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Five-year-old diagnosed with molluscum contagiosum
The lesions are typically treated with removal.
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A 5-year-old Hispanic female presented to the eye clinic with her mother reporting concerns over small elevated bumps on her face and eyelids. The child said the bumps itched and she got some relief by scratching them. Ocular examination revealed right and left eye unaided visual acuities of 20/20 and 20/25, respectively. The child wore no glasses. Pupil testing was normal. Slit lamp examination revealed a normal anterior segment. Multiple 1-mm umbilicated lesions were observed on the right upper and lower eyelid and nasal skin.
The patient’s medical history was unremarkable. She was on no medications and had no known allergies. The mother reported that the patient and her older sibling shared a bed. Upon examination in the office, the sibling also had the same cutaneous lesions as our patient.
Molluscum contagiosum
Molluscum contagiosum is a very common viral disease found primarily in the young and immunocompromised. A DNA pox virus known as the molluscum contagiosum virus (MCV) causes the disease. Humans are the only known hosts of the virus, and, as the name suggests, it is highly contagious. The small umbilicated lesions associated with the virus can be spread from person to person and can be autoinoculated. These lesions are known as mollusca. The virus remains sectioned off within the cutaneous lesions and cannot be spread via airborne particles from coughing or sneezing.
Transmission of molluscum is associated with public swimming pools, sharing of towels or linens and living in close quarters with infected individuals.
Images: Nash P
Children may have widespread involvement of various areas of the body. In adults it is more common to find an isolated molluscum lesion. The trunk is most commonly involved in all patient populations.
Itching, burning and associated erythematous outbreaks around the lesions are common. If the junction of the eyelid is involved, the mollusca will shed virus onto the eye and cause a chronic unilateral follicular conjunctivitis. In our patient, the skin lesions were assessed 2 weeks before surgical removal was performed. In the time between visits, the patient developed a follicular conjunctivitis in the right eye. A molluscum lesion was identified on the right upper eyelid margin near the base of the lashes.
Diagnosis made on case history, observation
Often, molluscum contagiosum presents in a classic appearance and can be diagnosed based on case history and direct observation alone. The differentials to consider include verruca, nevi and carcinomas, among other skin lesions. Insect bites may be another potential mimicking lesion depending on the time of year. Age and patient information regarding living situation and lifestyle should aid in the diagnosis.
If removed surgically, diagnosis may be confirmed by pathology. Molluscum lesions have a distinct physical appearance. Small isolated inclusion bodies are the hallmark histological appearance of molluscum.
Diagnosing molluscum and initiating treatment for infected individuals is important to facilitate healing. In addition, it is necessary to educate siblings and others living in close proximity with an infected individual to contain the spread of the virus through precautionary measures. In immunocompetent patients, the body should eventually be able to fight off the virus, and the mollusca will resolve on their own over the course of 6 to 9 months. In patients with acquired immunodeficiency syndrome, molluscum may be more involved and more persistent. The decision to treat should be based on the extent of involvement and patient lifestyle.
Treatment
Molluscum lesions are filled with viral inclusion bodies and need to be physically removed from the skin to prevent further autoinoculation. This can be accomplished through cryosurgery, curettage, lasers or topical treatment with trichloroacetic acid. Cryosurgery uses liquid nitrogen to destroy the superficial tissue. Curettage is physical removal using a small, handheld, rounded instrument known as a curette to scrape off each lesion. Laser surgery involves destruction of the lesions with light energy. Topical treatment with trichloroacetic acid destroys the top layer of the skin, which removes the virus. All of these procedures can cause localized permanent eyelash loss.
It may take up to 4 months for the lesions to completely resolve with topical treatment. As treatment is carried out, new lesions can appear during this time period. If at any point the patient presents with mollusca, they are contagious. Treatment may have to be repeated several times to completely remove the lesions as the infection resolves.
If the patient is mature enough, removal of molluscum lesions can be done in office. In our patient’s case, she was too young to tolerate curettage at her initial visit and had to return to be put under general anesthesia to allow for complete removal of approximately 20 lesions using a curette. An antibiotic ointment was applied to prevent potential secondary bacterial infection after the removal of the lesions. No cautery or suturing was required due to the small size of the lesions. The removed lesions were sent to pathology, where the diagnosis of molluscum contagiosum was confirmed.
At the 1 week follow-up, our patient was well-healed, and she and her mother were satisfied with the results. The mollusca had not recurred, and the conjunctivitis was fully resolved. The older sibling had undergone curettage during a subsequent office visit and was also free of any new mollusca. No further follow-up was required regarding this particular infection.
Although molluscum is a relatively benign viral infection, it has the potential to spread and can cause chronic unilateral follicular conjunctivitis if it involves the eyelid margin. If the causative mollusca lesion is not identified, it may result in ongoing failed treatment attempts. Patient education is important in preventing the spread of the disease while resolution is taking place or until the lesions can be removed. Confirmation of the diagnosis from pathology is not required but may be done if the lesions are removed with curettage. Recurrence after physical removal is rare.
- References:
- American Academy of Dermatology. https://www.aad.org/. Accessed July 6, 2015.
- Centers for Disease Control and Prevention. Molluscum Contagiosum. http://www.CDC.gov. Posted May 11, 2015. Accessed September 8, 2015.
- Charteris D, et al. Br J Ophthalmol. 1995;79(5):476-481.
- Griffith D, et al. Br J Ophthalmol. 1988;72(10):799.
- Hsu J, et al. Practical Dermatology for Pediatrics. June 2010.
- For more information:
- Paige Nash, BS, plans to graduate from Pacific University College of Optometry in 2016. She can be reached at: Nash7538@pacificu.edu.
- Leonid Skorin Jr., OD, DO, FAAO, FAOCO, can be reached at the Mayo Clinic Health System in Albert Lea, Minn.; skorin.leonid@mayo.edu.
Disclosures: Nash and Skorin report no relevant disclosures.