Bahan Veruca

8/10/2019 Bahan Veruca

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Background

Warts are benign proliferations of skin and mucosa caused by the human papillomavirus

(HPV). Currently, more than !! types of HPV have been identified. Certain HPV types tend

to infect skin at particular anatomic sites" ho#ever, #arts of any HPV type may occur at any

site. $he primary clinical manifestations of HPV infection include common #arts, genital

#arts, flat #arts, and deep palmoplantar #arts (myrmecia). %ess common manifestations of

HPV infection include focal epithelial hyperplasia (Heck disease), &' epidermodysplasia

verruciformis,and plantar cysts. Warts are transmitted by direct or indirect contact, and

predisposing factors include disruption to the normal epithelial barrier.

$reatment is difficult, #ith freuent failures and recurrences. any #arts, ho#ever, resolve

spontaneously #ithin a fe# years even #ithout treatment.

* small number of high+risk HPV subtypes are associated #ith the development of

malignancies, including types , , , -, , and /. alignant transformation mostcommonly is seen in patients #ith genital #arts and in immunocompromised patients. HPV

types /, -, 0!, and 12 have oncogenic potential in patients #ith epidermodysplasia

verruciformis.

Pathophysiology

Warts can affect any area on the skin and mucous membranes. $he HPV virus infects the

epithelium, and systemic dissemination of the virus does not occur. Viral replication occurs in

differentiated epithelial cells in the upper level of the epidermis" ho#ever, viral particles can

be found in the basal layer.

Epidemiology

Frequency

International

Warts are #idespread in the #orld#ide population. *lthough the freuency is unkno#n,

#arts are estimated to affect appro3imately 2+04 of the population. 5n school+aged children,

the prevalence is !+0!4. *n increased freuency also is seen among immunosuppressed

patients and meat handlers.

Mortality/Morbidity

Common #arts are usually asymptomatic, but they may cause cosmetic disfigurement or

tenderness. Plantar #arts can be painful, and e3tensive involvement on the sole of the foot

may impair ambulation. alignant change in nongenital #arts is rare but has been reported

and is termed verrucous carcinoma.&0, , 1' Verrucous carcinoma is considered to be a slo#+

gro#ing, locally invasive, #ell+differentiated suamous cell carcinomathat may be easily

mistaken for a common #art. 5t can occur any#here on the skin but is most common on the

plantar surfaces. *lthough this type of cancer rarely metastasi6es, it can be locallydestructive.
http://emedicine.medscape.com/article/219110-overviewhttp://emedicine.medscape.com/article/219110-overviewhttp://emedicine.medscape.com/article/219110-overviewhttp://emedicine.medscape.com/article/1131981-overviewhttp://emedicine.medscape.com/article/1131981-overviewhttp://emedicine.medscape.com/article/1131981-overviewhttp://emedicine.medscape.com/article/1101695-overviewhttp://emedicine.medscape.com/article/1965430-overviewhttp://emedicine.medscape.com/article/219110-overviewhttp://emedicine.medscape.com/article/219110-overviewhttp://emedicine.medscape.com/article/1131981-overviewhttp://emedicine.medscape.com/article/1131981-overviewhttp://emedicine.medscape.com/article/1101695-overviewhttp://emedicine.medscape.com/article/1965430-overviewhttp://emedicine.medscape.com/article/219110-overview


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Race

*lthough #arts may affect any race, common #arts appear appro3imately t#ice as freuently

in #hites as in blacks or *sians.&/' 7ocal epithelial hyperplasia (Heck disease) is more

prevalent among *merican 5ndians and 5nuit.&'

Sex

ale+to+female ratio approaches 8.

Age

Warts can occur at any age. $hey are unusual in infancy and early childhood, increase in

incidence among school+aged children, and peak at 0+ years.&'

istory

HPV is spread by direct or indirect contact. 5t can resist desiccation, free6ing, and prolonged

storage outside of host cells. *utoinoculation also may occur, causing local spread of lesions.

$he incubation period for HPV ranges from + months" ho#ever, latency periods of up to

years or more are suspected.

Physical

Physical findings for different types of nongenital #arts are as follo#s8

Common #arts8 Common #arts also are termed verruca vulgaris. $hey appear as

hyperkeratotic papules #ith a rough, irregular surface. $hey range from smaller than

mm to larger than cm. $hey can occur on any part of the body but are seen most

commonly on the hands and knees (see image belo#).

Common #art on the hand.

7iliform #arts8 7iliform #arts are long slender gro#ths, usually seen on the face

around the lips, eyelids, or nares.

9eep palmoplantar #arts (myrmecia)&2' 8 9eep palmoplantar #arts also are termed

myrmecia. $hey begin as small shiny papules and progress to deep endophytic,

sharply defined, round lesions #ith a rough keratotic surface, surrounded by a smooth

collar of calloused skin (see the image belo#). :ecause they gro# deep, they tend tobe more painful than common #arts. yrmecia #arts that occur on the plantar surface
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usually are found on #eight+bearing areas, such as the metatarsal head and heel.

When they occur on the hand, they tend to be subungual or periungual.

Plantar #arts.

7lat #arts8 7lat #arts also are termed plane #arts or verruca plana. $hey are

characteri6ed as flat or slightly elevated flesh+colored papules that may be smooth or

slightly hyperkeratotic. $hey range from +/ mm or more, and numbers range from a

fe# to hundreds of lesions that may become grouped or confluent. $hese #arts may

occur any#here" ho#ever, the face, hands, and shins tend to be the most common

areas. $hey may appear in a linear distribution as a result of scratching or trauma

(;oebner phenomenon).


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9eep palmoplantar #arts (myrmecia) + HPV type (most common), follo#ed by

types 0, , 1, 02, 0@, and /2

7lat #arts + HPV types , !, and 0-

:utcher=s #arts + HPV type 2 (although some data suggest the association may be

#eak)

7ocal epithelial hyperplasia (Heck disease) + HPV types and 0

Cystic #arts + HPV type !

"aboratory Studies

$he diagnosis of #arts is made primarily on the basis of clinical findings.

5mmunohistochemical detection of HPV structural proteins may confirm the presence of

virus in a lesion, but this has a lo# sensitivity. Viral 9?* identification using Aouthern blothybridi6ation is a more sensitive and specific techniue used to identify the specific HPV

type present in tissue. Polymerase chain reaction may be used to amplify viral 9?* for

testing. *lthough HPV may be detected in younger lesions, it may not be present in older

lesions.

Procedures

Paring of #arts may reveal minute black dots, #hich represent thrombosed capillaries. >btain

a biopsy if doubt e3ists regarding the diagnosis.

istologic Findings

Histologic findings for various types of nongenital #arts are as follo#s8

Common #arts8 Histopathologic features of common #arts include digitated

epidermal hyperplasia, acanthosis, papillomatosis, compact orthokeratosis,

hypergranulosis, dilated tortuous capillaries #ithin the dermal papillae, and vertical

tiers of parakeratotic cells #ith entrapped red blood cells above the tips of the

digitations. Blongated rete ridges may point radially to#ard the center of the lesion. 5n

the granular layer, HPV+infected cells may have coarse keratohyaline granules and

vacuoles surrounding #rinkled+appearing nuclei. ;oilocytic (vacuolated) cells are

pathognomonic for #arts.

9eep palmoplantar #arts (myrmecia)8 9eep palmoplantar #arts appear similar to

common #arts e3cept that most of the lesion lies deep to the plane of the skin surface.

$his endophytic epidermal gro#th often has the distinctive feature of polygonal,

refractile+appearing, eosinophilic, cytoplasmic inclusions composed of keratin

filaments, forming ringlike structures. :asophilic nuclear inclusions and basophilic

parakeratotic cells loaded #ith virions may be in the upper layers of the epidermis.

7lat #arts8 7lat #arts resemble common #arts on light microscopy" ho#ever, the

features tend to be muted. Cells #ith prominent perinuclear vacuoli6ation around

pyknotic, strongly basophilic, centrally located nuclei may be in the granular layer.

$hese may be referred to as o#l=s eye cells.


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:utcher=s #arts8 :utcher=s #arts have prominent acanthosis, hyperkeratosis, and

papillomatosis. Amall vacuoli6ed cells #ith centrally located shrunken nuclei may be

seen in clusters #ithin the granular layer rete ridges.

7iliform #arts8 7iliform #arts may appear similar to common #arts but tend to have

prominent papillomatosis.

7ocal epithelial hyperplasia (Heck disease)8 7ocal epithelial hyperplasia is

characteri6ed by a hyperplastic mucosa #ith thin parakeratotic stratum corneum,

acanthosis, blunting and anastomosis of rete ridges, and pallor of epidermal cells as a

result of intracellular edema. Aome areas may have prominent keratohyaline granules,

and some vacuolated cells may be present.

Cystic #arts8 * cyst filled #ith horny material characteri6es cystic #arts. $he #all is

composed of basal, suamous, and granular cells. any of the epithelial cells may

have large nuclei and clear cytoplasm #ith eosinophilic inclusion bodies. $he cyst

may rupture, resulting in a foreign body granuloma

Medical !are

ultiple modalities are available for the treatment of #arts, but none is uniformly effective. &-,

@' Atart #ith the least painful, least e3pensive, and least time+consuming methods.


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commonly in the treatment of genital #arts. *minolevulinic acid (*%*) is a photosensiti6er

that has been successfully used topically in combination #ith blue light to treat flat #arts. &0'

Aeveral prescription medications have proven beneficial in treating #arts. $hese can be

applied at home by the patient. 5miuimod is an immune response modifier approved for the

treatment of genital #arts.


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Aystemic agents that have been used to treat #arts include cimetidine, retinoids, and

intravenous cidofovir.

Cimetidine is a type+0 histamine receptor antagonist commonly used to treat peptic ulcer

disease. :ecause of its immunomodulatory effects at higher doses, cimetidine #as considered

a possible treatment for #arts" ho#ever, results have varied. 9ouble+blind placebo+controlledstudies have sho#n no benefit.&0!'


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%iuid nitrogen (+@EC) is the most effective method of cryosurgery. *pply liuid nitrogen

using a cotton bud applicator or cryospray to the recommended +0 mm rim of normal skin

tissue around the #art. ther side effects may include scarring, ulceration, or pigment alteration. 5n addition, rarely

cryosurgery can result in a central clearing #ith an annular recurrence of the #art

surrounding the treated area, kno#n as a doughnut #art. Cure rates of /!+-!4 have been

reported. Paring the #art, in addition to 0 free6e+tha# cycles, has been a valuable adDunct to

cryosurgery for plantar #arts.&!'

"asers

$his is an e3pensive treatment, and is reserved only for large or refractory #arts. ultiple

treatments may be reuired. %ocal or general anesthesiamay be necessary. * potential risk of

nosocomial infection also e3ists in health care #orkers, since HPV can be isolated in the

plume and can be inhaled.&'

Carbon dio3ide lasers have successfully treated resistant #arts" ho#ever, the procedure can

be painful and leave scarring. >ne retrospective study revealed a cure rate of 14 at 0

months #ith carbon dio3ide lasers.&0'

$he flashlamp+pumped pulse dye laser targets the blood vessels that feed #arts and has

sho#n mi3ed results in treating #arts, #ith decreased risk of scarring and transmission of

HPV in the smoke plume.&'

?d8G* laser may be used for deeper, larger #arts.

Electrodesiccation/curettage and surgery

*lthough electrodesiccation and curettage may be more effective than cryosurgery, it is

painful, more likely to scar, and HPV can be isolated from the plume. *void using surgical

e3cision in most circumstances because of the risks of scarring and recurrence.

Medication Summary

$he goals of pharmacotherapy are to reduce morbidity and prevent complications. 5n addition

to the medications listed belo#, propolis is a bro#nish resinous #a3y material collected by

honeybees from the buds of trees and used as a cement and used at /!! mgIday until #arts

resolve or until mo, #hichever occurs first.

9ibutyl suaric acidIdiphencyclopropenone has also been used. Contact sensiti6ers induce

allergic contact dermatitis, causing a locali6ed inflammation and immune response. *pply

solution in light+shielded accessible location (eg, arm) to achieve initial sensiti6ation" repeat

until reaction occurs" apply to #arts +0#eeks.

'eratolytic agents
http://emedicine.medscape.com/article/1271543-overviewhttp://emedicine.medscape.com/article/1271543-overview


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!lass Summary

Cause cornified epithelium to s#ell, soften, macerate, and then desuamate.

Salicylic acid ()* +!ompound ,- .uoilm0- or 12* pad +!urad Mediplast0

*vailable >$C in /+1!4 concentration and in a variety of vehicles, including creams, paints,

gels, karaya gum, impregnated plasters, collodion, or sodium carbo3ycellulose tape. %actic

acid may be a second ingredient in some #art varnishes. :y dissolving the intercellular

cement substance, salicylic acid desuamates the horny layer of skin. $herapeutic effect may

be enhanced by removal of surface keratin prior to application. *pply topically dIbid for

several #eeks.

Vie# full drug information

Podoilox +!ondylox0

Podofilo3 is a purified ingredient of podophyllin and, therefore, is less irritating. *vailable by

prescription and can be applied by patient at home. * !./4 purified solution may be applied

topically bid for consecutive days, repeat #eek, not e3ceed 1 #eeks


Podophyllum resin +Podocon3450


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Caustic compound that causes immediate superficial tissue necrosis. *vailable as -!4

solution that is painted onto lesions in physician=s office" apply after e3cess keratotic debris is

pared" repeat therapy #eek prn until #art is cured.

Immunomodulators

!lass Summary

Atimulate the release of key factors that regulate the immune system.&1'


Imiquimod +Aldara0

5nduces secretion of interferon alpha and other cytokines" 79* approved for treatment of

genital #arts in adults" reports indicate success in treatment of common #arts in children. *

/4 gel applied daily for daysI#eek" may apply hs and #ash off after +! h" t#ice+daily

administration for nongenital #arts reported, but irritation may be increased.


Intereron ala 4b +Intron A0

?aturally occurring cytokine #ith antiviral, antitumor, and immunomodulatory actions"

intralesional administration more effective than systemic administration and associated only

#ith mild flulike symptoms. $reatments may be reuired for several #eeks to months before

beneficial results are seen. Consider this treatment as third line, and reserve it for #arts

resistant to standard treatments.


Pegylated intereron ala34a +Pegasys0

PB+57? alfa+0a consists of 57? alfa+0a attached to a 1!+kd branched PB molecule. 5t is

predominantly metaboli6ed by the liver. Has immunomodulatory actions" intralesional

administration more effective than systemic administration and associated only #ith mild

flulike symptoms. $reatments may be reuired for several #eeks to months before beneficial

results are seen. Consider this treatment as third line, and reserve it for #arts resistant to

standard treatments.

http://reference.medscape.com/drug/aldara-zyclara-imiquimod-343508http://reference.medscape.com/drug/aldara-zyclara-imiquimod-343508http://reference.medscape.com/drug/intron-a-interferon-alfa-2b-interferon-alfa-2b-342615http://reference.medscape.com/drug/intron-a-interferon-alfa-2b-interferon-alfa-2b-342615http://reference.medscape.com/drug/pegasys-peginterferon-alfa-2a-342645http://reference.medscape.com/drug/pegasys-peginterferon-alfa-2a-342645http://reference.medscape.com/drug/efudex-carac-fluorouracil-topical-343545http://reference.medscape.com/drug/aldara-zyclara-imiquimod-343508http://reference.medscape.com/drug/aldara-zyclara-imiquimod-343508http://reference.medscape.com/drug/intron-a-interferon-alfa-2b-interferon-alfa-2b-342615http://reference.medscape.com/drug/intron-a-interferon-alfa-2b-interferon-alfa-2b-342615http://reference.medscape.com/drug/pegasys-peginterferon-alfa-2a-342645http://reference.medscape.com/drug/pegasys-peginterferon-alfa-2a-342645http://reference.medscape.com/drug/efudex-carac-fluorouracil-topical-343545


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53Fluorouracil +Eudex- !arac- Fluoroplex0

$opical chemotherapeutic agent that is approved to treat actinic keratoses and superficial

:CC" has been found more successful in treatment of flat #arts than plantar and common#arts. *pply /4 solution or cream daily for up to mo" may be used under occlusion, but

risk of irritation increases.

Antineoplastics- Antibiotic

!lass Summary

5nhibit cell gro#th and proliferation.


Bleomycin

Cytoto3ic polypeptide that inhibits 9?* synthesis in cells and viruses. Has affinity for HPV+

infected tissue and induces vascular changes that result in epidermal necrosis. Has been

beneficial in treating resistant #arts.


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ay be helpful in immunocompromised patients #ith e3tensive disabling hyperkeratotic

#arts. ay help alleviate pain and facilitate use of other treatments. 5n addition, retinoids

have helped reduce the number of lesions in immunosuppressed renal transplant patients.

$opical retinoids may be useful in treating flat #arts.


Isotretinoin +Amnesteem- !lara&is- Myorisan- Sotrel0

Aynthetic +cisisomer of the naturally occurring tretinoin (trans+retinoic acid)" structurally

related to vitamin *. *pproved for severe nodular acne but has also been helpful in certain

keratini6ation disorders.

* FA 7ood and 9rug *dministrationJmandated registry is no# in place for all individuals

prescribing, dispensing, or taking isotretinoin. 7or more information on this registry, see

iP%B9B. $his registry aims to further decrease the risk of pregnancy and other un#anted

and potentially dangerous adverse effects during a course of isotretinoin therapy. ay

administer !./+0 mgIkgId P> divided bid #ith food.

$opical Skin Products

!lass Summary

Products that become cytoto3ic follo#ing e3posure to light may be beneficial.


53Aminole&ulinic acid topical 42* solution +"e&ulan 'erastick0

$opical porphyrin available as %evulan ;erastick. $o be applied topically to #arts and kept

under occlusion for /h, then e3posed to red light+emitting diodes or other suitable red or blue

light source.

Prognosis

*ppro3imately /4 of #arts disappear spontaneously #ithin 0 years. When #arts resolve on

their o#n, no scarring is seen. Ho#ever, scarring can occur as a result of different treatment

methods. ro#th of periungual or subungual #arts may result in permanent nail dystrophy.

$reatment failures and #art recurrences are common, more so among immunocompromised

patients. ?ormal appearing perilesional skin may harbor HPV, #hich helps e3plain

recurrences.

Patient Education
http://reference.medscape.com/drug/amnesteem-claravis-isotretinoin-343544http://reference.medscape.com/drug/amnesteem-claravis-isotretinoin-343544http://www.ipledgeprogram.com/http://reference.medscape.com/drug/aminolevulinate-levulan-kerastick-aminolevulinic-acid-methyl-aminolevulinate-topical-343559http://reference.medscape.com/drug/aminolevulinate-levulan-kerastick-aminolevulinic-acid-methyl-aminolevulinate-topical-343559http://reference.medscape.com/drug/amnesteem-claravis-isotretinoin-343544http://reference.medscape.com/drug/amnesteem-claravis-isotretinoin-343544http://www.ipledgeprogram.com/http://reference.medscape.com/drug/aminolevulinate-levulan-kerastick-aminolevulinic-acid-methyl-aminolevulinate-topical-343559http://reference.medscape.com/drug/aminolevulinate-levulan-kerastick-aminolevulinic-acid-methyl-aminolevulinate-topical-343559


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*lert patients to the risk factors for transmission of #arts. $hese include trauma or

maceration of the skin, freuent #et #ork involving hands, hyperhidrosis of feet, s#imming

pools, and nail biting. :utchers and slaughterhouse #orkers also are at increased risk for

developing #arts.

*lert patients that some #arts may reuire multiple treatments and may be resistant to severaltreatment modalities. 5n addition, some #arts may regress spontaneously #ithout treatment.

7or e3cellent patient education resources, visit eedicineHealth=s Akin Conditions and

:eauty Center. *lso, see eedicineHealth=s patient education articles Wartsand Plantar

Warts.

6&er&ie7

Palmoplantar keratoderma (PP;) constitutes a heterogeneous group of disorders

characteri6ed by thickening of the palms and the soles of individuals #ho are affected. 5nrecent years, speculation has arisen that a molecular genetic classification system #ill replace

the traditional, clinically based, descriptive systems. Conseuently, the authors of this revie#

present each disorder according to traditional schemes and offer molecular and genetic

insights into each.

$he PP;s can initially be divided based on #hether they are inherited or acuired. 7ocusing

on the inherited PP;s, initial classification is into distinct clinical patterns of epidermal

involvement.

$he first is diffuse PP;, #hich is uniform involvement of the palmoplantar surface. $his

pattern is usually evident #ithin the first fe# months of life. $he second is focal PP;, #hichconsists of locali6ed areas of hyperkeratosis located mainly on pressure points and sites of

recurrent friction. $he third is punctate keratoderma, #hich features multiple small,

hyperkeratotic papules, spicules, or nodules on the palms and soles. $hese tiny keratoses may

involve the entire palmoplantar surface or may be restricted to certain locations (eg, palmar

creases).

$he keratodermas can then be further subdivided based on #hether only an isolated

keratoderma is present or #hether other skin findings are present andIor other organs are

involved.

$he first subclassification is simple keratoderma, #hich is isolated PP;. $he second iskeratodermas #ith associated features such as lesions of nonvolar skin, hair, teeth, nails, or

s#eat glands andIor #ith abnormalities of other organs.

*cuired forms are divided into keratoderma climactericum, keratoderma associated #ith

internal malignancy, PP; due to inflammatory and reactive dermatoses, PP; caused by

infections, drug+related PP;, and systemic diseaseJassociated PP;.

.iuse ereditary PP'

.iuse types 7ithout associated eatures
http://www.emedicinehealth.com/collections/CO1598.asphttp://www.emedicinehealth.com/collections/CO1598.asphttp://www.emedicinehealth.com/Articles/20289-1.asphttp://www.emedicinehealth.com/articles/20312-1.asphttp://www.emedicinehealth.com/articles/20312-1.asphttp://www.emedicinehealth.com/collections/CO1598.asphttp://www.emedicinehealth.com/collections/CO1598.asphttp://www.emedicinehealth.com/Articles/20289-1.asphttp://www.emedicinehealth.com/articles/20312-1.asphttp://www.emedicinehealth.com/articles/20312-1.asp


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Bpidermolytic PP; (Vorner PP;)

o Aynonyms for epidermolytic PP; (BPP;) include diffuse Vorner disease and

PP; cum degeneratione granulosa. 5n some ethnic groups, this form is the

most common type of hereditary PP;. 5t has an estimated prevalence of at

least 1.1 cases per !!,!!! population in ?orthern 5reland. 5t is inherited in an

autosomal dominant fashion. >nset occurs in the first fe# months of life, butthe disease is usually #ell developed by age +1 years.

o Clinical features are very similar to diffuse nonepidermolytic PP; (?BPP;).

* #ell+demarcated, thick, yello# hyperkeratosis is present over the palms and

soles. *n erythematous band is freuently present at the periphery of the

keratosis. $he surface is often uneven and verrucous. 7inally, it is usually

nontransgredient, #ith a sharp demarcation of the lesions at the #rists.

o Histologically, keratinocytes sho# epidermolysis, hyperkeratosis, acanthosis,

and papillomatosis. Perinuclear vacuoli6ation and large keratohyalin granules

are seen. Cellular breakdo#n in the spinous and granular cell layers sometimesleads to blister formation. Aeveral biopsy specimens may be reuired to

confirm the changes because they may be subtle and patchy.

o ;eratin and keratin @ mutations have been reported. $he keratin mutations

appear to be associated #ith a milder form of BPP;.&'

o $reatment includes salicylic acid, /!4 propylene glycol in #ater under plastic

occlusion several nights per #eek, and lactic acidJ and urea+containing creams

and lotions" all have been sho#n to be helpful. echanical debridement #ith a

blade also may be useful. >ral retinoid therapy has had variable effects and

may not benefit patients #ith certain genotype profiles, such as ; mutations.

?onepidermolytic PP; (Fnna+$host PP;)

o Aynonyms include diffuse Fnna+$host disease and PP; diffusa circumscripta.

9iffuse ?BPP; is inherited in an autosomal dominant fashion. $he condition

may manifest in the first fe# months of life but is usually #ell developed by

age +1 years. 5t is another common type of hereditary PP;.

o Clinically, even, #a3y, thick, #ell+demarcated hyperkeratosis is present over

the palms and soles. * red band is freuently present at the periphery of the

keratosis. 5t is usually nontransgredient, #ith a sharp demarcation of the

lesions at the #rists. *berrant keratotic lesions may appear in the dorsum ofthe hands, feet, knees, and elbo#s. $he dorsa of the fingers may be involved

#ith a sclerodermalike thickening of the distal digit. * cobblestone

hyperkeratosis of the knuckles may be seen. ?ails may be thickened.

o *lthough not al#ays distinguishable, some clinical features may help

differentiate BPP; from ?BPP;. ?BPP; may have a #a3y appearance,

compared #ith the dirty appearance of BPP;. Hyperhidrosis and pitted

keratolysis may be present #ith ?BPP;. 7inally, #ith ?BPP;, secondary

dermatophyte infections, resulting in maceration and peeling, are common.

o Histologic findings include orthokeratotic hyperkeratosis associated #ithhypergranulosis or hypogranulosis and moderate acanthosis. Changes are


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nonspecific and common to many varieties of keratoderma. *n absence of

epidermolysis differentiates it from BPP;.

o olecular biology features include linkage to type 55 keratin locus on band

0+, corresponding to a keratin gene mutation.

o $reatment includes salicylic acid, /!4 propylene glycol in #ater under plastic

occlusion several nights per #eek, and lactic acidJ and urea+containing creams

and lotions" all have been sho#n to be helpful. echanical debridement #ith a

blade may also be useful. >ral retinoid therapy has had variable effects.

$reatment #ith an antifungal agent is beneficial if dermatophyte infection

coe3ists #ith the ?BPP;.

al de eleda&0'

o * synonym is keratosis e3tremitatum hereditaria trangrediens et progrediens.

al de eleda is an autosomal recessive disease. >nset occurs in early

infancy, but the condition is rare. $he prevalence is case per !!,!!!population. 5nitially, it #as described in inhabitants of the *driatic 5sland of

eleda.

o Clinical features include diffuse, thick keratoderma #ith a prominent

erythematous border. %esions spread onto the dorsa of the hands and the feet

(transgredient). Constricting bands are present around the digits and can result

in spontaneous amputation. Well+circumscribed psoriasislike plaues or

lichenoid patches may be present on the knees and the elbo#s. Patients may

have severe hyperhidrosis, possibly accompanied by malodor. Aecondary

bacterial and fungal infections are common. Perioral erythema" periorbital

erythema and hyperkeratosis" nail changes (eg, koilonychia, subungualhyperkeratosis)" and lingua plicata, syndactyly, hair on the palms and the

soles, high+arched palate, and left+handedness are other clinical features.

o Histologic findings include orthokeratosis and normogranulosis #ithout

epidermolysis.

o olecular biology features include mutations in the gene encoding A%F


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o olecular biology studies in one case did not find any mutations in the gene

encoding A%Fnset occurs in early infancy but may occur later

in childhood.

o Clinically, diffuse PP; e3tends onto the dorsa of the hands and the feet

(trangredient), #ith characteristic involvement of the *chilles tendon. Acaly

plaues may be found on the elbo#s, knees, and fle3ural areas. Hyperhidrosis

and intrafamilial phenotypic variation are common. Pseudoainhum formation

#ith amputation of the digits has been described.

o Histologic features include epidermolysis of the granular cell layer. %ipid+

laden corneocytes may be seen.

o olecular biology features include mutations in the gene encoding keratin .&1'

o $reatment includes emollients, topical retinoids, keratolytics, and topical

steroids.

.iuse types 7ith associated eatures

utilating PP; (Voh#inkel syndrome)

o Aynonyms include PP; mutilans and keratoderma hereditaria mutilans.

utilating PP; is inherited in an autosomal dominant fashion. >nset occurs in

infancy.

o Clinically, this condition manifests in infants as a honeycomblike keratosis of

the palms and the soles. 5t becomes transgredient during childhood. %ater+

forming, constricting, fibrous bands appear on the digits and can lead to

progressive strangulation and autoamputation. Atarfish+shaped keratosis may

occur on the knuckles of the fingers and toes, #hich is a characteristic feature

of this disorder. *lopecia, hearing loss, spastic paraplegia, myopathy,

ichthyosiform dermatosis, and nail abnormalities are associated. Cases of

epithelioma cuniculatum have been reported.

o Histologic findings include hyperkeratosis, acanthosis, and a thickenedgranular cell layer #ith retained nuclei in the stratum corneum.

o olecular biological studies have confirmed that the most common mutation

found in Voh#inkel syndrome involves the gene encoding conne3in 0. $his

subtype is associated #ith hearing loss. 5n contrast, a mutation in the gene for

loricrin is associated #ith mutilating keratoderma and ichthyosis but not

deafness.

o $reatment includes oral retinoids.

o *lso see Voh#inkel Ayndrome.

:art+Pumphrey syndrome


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o * synonym is PP; #ith knuckle pads, leukonychia, and deafness. 5t is

inherited in an autosomal dominant fashion. >nset occurs in infancy.

o Clinically, all neonates are hearing impaired from birth and develop diffuse

PP; in childhood. %eukonychia and hyperkeratoses over the Doints of the hand

also appear.

o olecular biological studies include a ne# mutation in the gene that encodes

conne3in 0, #hich e3plains the clinical overlap #ith Voh#inkel syndrome.

9iffuse ?BPP; and sensorineural deafness

o $his condition is inherited in an autosomal dominant fashion.&/'

o Clinical features include diffuse palmoplantar hyperkeratosis in association

#ith slo#ly progressive, bilateral, high+freuency hearing loss (onset in early

childhood). 9eafness precedes the skin changes (onset in mid childhood).

o olecular biology features include a conne3in 0 mutation (different domains

than those mutated in Voh#inkel syndrome). 5n addition, a mitochondrial

point mutation has been demonstrated as the cause of this phenotype, making

this the only type of keratoderma associated #ith a mutation in mitochondrial

9?* (serine t


18/54

Aensorineural deafness, polydactyly, syndactyly, clubbing of fingers, mental

retardation, d#arfism, photophobia, and strabismus are associated.

o Clouston syndrome is mapped to . >ne form can be caused by mutation

in the gene encoding conne3in !. Fltrastructural studies of the hair of these

patients demonstrate disorgani6ation of hair fibrils #ith loss of the cuticularcorte3.

utilating PP; #ith periorificial keratotic plaues (>lmsted syndrome)

o ost cases of this condition are sporadic, #ith the e3ception of one report of

an autosomal dominant pattern of inheritance. >nset occurs in the first year of

life.

o Clinically, PP; begins focally in infancy and then becomes diffuse and severe.

%ater findings include fle3ion deformities and constriction of the digits,

sometimes leading to spontaneous amputation. Progressive, #ell+defined

perioral, perianal, and perineal hyperkeratotic plaues are present, as isonychodystrophy. *lopecia, deafness, nail dystrophy, and dental loss may be

associated. Auamous cell carcinoma and malignant melanoma have

developed in the areas of PP;.

o Histologic findings include hyperkeratosis #ithout parakeratosis and mild

acanthosis.

o *bnormal e3pression of keratin / and 1 has been reported.

o $reatment includes oral and topical retinoids. 7ull+thickness e3cision and skin

grafting has also been reported to result in clinical improvement.

PP; #ith periodontitis (Papillon+%efLvre syndrome)

o $his condition is inherited in an autosomal recessive fashion. $he freuency of

PP; #ith periodontitis is 1 cases per million population. $he male+to+female

ratio is eual. >nset occurs bet#een the first and fifth years of life. * variant,

Haim+unk syndrome, features, in addition to PP; and periodontitis,

arachnodactyly, acroosteolysis, and onychogryphosis.

o Clinically, diffuse transgredient PP; may be observed, typically developing

#ithin the first years of life. Punctiform accentuation, particularly along the

palmoplantar creases, may be seen. Fnless treated, periodontosis results insevere gingivitis and loss of teeth by age / years. ?o significant correlation

has been demonstrated bet#een the level of periodontal infection and the

severity of skin affections, #hich supports the concept that these maDor

components of this syndrome are unrelated to each other. Patients e3hibit

increased susceptibility to cutaneous and systemic infections. Acaly,

psoriasiform lesions are often observed over the knees, elbo#s, and

interphalangeal Doints. 7inally, patients may have malodorous hyperhidrosis.


19/54

lipidlike vacuoles in corneocytes and granulocytes, a reduction in

tonofilaments, and irregular keratohyalin granules.

o olecular biology findings include mutations in the gene for cathepsin C,

mapping to 1+0, #hich are responsible for this syndrome.&2' Cathepsin C

is a lysosomal protease kno#n to activate en6ymes that are vital to the body=sdefenses.

o $reatment includes oral retinoids for the PP;. Blective e3traction of involved

teeth may prevent e3cess bone resorption. *ppropriate antibiotic therapy may

be reuired for periodontitis and recurrent cutaneous and systemic infections.

$reatment #ith acitretin starting at an early age sho#s promise to#ards

allo#ing patients to have normal adult dentition.

9iffuse ?BPP; #ith #oolly hair and arrhythmogenic cardiomyopathy (?a3os

disease)

o $his condition is inherited in an autosomal recessive fashion.

o Clinically, a diffuse, nontransgredient keratoderma #ith an erythematous

border appears during the first year of life. Woolly (dense, rough, and bristly)

scalp hair is present at birth. Cardiac disease, manifested by arrhythmias, heart

failure, or sudden death, becomes evident during and after late puberty. >ther

cutaneous manifestations include acanthosis nigricans, 3erosis, follicular

hyperkeratosis over the 6ygoma, and hyperhidrosis.

o Histologic findings include hyperkeratosis, hypergranulosis, and acanthosis.

o

olecular biology findings include a mutation in the plakoglobin gene,mapping to 20, #hich is responsible for ?a3os disease. Plakoglobin is an

important component of cell+to+cell and cell+to+matri3 adhesion comple3es of

many tissues, including the skin and cardiac Dunctions. 5t also plays a role in

signaling in the formation of desmosomal Dunctions. utations in the

plakoglobin gene may lead to detachment of the cardiac myocytes, resulting in

myocyte death. Plakoglobin mutations may also lead to desmosomal Dunction

fragility in hair shafts, e3plaining the clinical phenotype of #oolly hair.

Cardiomyopathy #ith alopecia and palmoplantar keratoderma (C*P;)

Focal ereditary PP'

Focal PP' 7ithout associated eatures

7ocal BPP;

o Aynonyms include keratosis palmoplantaris nummularis and hereditary painful

callosities. $his condition is inherited in an autosomal dominant manner.

>nset occurs #ithin the first 0 years of life. &-'

o Clinical features include nummular keratotic lesions, mainly located on plantar

pressure points. $his condition is also painful.

o Histologic features include local epidermolytic hyperkeratosis. &@, !'


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o olecular genetic findings have not yet been reported.

Atriate PP;

o Aynonyms include :rMnauer+7uhs+Aiemens syndrome, Wachter+type focal

?BPP;, and PP; areataIstriata. Atriate PP; is inherited in an autosomal

dominant fashion. >nset occurs in infancy or in the first fe# years of life.

o Clinical features include marked variability in phenotypic e3pression. Hands

may sho# minimal callous formation, or, changes may be undetectable in

individuals #ith sedentary occupations. 7riction+associated trauma from

manual labor results in a striate pattern of PP; over the palmar aspects of the

digits (islands of linear hyperkeratosis). 5ncreased skin fragility may lead to

skin splitting follo#ing trauma. ?ails and hair may be involved.

o Histology demonstrates acanthosis and an increased granular layer.

o olecular biology findings include mutations in desmosomal proteins, #hichhave been implicated in this disorder, including desmoglein on -+0 and

the desmoplakin gene on p0. 9esmosomal function is very important in

areas prone to repeated friction. utations in keratin and keratin are also

associated #ith striate PP;.

o $reatment includes oral retinoids.

Focal type 7ith associated eatures

PP; associated #ith esophageal cancer (Ho#ell+Bvans syndrome)

o Aynonyms include tylosis esophageal cancer and focal ?BPP; #ithcarcinoma of the esophagus. $his condition is inherited in an autosomal

dominant fashion.

o Clinically, focal PP; develops at age /+! years. $he PP; is limited to the

pressure points on the balls of the feet, #ith later mild involvement on the

palms. Patients have an increased susceptibility to developing carcinoma of

the esophagus in the fifth decade of life. $#o variants, one #ith a late onset of

PP; and a higher risk of esophageal carcinoma and another #ith an early

onset and a benign course, have been described. >ral leukokeratosis and

follicular keratosis are often present.

o Histologic findings include acanthosis, a prominent granular cell layer, and

hyperkeratosis in the palms and soles. Patients have thickened s#eat ducts of

the dermis, #ith the lumen often occluded by a hyperplastic epithelium.

o $he tylosis esophageal cancer gene (TOC) is locali6ed to a small region on

band 20/, a region freuently deleted in persons #ith sporadic suamous

cell esophageal tumors.

>culocutaneous tyrosinemia (culocutaneous tyrosinemia is

inherited in an autosomal recessive fashion.


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o Clinical features include focal, painful PP; development in childhood or

adolescence. >ccasionally, hyperkeratotic lesions develop on the elbo#s,

knees, and tongue. Patients have hyperhidrosis and bullous lesions.

Photophobia and herpetiform corneal erosions often appear in infancy and can

lead to corneal ulcerations, scarring, and glaucoma. $yrosine crystal deposits

can be seen during slit+lamp e3amination. ental retardation develops,especially if patients are not treated.

o Histologic findings include acanthosis #ith hyperkeratosis and

hypergranulosis. Fnder electron microscopy, keratinocytes contain clumped

tonofilament #ith adherent globoid keratohyalin granules and intracellular

needle+shaped tyrosine crystalline inclusions can be found.

o olecular biology features include at least / mutations in the gene encoding

tyrosine aminotransferase at band 00.+00.. 9eficiency of the en6yme

tyrosine aminotransferase leads to increased levels of serum and urinary

tyrosine and phenolic acid metabolites of tyrosine.

o $reatment includes early institution of a lo#+phenylalanine and lo#+tyrosine

diet.

Pachyonychia congenita, types 5 and 55&'

o $his condition is inherited in an autosomal dominant manner" ho#ever, a rare

autosomal recessive pattern is also observed.

o Clinical features include locali6ed areas of hyperkeratosis on the palms and

the soles, typically found on pressure points and #eightbearing areas of the

palms and soles. Patients have discoloration and thickening of the nails, #hichmay be striking. 7ollicular hyperkeratosis, angular cheilitis, oral

leukokeratosis, hyperhidrosis, and hoarseness may develop.

o $ype is the Kadassohn+%e#ando#sky type and is the most prevalent type of

pachyonychia congenita. 5t is characteri6ed by severe focal PP;, possibly #ith

blistering. $ype 0 is the Kackson+%a#ler type. $he focal PP; is milder in type

0 than in type . ?atal or neonatal teeth and multiple pilosebaceous cysts

(steatocystoma multiple3) are also present and help distinguish this type from

type .

o Histologic features include hyperkeratosis #ith alternating orthokeratosis andparakeratosis. %arge keratohyalin granules are present. Fnder electron

microscopy, these granules appear as perinuclear keratin aggregates.

o olecular biology findings for the Kadassohn+%e#ando#sky type include a

keratin gene mutation and keratin a gene mutations. $he Kackson+%a#ler

type is associated #ith keratin 2 and keratin b gene mutations.

o $reatment includes emollients and keratolytics in mild cases and oral retinoids

in more severe disease. Aurgical e3cision of severely deformed nails offers a

temporary solution, but nail dystrophy recurs. 5nDection of botulinum to3in has

sho#n relief for hyperhidrosis and pain.

o *lso see Pachyonychia Congenita.


22/54


23/54

o olecular genetic studies have not yet identified specific genes involved,

although linkage analyses have mapped the disease bet#een bands /00.0

and /00..

o $reatment includes keratolytics, topical salicylic acid, mechanical

debridement, e3cision, and topical and systemic retinoids.

Punctate keratosis of the palmar creases

o Punctate keratosis of the palmar creases occurs most commonly in *frican

*merican patients aged /+1! years. *n autosomal dominant inheritance

pattern has been suggested.

o Clinical features include small, round depressions filled #ith conical

keratinous plugs, #hich typically occur on the creases of the palms, fingers,

and, less commonly, on the soles. $he lesions are aggravated by friction, and,

occasionally, they may be painful.

o Histologic features include hyperkeratosis and parakeratosis.

o $reatment may include keratolytics and topical retinoids.

*crokeratoelastoidosis

o Aynonyms include acrokeratoelastoidosis of Costa. *crokeratoelastoidosis is

usually sporadic, although familial cases suggest an autosomal dominant

pattern of inheritance. >nset usually occurs before the second or third decade

of life.

o Clinical features include round or oval, shiny, firm, yello#ish papules that canappear umbilicated. $hese papules are distributed along the marginal border of

the palms, soles, andIor digits and can also be seen in the space bet#een the

thumb and forefinger, on the anterior surface of the lo#er legs, and over the

knuckles and nail folds. $he papules are usually asymptomatic.

o Histologic features include focal hyperkeratosis and elastorrhe3is

(fragmentation and a decreased number of elastic fibers in the reticular

dermis).

o ?o treatment is usually reuired for acrokeratoelastoidosis because lesions are

asymptomatic. Ho#ever, methods to remove the lesions for cosmeticpurposes, including liuid nitrogen, salicylic acid, and topical tretinoin, have

largely been unsuccessful.

7ocal acral hyperkeratosis

o 7ocal acral hyperkeratosis is usually sporadic, but familial cases suggest an

autosomal dominant pattern of inheritance. >nset peaks in the third decade.

Aome believe this entity is a variant of acrokeratoelastoidosis.

o Clinically, the lesions are identical to those of acrokeratoelastoidosis. 5t has an

insidious onset in childhood, reaching a ma3imum in early life. 5nitial reports

suggested a predilection for those of *frican origin, but subseuent reports

have refuted the importance of ethnicity. *ssociated findings may include


24/54

hyperhidrosis, a gradual increase in the number and si6e of the lesions, and

rapid progression during pregnancy.

o Histologic features include focal hyperkeratosis, but no decrease or

fragmentation of dermal elastic fibers is reported.

o $opical treatments have been unsuccessful, although oral retinoids have been

partially effective in long+term treatment.

Punctate PP' 7ith associated eatures


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o *crokeratosis paraneoplastica of :a6e3 is associated #ith suamous cell

carcinoma of the upper gastrointestinal tract. $he condition affects #hite men

aged 1! years and older. Psoriasiform changes of the fingers and the toes #ith

nail dystrophy e3tend to involve the palms, soles, limbs, and trunk. $he

paraneoplastic nature of the condition is supported by a tendency for both the

time course and the skin involvement to parallel the e3tent of tumor. $he skinmay clear #ith the removal of the tumor, but relapses occur #ith tumor

regro#th and cervical metastasis. *lso see *crokeratosis ?eoplastica.

o $ripe palms (acanthosis palmaris) is a distinct cutaneous paraneoplastic

syndrome most often associated #ith malignancy of the stomach or lung. $he

palms are diffusely thickened, #ith a velvety te3ture and ridged appearance.

alignant tripe palms persists, #ith less than one third of patients responding

to tumor therapy. $ripe palms is also associated #ith bullous pemphigoid,

psoriasis, and e3foliative dermatitis.

PP; due to inflammatory and reactive dermatoses

o Chronic hand dermatitis is characteri6ed by marked irritation, scaling, and

fissuring. Causes may include atopic dermatitis, irritant contact dermatitis, or

allergic contact dermatitis.

o Psoriasis may manifest as diffuse hyperkeratosis or as scaly plaues #ith a

scalloped margin.

o ;eratoderma blennorrhagica (


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o Histologically, the epidermis and dermis may be normal or mild

orthohyperkeratosis, hypergranulosis, acanthosis, or dilated eccrine ostia may

develop.

o $reatment includes 0!4 aluminum chloride he3ahydrate, #hich has sho#n

significant clinical improvement in signs and symptoms. >ther options include04 ammonium lactate cream, 0!4 acid salicylic in petroleum Delly, !4

urea cream, and botulinum to3in inDections.

PP; caused by infections

o 9ermatophytes manifest as hyperkeratosis affecting the soles, toe #ebs, and

sides of the feet. Hyperhidrosis increases itching and malodor.

o Human papillomavirus may form confluent e3uberant masses on the palms

and the soles, mimicking keratoderma.

o Ayphilis may manifest as a diffuse, symmetric keratoderma or papular PP;.

o %eprosy can manifest as glove+and+stocking anesthesia, predisposing patients

to infection, ulceration, and hyperkeratosis. $uberculosis, especially miliary

tuberculosis, may cause hyperkeratosis of the palms and soles.

o Bncrusted scabies may progress into strikingly hyperkeratotic andIor crusted

lesions on palmar surfaces.

9rug+related PP;

o Chronic arsenic e3posure can lead to multiple, irregular, #arty keratotic

lesions on the palms and soles. >nset of the keratoses may occur !+! yearsafter ingestion

o 9rug hypersensitivity may result from agents such as glucan, verapamil,

uinacrine, etodolac, mepacrine, proguanil, me3iletine, methyldopa, lithium,

venlafa3ine, gold, tegafur, fluorouracil, bleomycin, hydro3yurea, practolol,

and do3orubicin.

o PP; may rarely occur as an adverse reaction to the influen6a vaccine. &/'

Aystemic diseaseJassociated PP;

o y3edema is associated #ith distinctive features that include its response to

treatment and the severity and verrucosity of the hyperkeratosis, #ith diffuse

involvement of the plantar surface and more limited involvement of the palms.

$he mechanism is unclear" ho#ever, it has been postulated that inhibition of

carotene conversion to vitamin * by thyro3ine deficiency may cause

hyperkeratosis. ild relief is achieved #ith thyroid hormone replacement.

o 9iabetes mellitus features include discrete plantar keratosis under the

metatarsal arch and the great toe.

o Chronic lymphedema and other circulatory disorders such as acrocyanosis and

livedo reticularis have been associated #ith keratoderma.


27/54

o Cutaneous $+cell lymphoma features diffuse hyperkeratosis accompanied by

subungual hyperkeratosis and nail dystrophy, #hich is typical of AO6ary

syndrome.

o 9iets lacking protein energy and vitamin deficiency have been implicated in

PP; #ith associated fissuring.

Syndromes ,ith PP' as an Associated Feature

:asal cell nevus syndrome

:ullous congential ichthyosiform erythroderma

Cantu syndrome + Hyperkeratosis+hyperpigmentation syndrome

Cerebral dysgenesis, neuropathy, ichthyosis, and keratoderma (CB9?5;) syndrome

Cole disease + uttate hypopigmentation and punctate PP;

Congenital nonbullous ichthyosiform erythroderma

9arier disease

Bctodermal dysplasia #ith skin fragility

Bpidermodysplasia verruciformis

Bpidermolysis bullosa herpetiformis (9o#ling+eara type)

Brythrokeratoderma variabilis 7amilial pityriasis rubra pilaris

Hystri3like ichthyosis+deafness (H59) syndrome

5chthyosis hystri3 of Curth+acklin

5chthyosis vulgaris

5ncontinentia pigmenti

;eratitis, ichthyosis, and deafness (;59) syndrome

%amellar ichthyosis

Progressive symmetric erythrokeratoderma

AchNpf+Achul6+Passarge syndrome + PP; #ith hidrocystomas, hypodontia and

hypotrichosis

ADNgren+%arsson syndrome

$reatment 8 Management


28/54

$reatment of all types of hereditary and nonhereditary keratodermas is difficult. $he most

common therapeutic options only result in short+term improvement and are freuently

compounded by unacceptable adverse effects. $reatment tends to be symptomatic and may

vary from simple measures (eg, salt#ater soaks, paring) to topical keratolytics, systemic

retinoids, or reconstructive surgery #ith total e3cision of the hyperkeratotic skin follo#ed by

grafting. $he mainstays of treatment include the follo#ing8

$opical keratolytics (eg, salicylic acid /4, lactic acid !4, urea !+1!4) are useful in

patients #ith limited keratoderma.

$opical retinoids (eg, tretinoin) are effective, but treatment is often limited by skin

irritation.

Consider potent topical steroids #ith or #ithout keratolytics in dermatoses #ith an

inflammatory component.

>ral retinoids are effective, especially in some hereditary PP;s such as mal de

eleda, Papillon+%efLvre syndrome, and erythrokeratoderma variabilis. osthereditary PP;s reuire long+term treatment.


29/54

olluscum contagiosum virus causes a benign viral infection that is largely (if not

e3clusively) a disease of humans. olluscum contagiosum virus causes characteristic skin

lesions consisting of single or, more often, multiple, rounded, dome+shaped, pink, #a3y

papules that are 0+/ mm (rarely up to ./ cm in the case of a giant molluscus) in diameter.

$he papules are umbilicated and contain a caseous plug. Aee the images belo# for e3amples.

(Aee Presentation and Workup.)

?ote the central umbilication in these classic lesions of

molluscum contagiosum. *ppro3imately !4 of patients

develop ec6ema around lesions. Bc6ema associated #ith molluscum lesions spontaneously

subsides follo#ing removal. %arger lesions may have several

clumps of molluscum bodies rather than the more common single central umbilication. $his
http://refimgshow%284%29/http://refimgshow%282%29/http://refimgshow%281%29/


30/54

may make them difficult to recogni6e as molluscum contagiosum.

olluscum contagiosum on the right a3illa.

olluscum contagiosum virus is an unclassified member of the Po3viridae family. 5t cannot

be gro#n in tissue culture or eggs" it has been gro#n in human foreskin grafted to athymic

mice but has not been transmitted to other laboratory animals. (Aee Btiology.)

$hrough restrictive endonuclease analysis of the genomes of isolates, molluscum

contagiosum virus types 5+5V have been identified. 5n a study of 12 patients, molluscum

contagiosum virus 5 caused @.4 of infections, and molluscum contagiosum virus 55 caused

.14" ho#ever, no relationship #as observed bet#een virus type and lesional morphology or

anatomical distribution.&' olluscum contagiosum viruses 555 and 5V are rare. 5n patients #ith

human immunodeficiency virus(H5V) infection, molluscum contagiosum virus 55 causes

most infections (!4).

:ateman first described the disease in -2, and Paterson demonstrated its infectious nature

in -1. 5n @!/, Kuliusburg proved its viral nature. 5nfection follo#s contact #ith infectedpersons or contaminated obDects, but the e3tent of epidermal inDury necessary is unkno#n.

%esions may spread by autoinoculation.

!omplications

Complications of molluscum contagiosum include irritation, inflammation, and secondary

infections. %esions on eyelids may be associated #ith follicular or papillary conDunctivitis.

:acterial superinfection may occur but is seldom of clinical significance. (Aee Prognosis,

$reatment, and edication.)

Cellulitis is an unusual complication of molluscum contagiosum in patients #ho are H5Vinfected.&0' Aecondary infection #ith Staphylococcus aureushas resulted in abscess formation,

#hereasPseudomonas aeruginosacan cause necroti6ing cellulitis.

Etiology

$ransmission

$he molluscum contagiosum virus may be inoculated along a line of minor skin trauma (eg,

from shaving), resulting in lesions arranged in a linear pattern (see the image belo#). $his

process, termed autoinoculation, can also result from manipulation of lesions by the patient.*utoinoculation is different from the ;oebner phenomenon, #hich is also called an
http://emedicine.medscape.com/article/211316-overviewhttp://refimgshow%2812%29/http://emedicine.medscape.com/article/211316-overview


31/54

isomorphic response. 5n the ;oebner phenomenon, ne# lesions develop along a line of

trauma and the etiology of the underlying condition is unkno#n. Psoriasis and lichen planus

are e3amples of skin conditions that commonly koebneri6e.

5n a patient #ho had pree3isting molluscum contagiosum, the

virus #as inoculated along a line of minor skin trauma, resulting in the development of the

ne# lesions.

olluscum contagiosum virus transmission through direct skin contact bet#een childrensharing a bath and bet#een athletes sharing gymnasium euipment and benches has been

reported. *n association bet#een school s#imming pool use and molluscum contagiosum

infection has also been reported.&, 1'

$hree distinct disease patterns are observed in different patient populations8 children, adults

#ho are immunocompetent, and patients #ho are immunocompromised (children or adults).

$he prognosis and therapy are different for each of these groups.

olluscum contagiosum is most common in children #ho become infected through direct

skin+to+skin contact or indirect skin contact #ith fomites, such as bath to#els, sponges, and

gymnasium euipment. %esions typically occur on the chest, arms, trunk, legs, and face.Hundreds of lesions may develop in intertriginous areas, such as the a3illae and intercrural

region (see the image belo#). %esions may rarely occur on the mucous membranes of the lip,

tongue, and buccal mucosa. $he palms are spared. Patients #ith atopic dermatitis may

develop large numbers of lesions.

olluscum lesions may become uite numerous in intertriginous areas.

$his child has autoinoculated lesions to both inner thighs.

5n adults, molluscum contagiosum most commonly is a se3ually transmitted disease (A$9).

Healthy adults tend to have fe# lesions, #hich are limited to the perineum, genitalia, lo#er

abdomen, or buttocks. olluscum contagiosum in healthy children and adults is usually aself+limited disease.


32/54

Widespread, persistent, and atypical molluscum contagiosum may occur in patients #ho are

significantly immunocompromised or have acuired immunodeficiency syndrome (*59A)

#ith lo# C91 $+lymphocyte counts (see the images belo#). olluscum contagiosum may be

the presenting complaint in patients #ith *59A. olluscum contagiosum virus infection in

immunocompromised patients may be particularly resistant to therapy. >ther opportunistic

infections in these patients may closely resemble molluscum contagiosum.

olluscum contagiosum rarely occurs on the face in an adult

unless the patient is infected #ith H5V. When molluscum contagiosum occurs in individuals

infected #ith H5V, facial lesions are common and freuently numerous.

olluscum contagiosum lesions in individuals infected #ith

H5V may number in the hundreds. 5n addition, they may become uite large and prominent.

ultiple papules on the face of a man #ith H5V.

Case reports have detailed molluscum contagiosum eruptions in areas that #ere treated #ith

tacrolimus !.4 (Protopic).&/, , 2'

Inection

$he molluscum contagiosum virus replicates in the cytoplasm of epithelial cells, producing

cytoplasmic inclusions and enlargement of infected cells. $his virus infects only the

epidermis. 5nfection follo#s contact #ith infected persons or contaminated obDects, but the

e3tent of necessary epidermal inDury is unkno#n. $he initial infection seems to occur in the

basal layer, and the incubation period is usually 0+2 #eeks. $his is suggested by the fact that,

although viral particles are noted in the basal layer, viral deo3yribonucleic acid (9?*)

replication and the formation of ne# viral particles do not occur until the spindle and granular


33/54

layers of the epidermis are involved. 5nfection may be accompanied by a latent period of as

long as months.

7ollo#ing infection, cellular proliferation produces lobulated epidermal gro#ths that

compress epidermal papillae, #hile fibrous septa bet#een the lobules produce pear+shaped

clumps #ith the ape3 up#ards. $he basal layer remains intact.

Cells at the core of the lesion sho# the greatest distortion and are ultimately destroyed,

resulting in large hyaline bodies (ie, molluscum bodies, Henderson+Paterson bodies)

containing cytoplasmic masses of virus material. $hese bodies are present in large numbers

and appear as a #hite depression at the center of fully developed lesions. >ccasionally, the

lesions can progress beyond local cellular proliferation and become inflamed #ith attendant

edema, increased vascularity, and infiltration by neutrophils, lymphocytes, and monocytes.

*s #ith other po3viruses, molluscum contagiosum virus does not appear to develop latency

but evades the immune system through the production of virus+specific proteins. Cell+

mediated immunity is most important in modulating and controlling the infection. Childrenand patients #ith H5V infection generally have more #idespread lesions. Prevalence of

molluscum contagiosum virus in patients #ith H5V may be as high as /+-4, and the severity

of infection is inversely related to the C91 $+lymphocyte count. ore e3tensive and resistant

infections also are noted in patients receiving prednisone and methotre3ate.

$he virus is not strongly immunogenic, as it infreuently induces antibody formation.

Apecific antibodies have been found in appro3imately -!4 of patients and in about /4 of

control subDects. * role for humoral immunity in regression of lesions is not established.


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$he primary structure and coding capacity of molluscum contagiosum virus #as determined

by Aenkevich et al.&-' *nalysis of the molluscum contagiosum virus genome has revealed that

it encodes appro3imately -0 proteins, !/ of #hich have direct counterparts in

orthopo3viruses.


35/54

to differences in access to medical care, other socioeconomic factors, or genetic

predisposition is unclear.&0'

Aeveral studies have sho#n that males are affected by molluscum contagiosum more

commonly than are females. 9ata from A$9 clinics in Bngland and Wales revealed that more

than t#ice as many men as #omen #ere diagnosed #ith the infection.

Age3related demographics

olluscum contagiosum is rare in children younger than age year, perhaps because of

maternally transmitted immunity and a long incubation period" other#ise, incidence seems to

reflect e3posure to others. $he greatest incidence is in children younger than age / years and

in young adults. $he peak among the pediatric age group correlates #ith casual contact,

#hereas the peak in young adults correlates #ith se3ual contact. &, 1'

Apread of the virus among households is common in #arm climate countries #here children

are lightly dressed and in close contact #ith one another and #here personal hygiene may be

poor. $he age of peak incidence is reported to be 0+ years in 7iDi and +1 years in the Congo

(formerly Saire). 5n ?e# uinea, the annual infection rate for children younger than age !

years #as found to be 4.

5n cooler climates, spread #ithin households is less common, and infection is more common

at a later age. Fse of school s#imming pools is correlated #ith childhood infections, #ith a

peak incidence in children aged !+0 years in Acotland and - years in Kapan. Prevalence

appears to be increasing in all age groups.

Prognosis

$he prognosis in molluscum contagiosum is generally e3cellent because the disease is usually

benign and self+limited. Apontaneous resolution generally occurs by - months in

immunocompetent individuals" ho#ever, lesions have been reported to persist for as long as /

years. 5n healthy patients, treatments are usually effective, although lesions can be disfiguring

and may produce an3iety in the patient, family, and daycare facility or school.


36/54

immunocompromised patients because they tend to have more lesions and more #idespread

infection. ost lesions resolve #ith no permanent residual skin defect" ho#ever, occasional

lesions may produce a slightly depressed scar. $his may represent deeper skin damage in

lesions that #ere particularly inflammatory or secondarily infected. 5nvolvement of the

margin of the eyelids may produce keratoconDunctivitis. ?o mortality has been associated

directly #ith the molluscum contagiosum virus.

Patient Education

:efore attempting any therapy, educate the patient or parents in+depth about the diagnosis,

prognosis, risk of autoinoculation or infection of others, therapeutic options, and risks of

therapy.&/, ' ore than treatment session is freuently reuired. Providing this information

at the first clinical visit is particularly important #hen treating benign lesions, such as those

of molluscum contagiosum and common #arts. * fe# e3tra minutes of e3planation at this

stage can prevent or mitigate numerous problems and uestions during later visits. &2'

When lesions fail to respond to initial therapy, a temptation to be over6ealous in treatment

may occur. Patients and families are more understanding and less likely to demand aggressive

therapy #hen reasonable goals and limitations of therapy are thoroughly discussed.

Atress the benign nature of this ubiuitous disease to the patient and his or her parents.

%imiting physical contact #ith infected areas of skin and good hand#ashing may reduce

transmission. 5nstruct the patient to avoid scratching, #hich may result in autoinoculation.

;eeping children out of school is not necessary" ho#ever, discourage physical contact and

sharing of clothes and to#els. 5n smaller children in #hom physical contact is more difficult

to prevent, keeping infected areas covered #ith clothing is reasonable. Cover e3posed lesions#ith tape or an adhesive bandage. 5nfection of other children cannot be completely prevented.

:ecause the disease is e3tremely common and of very little clinical significance, the decision

to limit infected children from daycare centers must be approached on a case+by+case basis.

5n adolescent and adult patient populations, this disease is usually se3ually transmitted.

Bncourage safe se3 and abstinence" ho#ever, #hether condoms and other barrier methods

provide adeuate protection against transmission is unclear.

Bmphasi6e that not all A$9s are as benign as molluscum contagiosum virus (eg, herpes

simple3, gonorrhea, chlamydia, H5V). Atress adherence to abstinence until lesions resolve. 5n

the patient #ith multiple se3ual partners or other risk factors, H5V testing is stronglyrecommended. ?ote that not all cases in adults are se3ually transmitted. $his diagnosis can

cause significant relationship stress.

7or patient education information, see theAkin Conditions and :eauty Center, as #ell as

olluscum Contagiosum.

istory

olluscum contagiosum is usually asymptomatic" ho#ever, individual lesions may be tender

or pruritic. 5n general, the patient does not e3perience systemic symptoms, such as fever,nausea, or malaise.
http://www.emedicinehealth.com/collections/SU306.asphttp://www.emedicinehealth.com/collections/SU306.asphttp://www.emedicinehealth.com/Articles/17423-1.asphttp://www.emedicinehealth.com/collections/SU306.asphttp://www.emedicinehealth.com/Articles/17423-1.asp


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$he patient may recall contact #ith an infected se3ual partner, family member, or other

person. Patients #ho report having multiple se3ual partners or unprotected se3 have an

increased risk of infection. Contact may be reported in children sharing a bath or in athletes

sharing gymnasium euipment and benches. Parents may report recent e3posure to other

children affected #ith molluscum contagiosum at school, camp, or public recreational

facilities (eg, gymnasiums, s#imming pools).

5f the patient has skin conditions that disrupt the epidermal layer, molluscum tends to spread

more rapidly.

$he patient may notice ne# lesions developing along a scratch in areas of involved skin.

Patients #ith atopic dermatitis may have more e3tensive disease and may have a positive

family history of atopy (eg, ec6ema, asthma, hayfever). Children freuently have active

atopic dermatitis.

* report detailed an eruption of molluscum contagiosum in a patient #ho had undergone a

renal transplant.&-' Case reports have detailed molluscum contagiosum eruptions in areas that#ere treated #ith tacrolimus !.4 (Protopic).&/, , 2'

9uration of the individual lesion and of the attack varies. *lthough most cases resolve

#ithout therapy #ithin +@ months, some persist for +1 years. 5ndividual lesions seldom

persist more than 0 months.

Patients #ith H5V or those receiving prednisone, methotre3ate, or other immunosuppressive

medications may have more e3tensive and resistant infections.

Patients inected 7ith I9

Patients generally have a lo# C91 count, #ith the severity of infection being inversely

related to the count.

Patients #ho are poorly compliant or noncompliant #ith highly active antiretroviral therapy

(H**


38/54

Presented here are the classic umbilicated papules of molluscum

contagiosum lesions on the cheek of a child. 7acial lesions occur freuently in children,

although lesions generally are fe#.

%esions are usually 0+/ mm (rarely up to ./ cm in the case of giant molluscus) in diameter

and may be present in groups or #idely disseminated. 5mmunocompetent children and adults

usually have fe#er than 0! lesions. %arger lesions may have several distinct clumps ofmolluscum bodies (see the image belo#). :eneath the umbilicated center is a #hite, curdlike

core that contains molluscum bodies. Aome lesions become confluent to form a plaue

(agminate form).

%arger lesions may have several clumps of molluscum bodies

rather than the more common single central umbilication. $his may make them difficult to

recogni6e as molluscum contagiosum.

%esions may be located any#here" ho#ever, a predilection for the face, trunk, and e3tremities

is observed in children and a predilection for the groin and genitalia is observed in adults.

%esions are seldom found on the palms and are rarely documented on the soles, oral mucosa,

or conDunctiva.

9istribution is influenced by the mode of infection, type of clothing #orn, and climate. 5n

se3ually active individuals, the lesions may be confined to the penis, pubis, and inner thighs

(see the image belo#). Widespread and persistent molluscum contagiosum may occur in

patients #ith *59A and may be the presenting complaint.


39/54

olluscum contagiosum on the shaft of the penis. olluscum

contagiosum in the genital region of adults is most commonly acuired as a se3ually

transmitted disease.

olluscum contagiosum may be randomly associated #ith other lesions, such as epidermal

cysts, nevocellular nevi, sebaceous hyperplasias, and ;aposi sarcoma. Pseudocystic

molluscum contagiosum, giant molluscum contagiosum, and molluscum contagiosumassociated #ith other lesions are responsible for freuent clinical misdiagnosis.

>ther characteristics of molluscum contagiosum to consider include the follo#ing8

5ntertriginous areas + Hundreds of lesions may develop in intertriginous areas, such as

the a3illae and intercrural region

*topic dermatitis + Patients #ith atopic dermatitis occasionally develop large numbers

of lesions, #hich are confined to areas of lichenified skin

Bc6ema + *ppro3imately !4 of patients develop ec6ema around the lesions, #ith

this being attributed to to3ic substances produced by the virus or to a hypersensitivity

reaction to the virus" ec6ema that is associated #ith molluscum lesions subsides

spontaneously follo#ing removal (see the first image belo#)

5nflammatory changes + $hese result in suppuration, crusting, and eventual resolution

of the lesion" this inflammatory stage does not usually represent secondary infection

and seldom reuires antibiotic therapy (see the second image belo#)

*ppro3imately !4 of patients develop ec6ema

around lesions. Bc6ema associated #ith molluscum lesions spontaneously subsides


40/54

follo#ing removal. *fter trauma, or spontaneously after

several months, inflammatory changes result in suppuration, crusting and eventual

resolution of the lesion. $his inflammatory stage does not usually represent secondary

infection and seldom reuires antibiotic therapy.

9isfiguring lesions may occur in patients #ith the follo#ing conditions8

*59A + 7acial and perioral molluscum contagiosum are most commonly observed as a

manifestation of H5V infection, particularly in homose3ual men #ith H5V&@' " at the

time of molluscum contagiosum diagnosis, the C91 count is lo#

5mmunocompromise + %esions are especially common and e3tensive on the face and

neck

Aarcoidosis

%ymphocytic leukemia

Congenital immunodeficiency

Aelective immunoglobulin (5g) deficiency

$hymoma

$reatment #ith prednisone and methotre3ate

9isseminated malignancy


41/54

$his lesion of cutaneous coccidioidomycosis could be

included among the differential diagnoses of molluscum contagiosum.

$his keratoacanthoma could be included among the

differential diagnoses of molluscum contagiosum.

olluscum contagiosum may be randomly associated #ith other lesions, such as epidermal

cysts, nevocellular nevi, sebaceous hyperplasias, and ;aposi sarcoma. Pseudocystic

molluscum contagiosum, giant molluscum contagiosum, and molluscum contagiosum

associated #ith other lesions are responsible for freuent clinical misdiagnoses.

5nfection of children through se3ual abuse is possible" ho#ever, to a greater e3tent than

#arts, molluscum contagiosum virus is uite common on the genital, perineal, andsurrounding skin of children.&0!, 0'


42/54

Perforating disorders (all very rare in children) to consider in the differential diagnosis of

molluscum contagiosum include the follo#ing8

*cuired reactive perforating dermatosis of renal failure

;yrle disease

Perforating serpiginous elastoma

Perforating folliculitis

Verrucous perforating collagenoma

Perforating granuloma annulare

9ifferential diagnoses to consider in patients #ith *59A include the follo#ing8

Cutaneous cryptococcus&00' + Cutaneous cryptococcus presents as molluscumlike

eruptions (on the face, it often has a very dramatic appearance)" the patient may have

fe# or no other symptoms associated #ith cryptococcal meningitis

Cutaneous coccidioidomycosis

Cutaneous histoplasmosis

Cutaneous aspergillosis

.ierential .iagnoses

:asal Cell Carcinoma Condyloma *cuminatum

Cryptococcosis

;eratosis Pilaris

ilia

Pearly Penile Papules

Pyogenic ranuloma

Aurgical $reatment of :asal Cell Carcinoma

Varicella+Soster Virus

Approach !onsiderations

5n most instances, a diagnosis is easily established because of the distinctive, central

umbilication of the dome+shaped lesion. Pseudocystic molluscum contagiosum, giant

molluscum contagiosum, and molluscum contagiosum associated #ith other lesions

may be more difficult to diagnose clinically.
http://emedicine.medscape.com/article/276624-overviewhttp://emedicine.medscape.com/article/264368-overviewhttp://emedicine.medscape.com/article/215354-overviewhttp://emedicine.medscape.com/article/910223-overviewhttp://emedicine.medscape.com/article/910405-overviewhttp://emedicine.medscape.com/article/1058826-overviewhttp://emedicine.medscape.com/article/910112-overviewhttp://emedicine.medscape.com/article/277783-overviewhttp://emedicine.medscape.com/article/231927-overviewhttp://emedicine.medscape.com/article/276624-overviewhttp://emedicine.medscape.com/article/264368-overviewhttp://emedicine.medscape.com/article/215354-overviewhttp://emedicine.medscape.com/article/910223-overviewhttp://emedicine.medscape.com/article/910405-overviewhttp://emedicine.medscape.com/article/1058826-overviewhttp://emedicine.medscape.com/article/910112-overviewhttp://emedicine.medscape.com/article/277783-overviewhttp://emedicine.medscape.com/article/231927-overview


43/54

5f diagnosis is uncertain, lesions may be biopsied. Characteristic intracytoplasmic

inclusion bodies (molluscum bodies, or Henderson+Paterson bodies) are seen on

histologic e3amination findings.

B3press the pasty core of a lesion by crushing the lesion bet#een 0 microscope slides

and staining it to reveal the particulate virions, #hich are present in abundance. 7irmcompression bet#een the slides is reuired to release the virions #ith the stain in

place. $he use of crystal violet, safranin, and ammonium o3alate in !4 ethanol" the

Papanicolaou test" or Wright, iemsa, or ram stains can reveal the virions that make

up the Henderson+Paterson bodies.

easure serum antibodies by complement fi3ation, tissue culture neutrali6ation,

fluorescent antibody, and gel agar diffusion techniues" ho#ever, they are not #ell

standardi6ed and are seldom used e3cept in research protocols.

Polymerase chain reaction (PC


44/54

image. %o#+po#er histopathologic e3amination

reveals an overall cup+shaped appearance.

Within the region of the indentation, the epidermis appears thickened (acanthosis),

possibly measuring up to times the thickness of the surrounding, uninvolved skin,

and the cornified layer typically is disintegrated. $he striking feature is the presence

of intracytoplasmic, eosinophilic, granular inclusions #ithin the keratinocytes of the

basal, spinous, and granular layers of the epidermis.

$hese inclusions, the Henderson+Paterson bodies, can measure /Um in diameter.

Fltrastructural studies have sho#n that these bodies are membrane+bound sacs that

contain numerous molluscum contagiosum virions. $he viral particles increase in si6e

as they progress up to#ard the granular layer, causing compression of the nucleus to

the periphery of the infected keratinocytes. $he surrounding dermis is relatively

unremarkable. 5ntact lesions sho# little or no inflammatory change. (Aee the images

belo#.)

$his is a medium+po#er vie# of a molluscum

contagiosum lesion. agnification allo#s better demonstration of the

intracytoplasmic molluscum bodies (staining purple+pink) #ithin the keratinocytes.

%esions of molluscum contagiosum have a

characteristic histopathology. %obules containing hyalini6ed molluscum bodies, also


45/54

kno#n as Henderson+Paterson bodies, are diagnostic.

$his molluscum contagiosum body is an intracytoplasmic inclusion body. ?otice in

the image that the keratinocyte nuclei are displaced to the periphery of the cell and

that the intracytoplasmic inclusions have a granular uality.

Cytoplasmic viral inclusions become progressively

larger to#ard the epidermal surface (hemato3ylin and eosin, 0!!Q)

Viral particles have a dumbbell+shaped appearance.Courtesy of *lvin Selickson, 9.

5n nonprototypical cases of molluscum contagiosum, in #hich intradermal rupture of

molluscum bodies occurs, an intense, inflammatory dermal infiltrate consisting of

lymphocytes, histiocytes, and occasional foreign bodyJtype, multinucleated giant

cells may be observed.


46/54

$herapeutic options for molluscum contagiosum can be divided into broad categories,

including the follo#ing8

:enign neglect

9irect lesional trauma

*ntiviral therapy

5mmune response stimulation

!hoice o therapy

$he most appropriate therapeutic approach largely depends on the clinical situation. 5n

healthy children, a maDor goal is to limit discomfort, and benign neglect or minor, direct

lesional trauma is appropriate. 5n adults #ho are more motivated to have their lesions treated,

cryotherapy or curettage of individual lesions is effective and #ell tolerated.

5n immunocompromised individuals, molluscum contagiosum may be very e3tensive and

difficult to treat. $he goal may be to treat the most troublesome lesions only. 5n severe cases,

these patients may #arrant more aggressive therapy #ith lasers, imiuimod, antiviral therapy,

or a combination of these. >f course, effective antiretroviral therapy in patients #ith *59A

makes therapy of molluscum contagiosum much more effective.

$he FA 7ood and 9rug *dministration (79*) has approved none of the topical or

intralesional agents for treatment of molluscum contagiosum.

5n a study of the treatment of molluscum contagiosum in children, Hanna et al determined

that curettage #as the most efficacious therapy. $he investigators conducted a prospective,randomi6ed trial that compared the efficacy and adverse effects of 1 recogni6ed treatments of

molluscum contagiosum in 01 children.&0/' >ne group #as treated #ith curettage, a second

#ith cantharidin, a third #ith a combination of salicylic acid and lactic acid, and a fourth #ith

imiuimod.

Curettage #as found to be the most efficacious treatment and had the lo#est rate of side

effects. Ho#ever, it must be performed #ith adeuate anesthesia and is a time+consuming

procedure. Cantharidin had moderate complications due to blisters and #as slightly less

effective. $he topical keratolytic used #as too irritating for children. $opical imiuimod #as

more effective than cantharidin but is e3pensive, and an optimum treatment schedule has yet

to be reported.

Follo73up


47/54

.eterrence and pre&ention

ost cases in adolescents and adults are secondary to se3ual contact. *bstinence and careful

selection of se3ual partners are important. Whether condoms are effective in preventing

spread is unclear. ood personal hygiene is important in limiting transmission.

*utoinoculation may result from trauma, such as shaving or the manipulation of lesions bythe patient.

Pharmacologic $herapy

Clinical success has been reported #ith the use of the follo#ing topical agents, #hich may act

as irritants, stimulating an immunologic response8

5miuimod cream + *n immune response modifier approved for the treatment of

e3ternal genital and perianal #arts in adults, imiuimod cream has been reported to be

effective in the treatment of molluscum contagiosum&0, 02'

" imiuimod cream may beused in conDunction #ith cantharidin&0-'

Cantharidin + Aeveral studies report that cantharidin, a chemovesicant that can be used

in combination #ith imiuimod, is effective in treating molluscum contagiosum" to

test the patient=s response to therapy, treat only a fe# lesions on the initial visit &0-'

$retinoin + $his agent has reportedly been successful in the treatment of small

molluscum contagiosum lesions

:ichloracetic acid

$richloroacetic acid

Aalicylic acid

%actic acid

lycolic acid

Ailver nitrate

$retinoin, cantharidin, and imiuimod may be dispensed to the patient #ith application

instructions and close follo#+up, although some recommend application in the office.

:ichloracetic acid, trichloroacetic acid, salicylic acid, lactic acid, glycolic acid, and silvernitrate must be applied in the office by the physician.

$opical podophylloto3in !./4 cream self+administered t#ice daily for #eeks has been

reported effective in a placebo+controlled, double+blind study.&0@'


48/54

Benign ;eglect

%eaving mollusca to spontaneously resolve is often reasonable,&' especially in young

children for #hom free6ing or curettage may be painful and frightening. $he dictumprimum

non nocere(first do no harm) has a special significance in children #ith minor, self+limited

conditions. any physicians refuse to treat children #ith small numbers of mollusca.

%esions on the eyelids

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