++
Molluscum contagiosum is a benign viral infection of the skin and mucous membranes. The infection has a worldwide distribution and occurs in all ethnicities. Children are most frequently affected. In adults, it is mostly seen in the genital area and represents a sexually transmitted disease. It is more common and severe in patients with HIV infection, especially in patients with low CD4 counts.
++
Molluscum contagiosum is caused by a member of the pox virus group that contain double-stranded DNA and replicate within the cytoplasm of epithelial cells. The virus is spread by direct skin-to-skin contact.
+++
Clinical Presentation
++
Small papules develop on the skin and sometimes on the genital mucous membranes usually within 2 to 7 weeks after contact with an infected individual. The lesions are typically initially asymptomatic, but pruritus and inflammation can develop.
++
The typical lesions present as pearly, 2 to 10 mm dome-shaped papules with a waxy surface (Figure 11-5), which often have a central umbilication and erythema around the rim. Papules may be larger and more extensively distributed in immunocompromised patients. The face, upper chest, and upper extremities are most frequently affected in children, whereas the anogenital, suprapubic, and thigh areas are the usual site of infection in adults.
++
++
The diagnosis can be confirmed by incising a lesion with a needle and squeezing out the core with gloved fingers or with a small curette. The core should be squashed between two glass slides to flatten the specimen. The specimen can be stained with Giemsa stain and examined for the presence of large, purple, oval bodies that are the viral inclusion bodies within the cytoplasm of keratinocytes.7 These inclusion bodies can also be seen in skin biopsy specimens.
++
The key diagnostic clinical features of molluscum are small skin-colored papules with central umbilication.
+++
Differential Diagnosis
++
✓ Acne: Presents with papules and pustules and cysts that could appear similar to molluscum. But, comedones should be present and there is no central umblications of acne lesions.
✓ Folliculitis: Presents with small papules and/or pustules without umbilication.
✓ Other: Syringomas, flat warts, and cryptococcosis.
++
A recent Cochrane review reported that no single treatment has been shown to be convincingly effective.8 However, several options for therapy are commonly used.
++
Molluscum papules can be removed surgically using a small skin curette. They can also be incised with a needle and the contents expressed with gloved fingers or with a comedone extractor. Liquid nitrogen cryotherapy can be used, in a single pulse. 17% salicylic acid nonprescription products that are normally used for common warts can also be used. Spontaneous resolution typically occurs in 6 to 9 months, but may take one to several years.
++
Because molluscum contagiosum is easily spread among children, the parents and the schools should be notified of the infectious nature of the virus and the potential for skin to skin transfer of the virus. There is also frequent spread in certain sports activities, particularly in wrestling. Therefore, coaches and participants should be educated about the infection. Individuals with involvement of the genital region should practice safe sex.
+++
Indications for Consultation
++
Patients with symptomatic lesions that have not responded to treatment should be referred to dermatology.
++
++
Warts (verrucae vulgaris) represent one of the most frequently seen viral mucocutaneous infections. All age groups can be affected; the incidence is higher in children and young adults. In immunocompromised individuals, warts are more common and widespread, more resistant to treatment and more frequently progress to intraepithelial neoplasms. Wart infections can be seen worldwide and affect all ethnicities.
++
Warts are caused by the human papillomavirus (HPV), a double-stranded DNA virus with over 100 genotypes. Some HPV genotypes are found on normal skin and mucous membranes, sometimes inducing wart development when patients become immunocompromised. Other HPV genotypes, such as 16, 18, 31 and 33, may be oncogenic, inducing malignant transformation to squamous cell carcinoma in the anogenital and oralpharengeal areas.9 The virus infects keratinocytes in skin and mucous membranes by direct skin-to-skin contact or less commonly via fomites such as floors. Autoinoculation frequently occurs. Warts can spontaneously resolve after months to a few years. In two-thirds of infected individuals, warts regress within 2 years.
+++
Clinical Presentation
++
Warts may develop on any skin or mucous membrane surface, most frequently affecting the hands, feet, and genitalia. Trauma to the skin may encourage inoculation of the virus. Widespread infection can be seen in immunocompromised individuals. There may be an inherited susceptibility to wart infections.
++
There are several clinical presentations for warts, which depend on location and genotype.
++
Verrucae vulgaris (common warts): Skin-colored, hyperkeratotic, exophytic dome-shaped papules ranging in size from 1 to 10 mm. Mild erythema may be seen around the borders (Figure 11-6). The papules can be in a linear configuration, due to inoculation of the virus in an excoriation. Warts are most frequently seen on the hands, but may involve other skin areas.
Verrucae plantaris (plantar warts): Verrucous or endophytic papules, 1 to 10 mm, affecting the plantar surface of the foot. Black or brown dots created by thrombosed capillaries may be seen on the surface or after paring the wart (Figure 11-7).
Mosaic warts: Localized confluent collection of small warts, usually seen on the palms and soles (Figure 11-7). Brown dots are commonly seen.
Verrucae planae (flat warts): Small, 1 to 3 mm, slightly elevated, flat-topped papules with minimal scale, frequently seen on the face and hands (Figure 11-8).
Filiform/digitate warts: Pedunculated papules with finger-like projections arising from the skin's surface, frequently seen on the face and neck.
Condylomata accuminata (genital or venereal warts): Sessile, smooth-surfaced exophytic papillomas that may be skin-colored, brown, or whitish (Figure 11-9). The papillomas may be pedunculated or broad-based, sometimes coalescing to form confluent plaques. There may be extension into the vagina, urethra, or anal canal.
++
++
++
++
++
A skin biopsy may be done, especially if a carcinoma is suspected, or if the diagnosis is unclear. Histopathologic examination of a skin biopsy of an active wart infection is usually diagnostic.
++
The key diagnostic clinical features of warts are 2 to 10 mm verrucous or smooth papules, usually present on the hands, feet, or genitals.
+++
Differential Diagnosis
++
✓ Squamous cell carcinoma: Typically presents as an isolated papule or plaque that may ulcerate or appear inflamed. It usually occurs on sun-exposed areas of older patients. It can also occur on the genitals.
✓ Seborrheic keratoses: Presents with verrucous tan to dark brown papules or plaques and is commonly seen in older adults. Skin-colored lesions on the dorsum of the hand may closely resemble warts.
✓ Corns and calluses: These lesions have no red or brown dots (thrombosed capillary loops) when pared.
✓ Pearly penile papules: These are often confused with HPV warts on the penis. They present with numerous 1- to 3-mm smooth papules (angiokeratomas), in a linear arrangement, on the corona and are seen in up to 10% of males.
+++
Management of Nongenital Warts
++
There are multiple treatments for warts, none showing consistent efficacy in controlled studies, with the exception of topical salicylic acid products.10 Existing modalities mostly aim at destruction or removal of visible lesions or induction of an immune response to the virus. Choice of treatment depends on the location, size, number, and type of wart, as well as the age and cooperation of the patient. Induction of pain and the risk of scarring need to be considered. The patient and the treating clinician need to be persistent with therapy as it may take up to 4 to 6 months for the warts to resolve.
++
Topical Therapies: Salicylic acid preparations are available as nonprescription solutions, gels, plasters, or patches. Compound W wart remover, Dr. Scholl's Clear Away, Duofilm, Mediplast, Occlusal, Trans-Ver-Sal, and Wart-Off are examples of some available products with salicylic acid. The patients should follow the package instructions. Most preparations are applied at bedtime, after the wart(s) has been soaked in warm water. Surface thick layers of keratin should be removed with an emory board. The induced irritation causes an inflammatory immune response, which speeds resolution of the wart. Treatment may take up to 4 to 12 weeks to be effective.
Cryotherapy: Liquid nitrogen is applied to the wart by a healthcare provider using a Q-tip or a spray canister for 10 to 20 seconds or until a 2-mm rim of white frost appears beyond the border of the wart. The treatment can be repeated 2 or 3 times during a visit (see Chapter 7 for instructions). Repeat treatments can be done every 2 to 3 weeks if improvement is noted. Over-the-counter cryotherapy kits are available. Although the agent is not as cold as liquid nitrogen, these home kits can sometimes be successful in destroying warts. Patients must carefully follow the package insert directions for use, to avoid injury.
Procedures: Surgical excision, electrosurgery, and laser surgery may be used to remove or destroy warts, but these may result in significant scarring and recurrence of the wart within or adjacent to the scar.
+++
Management of Genital Warts
++
Imiquimod 5% cream (Aldara cream) is an immune response modifier, used primarily for genital warts.9 A thin layer of the cream is applied by the patient 3 times a week (eg, Monday, Wednesday, and Friday) sparingly to warts at bedtime and washed off in 6 to 10 hours for a maximum of 16 weeks. The cream may induce an inflammatory response prior to clearing of the warts.
25% podophyllin in tincture of benzoin is an antimitotic agent applied every 1 to 3 weeks to external genital warts by a healthcare provider. It should be washed off in 20 minutes to 2 hours. It is should not be used in pregnant or lactating women.
0.5% podophyllotoxin (Condylox gel or solution) is a prescription medication that can be used at home by the patient. It is applied to external genital warts twice a day for 3 consecutive days per week, for up to 4 weeks. It should not be used in pregnant or lactating women.
15% sinecatechins (Veregen) ointment, a green tea extract, is applied 3 times a day to external genital warts until the warts are clear. It should not be used longer than 16 weeks. It should not be used in pregnant or lactating women or in children.
HPV vaccine: Two HPV vaccines are currently available, Gardasil and Cervarix. Both protect against the two HPV genotypes (HPV-16 and 18) that cause 70% of cervical cancers. Garadisil also protects against the 2 HPV genotypes (HPV 6 and 11) that cause 90% of genital warts. Vaccination is recommended for young women to prevent cervical intraepithelial neoplasia and cervical carcinoma. Gardasil has also been shown to be effective in preventing genital warts in males. The CDC has up to date information on these vaccines.
++
Patients with anogenital warts need to use safe-sex practices. Sexual partners should be examined and treated, if necessary. Infected women should undergo evaluation of the uterine cervix to rule out neoplasia.
+++
Indications for Consultation
++
Widespread warts that have not responded to therapy should be referred to dermatology or to gynecology, in cases of female genital warts.
++
++