Pearly White Nodules in Children
The diagnosis is molluscum contagiosum, a self-limited viral infection that presents as flesh-colored or pearly white, dome-shaped papules with central umbilication, most commonly affecting preschool and elementary school-aged children. 1, 2
Clinical Diagnosis
The characteristic features that confirm molluscum contagiosum include:
- Pearly white or flesh-colored, smooth, dome-shaped papules measuring 2-6 mm in diameter with central umbilication from which a cheesy plug of material can be expressed 1, 3, 2
- Lesions typically appear on the trunk, extremities, and face in children (versus genital region in sexually active adults) 4, 3
- Dermoscopy reveals yellowish-white polylobulated structures with peripheral telangiectasia, which can confirm the diagnosis when clinical appearance is unclear 5
- The infection is caused by molluscipox virus of the Poxviridae family and spreads through direct skin contact, autoinoculation, and fomites 1, 3
A common pitfall is confusing molluscum with other conditions. The shiny, dome-shaped umbilicated lesions distinguish molluscum from verruca vulgaris (which has a white pebbly or papillary surface) 6, and from the red, telangiectatic macules of telangiectasia macularis eruptiva persistans 6.
Management Algorithm
The primary decision is whether to observe or actively treat, based on lesion extent, complications, and family preference:
Observation (Watchful Waiting)
- Appropriate for limited, asymptomatic lesions in immunocompetent children 3
- Natural resolution typically occurs within 6-9 months, though lesions may persist for months to years 1, 3
- Spontaneous regression is common and avoids treatment-related discomfort 6
Active Treatment Indications
Active treatment should be pursued when: 1
- Extensive disease is present
- Complications develop (perilesional eczema, bacterial superinfection, BOTE sign) 5
- Aesthetic concerns exist
- Risk of transmission to others or autoinoculation is high 4, 3
Treatment Options (in order of preference)
Physical destruction methods:
- Cryotherapy with liquid nitrogen is the method of choice for most patients 3
- Curettage provides immediate removal but requires local anesthesia 3
- Pulsed dye laser therapy for resistant cases 3
Chemical destruction:
- Cantharidin application is highly effective and well-tolerated 3
- Potassium hydroxide, trichloroacetic acid, or salicylic acid preparations 1, 3
Immunomodulatory therapy:
- Topical imiquimod 5% cream once daily under occlusion achieved complete remission in 73.91% of children within 3-8 weeks in clinical practice 4
- Mild to moderate local irritation is the only adverse effect; no systemic side effects occur 4
- Despite unpublished FDA trials suggesting lack of efficacy, multiple peer-reviewed studies demonstrate safety and effectiveness in real-world practice 4
Important Caveats
Immunocompromised patients may develop atypical manifestations including giant, disseminated, necrotic, polypoidal, or nodular lesions that complicate diagnosis and management 5. These patients require more aggressive treatment approaches.
Associated inflammatory reactions can mimic other dermatological conditions, including perilesional eczema, Gianotti-Crosti syndrome-like reaction, ID reaction, erythema annulare centrifugum, and folliculitis 5. Recognition of these patterns prevents unnecessary treatments for misdiagnosed conditions.
The choice of treatment method depends on: 3
- Physician comfort with various options
- Patient age and cooperation
- Number, severity, and location of lesions
- Family preference regarding intervention versus observation
No FDA-approved treatments exist for molluscum contagiosum, but the evidence strongly supports both observation and active treatment as reasonable approaches depending on clinical circumstances 1, 4, 3.