Kembara Xtra - Medicine - Molluscum Contagiosum A typical, benign viral (poxvirus) skin illness called molluscum contagiosum is characterized by small (2 to 5 mm), waxy, flesh-colored, dome-shaped papules that frequently have a central umbilication. A cheesy, grayish-white substance is seen in lesions. Skin-to-skin contact, sexual contact, sharing of towels and clothing, and autoinoculation are the main ways that Molluscum contagiosum spreads. In immunocompetent people, Molluscum contagiosum is a self-limited illness, but in immunocompromised patients, it can be difficult to treat and disfiguring. HIV prevalence in the United States is between 5 and 18% among sexually active young adults and less than 1% in children aged two to fifteen. Pathophysiology and Etiology Four genetic virus types that are clinically interchangeable belong to the Poxviridae family of DNA viruses. Viral replication and invasion into the cytoplasm of epithelial cells result in aberrant cell growth. To circumvent the host immune system, the genome encodes proteins. There is no association with malignancy, no cross-hybridization, and no reactivation by other poxviruses. The incubation period is 2 to 6 weeks, and the time to resolution is 6 to 24 months. Risk factors include skin-to-skin contact with an infected person, contact sports, swimming, atopic dermatitis, and sexual activity with an infected partner. Immunocompromised individuals include those with HIV, chemotherapy, corticosteroid therapy, organ transplant recipients, and those on biologics. Basic Prevention Prevent skin-to-skin contact with the host (such as during sexual activities or contact sports). Don't exchange clothes or towels. Atopic dermatitis, immunosuppressive drugs such as corticosteroids, biologics, chemotherapy, etc., and HIV/AIDS are associated conditions. Diagnosis: Participation in contact sports, Sexual activity, Contact with a Known Infected Person clinical assessment Conjunctiva and the anogenital region should both be thoroughly examined. Clear, firm papules with an umbilication in the center. White core with an umbilicated center. Lesions are typically found in intertriginous areas and are flesh, pearl, or crimson in color. Possible erythema or dermatitis in the area. Immunocompromised hosts may have hundreds of extensive lesions or "giant" molluscum (lesions >1 cm). Immunocompetent hosts typically have 11 to 20 lesions that are 2 to 5 mm in diameter (range: 1 to 10 mm). Anogenital region, inner thighs, and sexually active Child Safety Considerations Infants under 3 months: Take vertical transmission into account. If vertical transmission, lesions are frequently found on the scalp. Children: fever, more than 50 lesions, poor therapeutic response; consider immunodeficiency. Children: anogenital lesions; if lesions are present elsewhere on the body, autoinoculation is most likely the cause. However, the provider should think about potential sexual assault. Differential diagnosis: AIDS patients' Cryptococcus neoformans, penicilliosis, histoplasmosis, and coccidioidomycosis; verruca vulgaris; chickenpox; milia; basal cell carcinoma; benign appendageal tumors; syringomas; hidrocystomas; ectopic sebaceous glands; Condyloma acuminatum; Keratoacanthoma, Oral Squamous Cell Carcinoma, Trichoepithelioma, Warty Dyskeratoma, Amelanotic Melanoma, Papular Urticaria, Folliculitis/Furunculosis, Laboratory Results Initial examinations (lab, imaging) Viruses are not cultureable. If subsequent infection is a concern, culture the lesion. Test for HIV and other STIs, among other sexually transmitted diseases. The core material of the scrape lesion has the distinctive intracytoplasmic viral inclusion bodies of Henderson-Paterson. Hematoxylin-eosin-stained formalin-fixed tissue also exhibits the same confirming characteristics, as does a crush prep with 10% potassium hydroxide. Other/Diagnostic Procedures Dermatoscopy, while not always diagnostic, can be useful. Interpretation of Tests Central pore or umbilication, white-to-yellow polylobular structure, and crown vessels are distinctive dermoscopic features. Management Molluscum contagiosum is typically self-limited and resolves spontaneously in healthy patients; hence, therapy is not necessary. No single treatment for molluscum contagiosum has been demonstrated to be significantly more effective than any other. The choice of treatment is often based on the patient's age, location, number of lesions, comorbidities, availability, and cost. There are no FDA-approved treatments for molluscum contagiosum. There are three types of treatment: corrosive, immune-boostering, and antiviral. First Line of Medicine Cantharidin solution, 0.7-9%: Apply dressing to lesions in the office; remove after 2 to 6 hours, or sooner if blistering. Continue treatment until lesions disappear every 2 to 4 weeks. Not commercially available in the United States, but may be made there by a compounding pharmacy using powder; it could be imported as a solution from Canada. Negative effects include erythema, soreness, and pruritus. Use sparingly on the face and vaginal mucosa. Next Line Apply a 10% benzoyl peroxide cream twice daily for four weeks to each lesion. Cost-effective, available without a prescription; side effects: mild dermatitis Mucositis, leukopenia, and vitiligo are some of the side effects of using imiquimod 5% cream three to five times a week for a period of 12 weeks. Other topical medications include podophyllotoxin, trichloroacetic acid, salicylic acid, lactic acid, glycolic acid, and tretinoin. Consider Cidofovir: topical cream or IV for immunocompromised individuals (including HIV) with refractory lesions. 25 to 40 mg/kg/day Immunocompromised individuals who have not responded to first- or second-line therapy should be referred Surgery Cryotherapy: 1 or 2 cycles of 10 to 20 seconds (1); repeat as necessary every 3 to 4 weeks until lesions are gone. - Negative effects: blistering, erythema, edema, and pain - Contraindications: Raynaud illness and cryoglobulinemia Curettage performed under topical or local anesthetic (2)[A] - Negative outcomes: pain and scars The use of intralesional immunotherapy[C]: - MMR, vitamin D, PPD, and Candida antigen - Advantages: little to no recurrence - Negative effects: anaphylaxis, allergic response, erythema, and edema Alternative Therapies Use 10% solution of Australian lemon myrtle oil once day for 21 days. Apply the potassium hydroxide 5–10% solution once or twice day until the lesions are entirely gone. Child Safety Considerations Immunocompetent youngsters are not required to get treatment. Surgery is only used as a last resort in young patients because of the discomfort it causes. To manage pain before surgery, use topical lidocaine or EMLA. Note: Negative effects include methemoglobinemia and CNS toxicity when lidocaine or EMLA is applied to a substantial portion of the body. Consult the manufacturer's instructions for use and dosage in youngsters. pregnant women's issues Cryotherapy, incision, expression, curettage, and other procedures are safe during pregnancy. Patient Follow-Up Monitoring Is Determined by the Type of Treatment Cover lesions to stop spread, according to patient education. To avoid autoinoculation, refrain from scratching. Don't exchange clothes and towels. When lesions are present, engage in safe intercourse or abstain from it. Immunocompetent: a self-limited illness that clears up in 3 to 12 months (range: 2 months to 4 years) Immunocompromised: challenging to cure lesions that may last for years Secondary infection, scarring, hyper-/hypopigmentation, and other complications (which typically only happen as a result of treatment, not when lesions go away on their own)
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