in 1/3 patients
- 6. treatment • Cochrane database2012 – “no single itervention has been shown to be convincingly effective in treating molluscum contagiosum” • Reasons to treat – Alleviating discomfort – Cosmetic reasons – Social stigma associated with visible lesions – Limiting spread to other areas and other people – Preventing scarring and secondary infection – Preventing trauma and bleeding of lesions • Benign neglect • Direct lesional trauma – Caustic agents – cryotherapy – Lasers – curettage • Antiviral therapy – Ritonavir, cidofovir • Immune response stimulation – Imiquimod cream,intralesional interferon alfa
- 7. Treatment: General rules Individualmolluscum lesions may go away on their own ,lasting generally from 6 to 8 weeks, to 2 or 3 months. via autoinoculation, the disease may propagate and so an outbreak generally lasts longer with mean durations variously reported as 8 months, to about 18 months, and with a range of durations from 6 months to 5 years. Treatment is often unnecessary[ depending on the location and number of lesions, treatments causing the skin on or near the lesions to rupture may spread the infection further. treating bumps located in the genital area to prevent them from spreading. The virus lives only in the skin and once the growths are gone, the virus is gone and cannot be spread to others. Types of Treatment: Cryotherapy Cryotherapy involves killing infected cells by "freezing" them with a pressurized liquid spray, usually liquid nitrogen or nitrous oxide. Astringents Astringent chemicals applied to the surface of molluscum lesions to destroy successive layers of the skin include potassium hydrochloride, and cantharidin. Benzoyl peroxide In a small randomized controlled trial twice daily application of 10% benzoyl peroxide cream for 4 weeks was found to be more effective than tretinoin 0.05% cream; after 6 weeks 92% of the benzoyl peroxide group were lesion-free, compared with 45% of the tretinoin group (p = 0.02) Over-the-counter substances For mild cases, over-the-counter wart medicines, such as salicylic acid may or may not[ shorten infection duration. Daily topical application of tretinoin cream ("Retin-A 0.025%") may also trigger resolution.These treatments require several months for the infection to clear, and are often associated with intense inflammation and possibly discomfort. Surgical treatment Surgical treatments include cryosurgery, in which liquid nitrogen is used to freeze and destroy lesions, as well as scraping them off with a curette.
- 8. Laser 1) Pulsed dyelaser therapy for molluscum contagiosum may be the treatment of choice for multiple lesions in a cooperative patient (Dermatologic Surgery, 1998). 2) The use of pulsed dye laser for the treatment of MC has been documented with excellent results. 3) The therapy was well tolerated, without scars or pigment anomalies. 4) The lesions resolved without scarring at 2 weeks. 5) Studies show 96%–99% of the lesions resolved with one treatment. 6) The pulsed dye laser is quick and efficient, but its expense makes it less cost effective than other options.
- 9. RELEVANCE TO NSFA Prospective, non-randomised pilot study Binder et al, 2008, Journal of the German Society of Dermatology Using the flash-lamp pumped pulse dye laser 585nm wavelength 19 children All patients tolerated laser well 84.3% needed only one laser treatment to produce full remission 10.5% further session necessary One patient treated 3 times to achieve remission Similar study with 32 patients achieved strikingly similar success rates – retrospective looking back over 5 years – (Klinda et al, Medical Laser application 2011)
- 10. References: 1. Hanson D,Diven DG (March 2003). "Molluscum contagiosum". Dermatol. Online J. 9 (2): 2. PMID 12639455. http://dermatology.cdlib.org/92/reviews/molluscum/diven.html. 2. "Frequently Asked Questions: For Everyone. CDC Molluscum Contagiosum". United States Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/dvrd/molluscum/faq/everyone.htm#whogets. Retrieved 2008-06-29. 3. Pamphlets: Molluscum Contagiosum". American Academy of Dermatology. 2006. http://www.aad.org/public/publications/pamphlets/viral_mollscum.html. Retrieved 2008-11-30. 4. Weller R, O'Callaghan CJ, MacSween RM, White MI (1999). "Scarring in molluscum contagiosum: comparison of physical expression and phenol ablation". BMJ 319 (7224): 1540. PMC 28297. PMID 10591712. http://www.bmj.com/cgi/content/full/319/7224/1540. 5. Molluscum Contagiosum at eMedicine 6. MedlinePlus Encyclopedia Molluscum Contagiosum 7. Tyring SK (2003). "Molluscum contagiosum: the importance of early diagnosis and treatment". Am. J. Obstet. Gynecol. 189 (3 Suppl): S12–6. DOI:10.1067/S0002-9378(03)00793-2. PMID 14532898. 8. "Molluscum Contagiosum - Treatment Overview". WebMD. January 12, 2007. http://www.webmd.com/skin-problems- and-treatments/tc/molluscum-contagiosum-treatment-overview. Retrieved 2007-10-21 9. Papa C, Berger R (1976). "Venereal herpes-like molluscum contagiosum: treatment with tretinoin". Cutis 18 (4): 537– 40. PMID 1037097. 10. Credo, BV; Dyment, PG (1996). "Molluscum Contagiosum". Adolesc Med 7 (1): 57–62. PMID 10359957. 11. Hanna D, Hatami A, Powell J, et al. (2006). "A prospective randomized trial comparing the efficacy and adverse effects of four recognized treatments of molluscum contagiosum in children". Pediatric dermatology 23 (6): 574–9. DOI:10.1111/j.1525-1470.2006.00313.x. PMID 17156002. 12. Hammes S, Greve B, Raulin C (2001). "Molluscum contagiosum: Treatment with pulsed dye laser" (in German). Der Hautarzt; Zeitschrift für Dermatologie, Venerologie, und verwandte Gebiete 52 (1): 38–42. PMID 11220237. 13. Hughes P (February 1998). "Treatment of molluscum contagiosum with the 585-nm pulsed dye laser". Dermatol Surg 24 (2): 229–30. DOI:10.1016/S1076-0512(97)00178-7. PMID 9491117.
Editor's Notes
- #5 Characteristic lesions Smooth, umbilicated, symmetrical papules, usually 1-20mm in diameter Can be white, flesh coloured, transleucent, yellow pink or red. Central umbilication sits atop a white, waxy curdlike core. Core contains molluscum bodies Solitary or in groups In children mostly found in chest, arms, trunk, legs and face In adults, usually in genitalia, lower abdomen or buttocks If nodules occur above umbilicus or below inner upper thigh, then hiv testing should be perfomed Prevalence of MCV infection in patients also infected with HIV may be as high as 20% - incidence and severity of MCV infection increases as CD4 t cell count falls – when less than 100 cells/mm3 prevalence of MCV approaches 33% Self limiting disease – spentanous resolution within 18months – longer in immunocompromised Infection can recur after initial clearance in 1/3 patients Unsure whether recurrence is due to reinfection, ongoing disease exacerbation or a rebound from latency
- #7 Cochrane database 2006 – “no single interention has been shown to be convincingly effective in treating molluscum contagiosum” Benign neglect Leaving mollusca to spontaneously resolve is often reasonable,[31] 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 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.[32] 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[33, 34] may be used. Cantharidin,[28, 35] silver nitrate,[36] trichloroacetic acid, and phenol also are options. Children may tolerate therapy with these agents better than curettage or cryotherapy. None of these caustic agents has been approved by the FDA for treatment of molluscum contagiosum. . 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,[40, 41] expression of the central core with tweezers, rupture of the central core with a needle or a toothpick,[42, 43] electrodesiccation, shave removal, or duct tape occlusion.[44] 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. 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.[45, 46, 47, 48, 49] Antiviral therapy Only considered in immunocompromised patients In immunocompromised patients, improvement of lesions has been observed in individual patients treated with ritonavir, cidofovir (intravenous and topical),[62, 63] and zidovudine. Not surprisingly, patients with AIDS and severe molluscum contagiosum improve with effective antiretroviral therapy. Immune response stimulation Imiquimod cream, intralesional interferon alfa,[50] and topical injections of streptococcal antigen[51] 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. Imiquimod cream applied 3 times per week for 16 weeks is an option in severe cases. The dosing schedule and length of treatment require further evaluation.[25, 27, 52, 53, 54, 55, 56, 57] Imiquimod is a novel topical immune response modifier that is a potent inducer of interferons. Various treatment regimens have been effective in treating molluscum contagiosum. In children[58, 59] and in some patients with AIDS-associated molluscum contagiosum,[60, 26] 1% cream applied 3 times daily or 5% cream applied at every bedtime for 4 weeks appears to be effective treatment. 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.[61]