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Key Features

  • Caused by a poxvirus

  • The lesions are autoinoculable and spread by wet skin-to-skin contact

  • In sexually active individuals, lesions may be confined to the penis, pubis, and inner thighs and are considered a sexually transmitted infection

  • Common in AIDS patients

    • Usually with a helper T cell count < 100/mcL

    • Extensive lesions tend to develop over the face and neck as well as in the genital area

    • Lesions are difficult to eradicate unless immunity improves, in which case spontaneous clearing may occur

Clinical Findings

  • Presents as single or multiple, dome-shaped, waxy papules 2–5 mm in diameter that are umbilicated

  • Lesions at first are firm, solid, and flesh colored but on reaching maturity become soft, whitish, or pearly gray and may suppurate

  • The principal sites are the face, lower abdomen, and genitals

  • Individual lesions persist for about 2 months

Diagnosis

  • Clinical; based on the distinctive central umbilication of the dome-shaped lesion

  • Differential diagnosis

    • Warts

    • Varicella (chickenpox)

    • Basal cell carcinoma

    • Lichen planus

    • Smallpox

    • Cutaneous cryptococcosis (in AIDS)

Treatment

  • The best treatment is by curettage or applications of liquid nitrogen as for warts but more briefly

  • When lesions are frozen, the central umbilication often becomes more apparent

  • Light electrosurgery with a fine needle is also effective

  • Cantharidin (applied in the office and then washed off by the patient 4 hours later) is a safe and effective option

  • Other treatment options

    • Potassium hydroxide 10% solution applied twice daily until lesions clear

    • Salicylic acid

    • Tretinoin

    • Imiquimod

    • Pulsed dye laser

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