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Molluscum Contagiosum Background Molluscum contagiosum is a benign viral infection of the skin, caused by a double-stranded DNA virus of the Poxviridae family. Transmission occurs by direct bodily contact (eg, through sexual activity), fomites (eg, underwear), or self-inoculation. The incubation period is 14-50 days. The infection is most common in children, sexually active adults, and immunocompromised persons and occurs in 5-18% of HIV-infected patients. In immunocompetent persons, the infection usually lasts 6 to 12 months, although genital lesions in HIV uninfected adults may persist longer. Persons with HIV infection may have extensive lesions and a strong correlation exists between the degree of immunosuppression and the risk of molluscum, the number of lesions, and their resistance to treatment. S: Subjective The patient complains of new or increased papular lesions on the face, upper trunk, or genitals. Papules of molluscum contagiosum may cause no symptoms or can be pruritic or tender to the touch. Genital lesions are transmitted sexually; the patient may recall seeing such lesions on the genitals of a previous partner. Ask about fever or other systemic symptoms. O: Objective Perform a thorough evaluation of the skin, the genitals, and the mouth. Molluscum lesions are white, pink, or flesh-colored; smooth-surfaced, firm, pearly, and spherical (dome-shaped) papules (2-5 mm) or nodules (6-10 mm), with umbilicated centers. Lesions are usually found on the head or neck and the genital area, but may affect every part of the body except the palms and soles of the feet. Molluscum may occur intraorally. Molluscum commonly presents as multiple lesions. Patients with HIV infection may develop giant lesions (>1 cm) or clusters of hundreds of small lesions. A: Assessment Section 6—Disease-Specific Treatment | 6–59 A partial differential diagnosis includes the following: ♦ ♦ ♦ ♦ ♦ Disseminated cryptococcosis Other fungal infection Folliculitis Syphilis, condyloma acuminata, vulvar syringoma for multiple small molluscum genital lesions Squamous or basal cell carcinoma for large, solitary genital lesions P: Plan Diagnostic Evaluation The diagnosis of molluscum is usually based on the characteristic appearance of the lesions. Perform laboratory testing, if indicated, to exclude other infections or malignancies. Treatment Because molluscum does not cause illness and rarely causes symptoms, the goal of treatment is primarily cosmetic. Molluscum is difficult to eradicate in HIVinfected patients, and lesions often recur, particularly if immune suppression persists. Effective antiretroviral therapy may achieve resolution of lesions or significant improvement in the extent or appearance of molluscum. Refer complex cases to a dermatologist. Other therapeutic options include: ♦ ♦ ♦ Local excision may be done by electrocautery, evisceration, curettage, or cryotherapy. Adverse effects include pain, irritation, soreness, and mild scarring. Repeated treatments are necessary. Imiquimod 5% (Aldara), an immune response modifier, stimulates production of interferon-alpha and other proinflammatory cytokines, inducing a tissue reaction known to be associated with viral clearance from the skin. Apply 3 times per week for up to 16 weeks or nightly for 4 weeks. Clearing can take up to 3 months. Tretinoin (Retin-A) 0.1% cream can be applied to lesions twice daily. Adverse effects include drying, peeling, irritation, and soreness.
6–60 | Clinical Manual for Management of the HIV-Infected Adult/2006 ♦ ♦ ♦ ♦ ♦ ♦ Podophyllum resin (podophyllin) is administered by a health care provider and washed off after 1- 4 hours. This treatment is caustic and may cause significant irritation, is contraindicated in pregnancy, and has limited effectiveness. Patient-administered podophyllotoxin (Podofilox) may be a safer alternative to podophyllum. Adverse effects include burning, pain, inflammation, erosion, and itching. Trichloroacetic acid is administered by a health care provider. Controlling the depth of acid penetration is difficult. Adverse effects include pain, irritation, and mild scarring are common. Laser therapy may be used to remove lesions. Cidofovir 1% to 3% topical cream, combined with a vehicle, is applied twice daily for 2 weeks, followed by a 30-day rest period and then 2 additional cycles. This treatment was effective in several small studies and case reports, but it is expensive and difficult to compound. No systemic adverse effects are noted. Investigational treatments include 5-aminolevulinic acid with subsequent photodynamic therapy and intravenous cidofovir. Patient Education ♦ ♦ ♦ Molluscum infection is benign but may be distressing. Patients should avoid shaving in areas with lesions because shaving could spread the lesions to other areas. Molluscum infection may be transmitted both sexually and nonsexually, through direct contact with lesions. Patients should avoid close contact between their molluscum lesions and the skin, mouth, and genitals of other people. Latex condoms may not prevent transmission. References ♦ ♦ ♦ ♦ ♦ ♦ Calista D. Topical cidofovir for severe cutaneous human papillomavirus and molluscum contagiosum infections in patients with HIV/AIDS. A pilot study. J Eur Acad Dermatol Venereol. 2000 Nov;14(6):484-8. Fornatora ML, Reich RF, Gray RG, et al. Intraoral molluscum contagiosum: a report of a case and a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Sep;92(3):318-20. Moiin A. Photodynamic therapy for molluscum contagiosum infection in HIV-coinfected patients: review of 6 patients. J Drugs Dermatol. 2003 Dec;2(6):637-9. Strauss RM, Doyle EL, Mohsen AH, et al. Successful treatment of molluscum contagiosum with topical imiquimod in a severely immunocompromised HIV-positive patient. Int J STD AIDS. 2001 Apr;12(4):264-6. Toro JR, Wood LV, Patel NK, et al. Topical cidofovir: a novel treatment for recalcitrant molluscum contagiosum in children infected with human immunodeficiency virus 1. Arch Dermatol. 2000 Aug;136(8):983-5. Tyring SK. Molluscum contagiosum: the importance of early diagnosis and treatment. Am J Obstet Gynecol. 2003 Sep;189(3 Suppl):S12-6.
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Patient Education ♦ ♦ ♦ ♦
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Page 246 and 247: Cervical Dysplasia Background Cervi
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Page 254 and 255: Cryptosporidiosis Background Crypto
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Page 266 and 267: Gonorrhea and Chlamydia Background
Page 268 and 269: Treatment of Gonorrhea Treatment op
Page 270 and 271: Hepatitis B Infection Background He
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Page 274 and 275: Hepatitis C Infection Background He
Page 276 and 277: pregnancy. Ribavirin is teratogenic
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Page 294 and 295: Mycobacterium avium Complex Backgro
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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