Skin Infections

European Guideline Offers Recommendations on the Diagnosis, Management of Genital Molluscum Contagiosum

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November 19, 2020

Molluscum contagiosum occurs in approximately 5% to 18% of HIV-infected people, but is becoming rare in areas of the world with good access to highly effective antiretroviral therapies (HAART).16 It is caused by an infection of the epidermal keratinocytes by the molluscum contagiosum virus, a double-stranded DNA virus belonging to the Poxviridae family.16,17 Patients present with small (≤5 mm in diameter), raised lesions that are usually white, pink, or flesh colored with a dimple or pit in the center.17 The lesions are typically smooth, firm, and pearly appearing, and can affect any area of the body, although they are rarely found on the palms or soles. They may occur as solitary lesions or in groups and typically resolve within 6 to 12 months without any scarring.17 Genital lesions may take longer to resolve, and healing times up to 4 years have been reported.16,17 Photo Credit: Medical Images RM/AL LAMME. — Molluscum contagiosum occurs in approximately 5% to 18% of HIV-infected people, but is becoming rare in areas of the world with good access to highly effective antiretroviral therapies (HAART).¹⁶ It is caused by an infection of the epidermal keratinocytes by the molluscum contagiosum virus, a double-stranded DNA virus belonging to the Poxviridae family.^16,17

Patients present with small (≤5 mm in diameter), raised lesions that are usually white, pink, or flesh colored with a dimple or pit in the center.¹⁷ The lesions are typically smooth, firm, and pearly appearing, and can affect any area of the body, although they are rarely found on the palms or soles. They may occur as solitary lesions or in groups and typically resolve within 6 to 12 months without any scarring.¹⁷ Genital lesions may take longer to resolve, and healing times up to 4 years have been reported.^16,17

Photo Credit: Medical Images RM/AL LAMME.

A new European guideline on the management of sexually transmitted genital molluscum contagiosum offers recommendations on facilitating diagnosis, initiating physical and topical treatments, and managing patients with immunosuppression. The guideline was published in the Journal of the European Academy of Dermatology and Venereology.

To form this guideline, a panel of dermatology experts across Europe convened to review existing data from the British Association for Sexual Health and HIV guideline (2014) as well as the Centers for Disease Control and Prevention recommendations (2015). An additional comprehensive literature search of publications from 1980 to 2019 was also conducted.

Recommendations on Diagnosis

Although the diagnosis of molluscum contagiosum is typically performed on clinical grounds, the panel suggests that dermoscopy and in vivo confocal microscopy may facilitate diagnosis and help exclude differentials.

Skin lesions that mimic the disorder in patients without immunosuppression include genital warts and flat warts, lichen planus, lichen nitidus, dermal cyst, basal cell carcinoma, and amelanotic melanoma, among others. In patients who are immunocompromised, opportunistic skin infections such as penicilliosis and coccidioidomycosis may resemble molluscum contagiosum lesions.

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Dermoscopy in particularly offers greater sensitivity than visual inspection for identifying orifices, vessels, and certain vascular patterns. This technique may be especially helpful for “clinically difficult cases,” such as those featuring small lesions and inflammation or perilesional inflammation.

Histological examination, polymerase chain reaction, or electron microscopy may also be helpful for identifying “unclear” cases of molluscum contagiosum, according to the guideline.

Recommendations on Treatment Options

The guideline recommends that clinicians ensure immunocompetent patients who are otherwise well understand that their condition is a viral skin infection that is relatively benign and should resolve spontaneously in 6 to 12 months.

Patients should also be made aware that molluscum contagiosum is contagious. The patient should not share bedding or towels during the recovery process, and lesions should be completely covered. Clinicians should also advise against waxing and shaving the affected area.

The use of active treatment against molluscum contagiosum, although effective, should be weighed against the potential side effects of therapy. Physical treatments for the disorder include liquid nitrogen cryotherapy, cautery, and curettage. However, robust formal studies for curettage and cryotherapy are lacking.

In terms of topical chemical therapy, podophyllotoxin is a promising option. This treatment is applied to the lesions by the patient twice per day for 3 consecutive days followed by a 4-day break. The regimen should be repeated until the lesions are cleared. Additional topical chemical therapies for non-genital molluscum that lack consistent evidence for genital infection include potassium hydroxide, silver nitrate, glycolic acids, and benzoyl peroxide.

Diphencyprone, imiquimod cream, intralesional or systemic interferon, oral cimetidine, and intralesional immunotherapy with candida antigen are other treatments that can stimulate an immune response to the molluscum virus. Evidence to support the use of these agents in molluscum contagiosum is poor in quality.

Dupilumab was associated with clearance of recalcitrant molluscum contagiosum in a series of 4 patients with severe atopic eczema, but more studies are needed to develop a firm recommendation for the use of this drug in patients with molluscum contagiosum.

Recommendations on the Management of Patients Who Are Pregnant

Physical destructive methods, such as cryotherapy, are safe and recommended for women who are pregnant and have genital molluscum contagiosum. Conversely, imiquimod and podophyllotoxin are not advised for women who are pregnant or breastfeeding. Pregnant women should be counseled about the risk for vertical transmission, the guideline states.

Recommendations on the Management of Patients With Immunosuppression

In patients with immunosuppression, including patients living with HIV, spontaneous clearance of molluscum contagiosum lesions is unlikely. The guideline authors indicate that some studies have found that lesions can resolve with antiretroviral therapy. The use of topical and intravenous cidofovir in these patients has been reported in some case series but not for lesions located in the genital site.

Prevention Recommendations

The guideline also emphasizes the importance of prevention. Patients should understand the risk for transmission via sexual contact throughout treatment and during remission of the lesions. Although condom use may be helpful for reducing transmission, the evidence to support this prevention method varies considerably.

In addition, the guideline recommends that clinicians offer screening for other sexually transmitted infections in patients with genital molluscum contagiosum. Unless the clinician diagnoses a concomitant sexually transmitted infection, it is not required that partners of patients with molluscum contagiosum be notified of molluscum contagiosum, the guideline added.

Recommendation on Follow Up

The guideline suggests that follow-up visits are not typically required, but “patients should be informed about the treatment of possible adverse reactions, and a review visit can be scheduled if needed.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Edwards S, Boffa MJ, Janier M, et al. 2020 European guideline on the management of genital molluscum contagiosum. Published online September 2, 2020. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.16856