August 2005

This 5-year-old girl presented to the office with papules of the lower eyelids. The lesions had been present for a few months. They are asymptomatic. Two weeks ago one lesion became red and painful, but then resolved.

What do you think is the diagnosis?

Answer

The lesions are molluscum contagiosum. These are caused by a poxvirus. This is a DNA virus that indeed can leave a “pock mark” when the lesions heal. The incubation period is approximately two to seven weeks. The lesions are generally spread by direct contact or by fomite contact.

Wrestlers are especially susceptible because of direct contact in the setting of superficial skin erosions. Fomite spread may be noted from kickboards in swimmers or towel sharing with siblings. Later, autoinoculation can occur. In adolescents and adults, if the papules are primarily located in the genital area, sexual contact may be the mode of transmission.

The molluscum contagiosum papules are usually 2 to 5 mm in diameter. They tend to be skin colored, pearly and dome-shaped lesions. Occasionally, a lesion may be noted to have central umbilication. The trunk and extremities are the most common locations for the papules. In about 10% of patients, an eczematous dermatitis can be seen surrounding the individual lesions — this is known as molluscum dermatitis. This dermatitis requires treatment separate from the molluscum treatment.

Molluscum contagiosum occurs somewhat commonly in children and is noted to have an increased incidence in children with atopic dermatitis. In immunosuppressed individuals, there may be hundreds of papules.

Diagnosis is typically made from the clinical appearance. If the diagnosis is in question, a Wright or Giemsa stain of the contents of a papule will demonstrate viral intracytoplasmic inclusions.

Some of the lesions will resolve spontaneously and require no treatment. Other molluscum, especially if there are numerous or persistent, may require treatment with a blistering agent, liquid nitrogen, curettage or a salicylic acid preparation.

Since these methods are destructive, children with lesions of the eyelid margin should be referred to an ophthalmologist. Molluscum dermatitis is treated with a mild topical steroid (class 5-7). To prevent inoculation among children in a household, it is recommended that they not take baths together and that they have separate towels.

For more information:

• Andrews MD. Cryosurgery for common skin conditions. Am Fam Physician. 2004;69(10):2365-2372.
• Silverberg NB. Warts and molluscum in children. Adv Dermatol. 2004;20:23-73.
• Smolinski KN et al. How and when to treat molluscum contagiosum and warts in children. Pediatr Ann. 2005;34(3):211-221.