Molluscum Contagiosum: Diagnosis and Management
Diagnosis
The clinical presentation describes molluscum contagiosum, a benign viral skin infection caused by molluscum contagiosum virus (MCV). The characteristic features—2mm flesh-colored, dome-shaped papules with smooth central umbilication on the trunk and armpits, lasting several weeks without pain or itching—are pathognomonic for this condition 1, 2, 3.
Key Diagnostic Features
- Lesion morphology: Dome-shaped, smooth-surfaced, pearly, firm papules measuring 2-5mm in diameter with central umbilication are diagnostic 4
- Distribution: Most commonly affects trunk, face, and extremities in children; genital region in sexually active adults 1, 3
- Symptomatology: Typically asymptomatic, though may occasionally present with pain, itching, redness, or bacterial superinfection 1
- Clinical diagnosis: Based primarily on visual inspection; dermoscopy can facilitate diagnosis if uncertainty exists 3, 4
Important Clinical Caveat
Note the question mentions fever, which is NOT typical of molluscum contagiosum. If the patient truly has fever, this warrants investigation for alternative diagnoses or complications such as bacterial superinfection 1. Uncomplicated molluscum contagiosum does not cause systemic symptoms 3.
Treatment Approach
For immunocompetent patients, observation with expectant management is the primary recommendation, as spontaneous resolution typically occurs within 6-12 months. 1, 3
When to Treat Actively
Active treatment should be considered in the following scenarios 1, 3:
- Extensive disease affecting multiple body regions
- Lesions in cosmetically bothersome locations
- Underlying skin conditions such as eczema
- Risk of autoinoculation or transmission to others
- Patient/family preference for intervention
Treatment Modalities (in order of evidence strength)
Physical treatments:
- Cryotherapy with liquid nitrogen: Effective first-line option but may cause postinflammatory hyperpigmentation or uncommonly scarring 1
- Curettage: Mechanical removal under local anesthesia 4
- 10% potassium hydroxide: Similar efficacy to cryotherapy in children 1
Topical chemical treatments:
- Cantharidin: Open-label studies show effectiveness, though one small RCT (n=29) showed improvement greater than placebo but not statistically significant 1
- Podophyllotoxin: Option for genital lesions 4
Immunomodulatory therapy:
- Imiquimod: Randomized controlled trials showed NO benefit compared to placebo 1. However, this contradicts clinical experience reported in multiple case series showing 74% complete remission rates within 3-8 weeks 5. Given the conflicting evidence and FDA position, imiquimod should be considered only after physical treatments have failed or are not feasible 1, 5
Special Populations
Immunocompromised patients (HIV, transplant recipients, those on immunosuppressive therapy):
- Develop severe and recalcitrant lesions requiring active treatment 4
- Consider cidofovir, imiquimod, or interferon therapy 4
- Lesions may not spontaneously resolve without immune reconstitution 3
Pregnant patients:
- Physical procedures such as cryotherapy are safe 4
- Avoid systemic or potentially teratogenic topical agents 4
Return to Activities
For athletes or those in contact sports 1:
- Exclude from skin-to-skin contact activities until lesions are covered
- Avoid sharing towels and other fomites
- Limit exposure to swimming pools during active infection
Critical Pitfall to Avoid
Do not perform surgical debridement or aggressive destructive procedures, as this can lead to scarring and does not prevent recurrence 1. The goal is lesion removal with minimal cosmetic impact, particularly in children 3.
Screening Recommendation
Patients with genital molluscum contagiosum should be screened for other sexually transmitted infections, as sexual transmission indicates potential exposure to other STIs 4.