MOLLUSCUM CONTAGEOSUM ------------------------------------------------------ Two separate small children with molluscum contagiosum were seen in one of our clinics today; both treated with the curette. Although effective, this seems like a barbaric treatment -- but I'm less than impressed with the topical wart remedies, liquid nitrogen (for hypopigmentation, not for lack of efficacy), or irritants (e.g. Retin-A). Does anyone have a "magic" answer for treating these children? Chris Scholes MD ---------------- A tiny drop of cantherone on each. Alt: in cooperative kids, I tease out the center of the lesion by going in from the side, using a #11 blade. It is almost painless, but scary to younger kids. In delicate areas not affected by any sig sx, like the eye, I counsel patience. Jerry D. Eisner MD ------------------ More ideas on rx: Painless very superficial lateral nick and flip of the very top stratum corneum with a 25 gauge needle, no pain, no blood, the molluscum die within the next two weeks from this very slight trauma. Mom or dad can do it as well. Also, irritants, such as topical wart acids. 5FU topical Liquid, but they may hyperpigment. Retin A liquid via Q tip. And griseofulvin for one to two months, the liquid for children, when the molluscum are extensive or the patient is uncooperative or you want to avoid any trauma. Remember the incentive of griseofulvin po bid with ICE CREAM, that way you will not only get absorption, but intake, guaranteed. Diane Thaler ------------ I like this technique as well, but it is usually only possible in a young child who hasn't had traumatic therapy of the molluscum. I deliver the molluscum infested core keratinocytes with the needle. I prefer a 20 to 22 guage because it is a bit stronger. Rhett Drugge, M.D. ------------------ I have had great results treating molluscum in kids with Griseofulvin 5-10 mg/kg per day. I expect to see near total resolution in between 10-30 days. I give up on Griseo. if there is no response by 1 month. It seems to work about 60% of the time. I would be glad to provide references if anybody wants them -- the studies were quite poorly done. Michael Rosenbaum, M.D. ----------------------- [when using canthrone] do you counsel the parents on the unpredictablilty of the size of the blister, and the possibility of painful blisters. It seems as though a certain percentage of people/blisters are painful. I suggest if the physician has not used canthrone before, that she/he try it on herself/himself first. If nothing else, the tense little (hopefully) blister is quite interesting. Diane Thaler ------------ I tell the parents about the blisters, but I keep the drop quite small, which helps. I also mostly do this on legs, arms etc. Jerry Eisner MD --------------- Try emla plus light dessication and they pop out easily or Cantharone -- painless and effective Dr Edelson ---------- I do not treat molluscum since it it a self-limited disease. I see no reason to hurt little children. Thirty years ago, I asked old timers what happened to molluscum without treatment (it was not in the literature then) and was told it was self-limited and I stopped treating right away and have never had any complaints. Some patients may have gone elsewhere but I have not heard about it. John Ziegler ------------ You can mix your own cantharone by getting the ingredients from Delasco. Yelva@aol.com -------------------- The treatment I attempted to describe is much more superficial than delivering the core. This is a newly described much more superficial prick and flip which actually can be done with a 30 gauge as well. You can actually promise the child it won't hurt, and it won't. By the way, does anyone know why griseofulvin might work ? Diane Thaler -------------------- If one does a KOH of molluscum lesions, over 50% have branching hyphae. My old boss, Paddy Menon, tried to publish this but was turned down. Might explain the success of griseofulvin. Dan Mitchell, MD -------------------- Ranitidine syrup 15 mg / ml eg. 5 ml bid sometimes is helpful, but it takes a month or two to work usually, and it is best to use photos to document progress. Worked great for my own kid. Tastes like mint. Cantarone is also very helpful. Send me a private message and I'll see that you get some. KC Smith MD FRCPC -------------------- I have had kids with clearcut scarring after long bouts of molluscum. It may reflect underlying atopy as well with possible staph superinfection, but I'm still prone to treat these, since many treatments are pretty benign. Mark Ling, M.D., Ph.D. -------------------- As an editor, an fungal organism identifiable by culture would be the proof I would want to see before I published these findings. Rhett Drugge -------------------- Cryotherapy with a heavy pair of forceps dipped into liq N2 is effective for some. The molluscum is grasped with the forceps. Amother method is to give the mother 10% podophyllum (with appropriate warnings) and get her to prick the lesions horizontally after applying a drop. Four to six lesions are treated per night. Another effective method is stripping them with sticking plaster! Chris Clay -------------------- It has been my experience that they can and do spread extensively in certain patients, expecially atopics. I've seen a number referred by pediatrics which went from 2 lesions to about 300 in a month. Jay Barnett -------------------- The grab with the icey forceps is a great idea! We should develop a list of things to grab. But, I bet that just the prick, without the podophyllum , would be enough. Give it a try. This may explain why many years ago Dr. Norrins (sp?) from I.U. (I think it was him) recommended treating molluscum with Erythromycin as he thought that children with multitudinous molluscum were atopics colonized with staph-and he had great results after several weeks. Nowadays I would substitute Duricef or another pleasant tasting better anti-staph drug . Everything makes sense now. Diane Thaler -------------------- Why is culture "proof" necessary? If an organisim is highly fastidious, it may not be easy to culture, but it may be easy to find with direct microscopic exam, and certainly with special stains. I think the real issue is whether the observation is or is not correct. Independent verification anyone? If independently verified by more than one observer/lab, the observation should be published. I find it hard to believe that this would not have been detected early in the history of dermatopathology. Walter H. Wood, M.D. -------------------- Paddy did publish!. Dr.Mitchell sent me the reference, International Journal of Derm, 27(1), p69-70, l988, a letter complete with photos, and 30 out of 30 patients were koh positive. Thaler -------------------- References for Grieo. Rx of molluscum: Indian J. of Dermatology 32:104-6 1987 Arch. Derm. 113:1615 1977 (letter) Michael Rosenbaum, M.D. -------------------- It is interesting to see those who do a nd don't treat molluscum. In my experience the pediatricians usually don't and the derms usually do. I, for one, have not had the experience of seeing multiple molluscum disappear without considerable inflammation and scarring. In those patients with spontaneous resolution I see just as many new lesions appear as disappear. If you recall your basic science the brick shaped virus of molluscum is a member of the pox virus family and it is therefore not surprising that it causes scarring. Usually if I see one I see 20 mainly because someone a year ago told the patient or mother that "they will all go away". L.J. Gregg,MD, -------------------- I know molluscum can occasionally leave atrophic "pock mark-like" scars, and this might make one tempted to treat. However, I think I have seen such scars just as often from cantharone treatment as I have from molluscum, so I am no longer very enthusiastic about this modality. Perhaps this was related to use of Blenderm occlusive tape over the Cantharone, which I now cover with paper tape on those few occasions where I use it. I tend to discourage treatment when patients accept this; a good, informative handout helps parental acceptance of nontreatment. Mark Valentine -------------------- It turns out that Paddy did get this published as a letter (complete with impressive photos) in International Jounal of Derm., 1988, Vol. 27, No. 1, p. 69-70. My memory was a little off; lesions from 30 of 30 pts were KOH +. Only one culture grew anything: Candida albicans. So I'm still not sure how to explain the apparent success of Gris-peg in some cases. Dan Mitchell, MD -------------------- I have followed the discussion on molluscum and think this might be an ideal project for our group: Many of us have biopsied solitary molluscum only to be surprised at the diagnosis.If we review our biopsies for the past few years and restain them with methenamine silver as well as Brown and Bren stain for bacteria we should either see or not see hyphae or gram positive bacteria in chains (sometime confused with hyphae on KOH.I'll let you know what I see when I do it. Haines Ely -------------------- I've noticed that a lot of the kids I see with MC seem to have a strong predominance on one side of the body or the other. This does not seem to be related to right- or left-handedness. Anyone else notice this pattern? Any hypotheses about why this would happen? Kevin C. Smith MD FRCPC -------------------- Mark, why use any tape. I would think the tape would not only spread the canthrone beyond the borders, but also occlusion increases the potency/penetration (Dr. Ling could give us these stats I bet). Canthrone, allowed to dry, will no longer induce blisters on casual touch. They used to say that the number one missed diagnosis by Derms when they sent in biopsies of 'tumor' were molluscum. So, Haines, I am sure there are plenty around to restain. Actually, I will ask my Dermpath to retrieve some and go for it. Diane Thaler -------------------- I think tape is essential: 1. to keep the stuff from rubbing off 2. to reduce the risk that the kid will get cantharone in an eye or swallow it (remember the Legionairres and the cantharone-tainted frogs!) By waiting until the cantharone has dried I avoid the risk of having it spread. I get "Doctor Mom" to put tape on after I've applied the cantharone. The mon and kid seem to like this, and it speeds things up for me. KC Smith MD FRCPC -------------------- If you do this "experiment", I suggest incorporating some controls. As a positive control, include some cases of known fungus to make sure the staining and reading is done right. More importantly, include some (a lot) of negative controls, cases where there couldn't be fungus. Ideally, assess the cases and controls blindly. Looking at silver stained specimens, you can almost always find things you could call fungus (or for that matter, spirochetes) if you wanted to. Steve Feldman, MD, PhD -------------------- Unilateral molluscum in kids. I've noticed that too. I always attributed it to autoinoculation. Much = in the way you see a great deal of molluscum in the beard areas of HIV = positive people who shave. Warren J. Winkelman, MD, FRCPC -------------------- I have seen the fine hyphae like filaments on KOH smears of molluscum. Paddy Menon showed them to me when he was Chief of Derm at Portsmouth Naval Hospital and Dan Mitchell and I were staff Derms there. They are real. Jeff Thompson -------------------- All these comments have convinced me to try griseofulvin for molluscum, but I cannot find the written reference. Can anyone send it to me? Thanks Yelva Lynfield, MD -------------------- Not all, but a significant number of the kids we see have many more on one side of the body or the other -- I guess I'd always blamed Dr. Koebner... Chris Scholes -------------------- I am fighting a losing battle with MCV in the face of a low T-Cell count HIV patient. I am treating weekly with LN2 to the groin region. I can eradicate the lesions I see, but every week there are more new lesions. Any suggestions? The patient is on three antiprotease inhibitors and no other meds. Rhett Drugge, M.D. -------------------- How about isotretinoin locally? It sometimes works in children... The major problem might be the prevention of spreading, caused e.g. by rubbing the face. Maybe a tranquilizer for a few days would be recommendable. By the way, never heard of the combination of three protease inhibitors (cross resistences etc.). Ultima ratio? Hans J. Kammler -------------------- Going through my molluscum contagiosum file I found lots of reports (in particular in the Schoch letter) of success with griseofulvin, including patients who also had AIDS. It would be interesting to stain a biopsy specimen with methenamine silver and look for hyphae. There was also one report where Meclan (tetracycline) cream was helpful. Kevin C. Smith MD FRCPC -------------------- The recent note, concerning pulse dye laser for flat warts, makes me wonder if anyone has tried it for molluscum. No plume, quick,... Anyone tried pulse dye laser for these? Mark Crowe, MD -------------------- Don't know about molluscum treatment with dye laser, but had one observation on your comments: those who does warts with dye laser especialy at high fluences I suspect would agree that there's SMOKE after an aggressive treatment. Whether the plume contains potentially infectious viral particles a la CO2 laser isn't as clear, but at least in my case I sure do use a smoke evacuator and laser masks for condyloma treatment, and have been extra careful with the few HIV+ patients I've treated for warts. Mark Ling, M.D., Ph.D. -------------------- I have a whole collection of these guys. In some adding tagamet 1200mg/day appears to have made the difference in slowing the recurrences. A couple of trustworthy MC patients have been given a disposable curette to take home so that they can pluck off the little ones when they first appear. Guy Webster -------------------- Rhett, there is a new topical specific anti MC Dna antiviral which is supposed to be released this Spring. I think it is from the Valtrex people. Maybe you could obtain it on a compassionate basis. If you can't find it I will search through my desk heap. Diane Thaler -------------------- I have found griseofulvin to be less than impressive in tx molluscum. The most effective tactic I've found lately,esp. in hiv pts, and this includes pts w extremely low t-cell counts,has been applying 35% tca(trichloracetic acid).Usually takes 2 or 3 sessions at 3-4 week intervals,this in pts w innumerable mcv in near total contiguous distribution...much better tolerated too than LN2. Pierre Jaffe,MD -------------------- << No plume, quick,... Anyone tried pulse dye laser for these? >> Yes, it has not been as magical as for flat warts . I suspect that the MC has less of a vascular supply forthe laser to attack. Guy webster -------------------- Is it possible that the patients were on low fat diets and hence didn't absorb the griseofulvin? I prescribe it with ice cream and this has been no fail in all of the children atleast. Diane Thaler -------------------- I haven't tried ice cream which is a great idea, but usually suggest "with a meal" or " with milk". Do you have the name generic/trade of the new(!) topical molluscum tx Pierre Jaffe -------------------- Ice cream is the key. The kids remember to take the drug. The yup parents are forced to come down to earth again and enjoy a taste treat. The poor or non ambulatory parents have an easier time keeping icecream in the house than milk etc (icecream doesn't sour). Write for a defined amount-like atleast four tablespoons per dose. I will search my desks today/tonight for the name of the new topical. Diane Thaler -------------------- Thank you, Dr. Valenitine for your contribution. Honestly, my attending deferred sending any of the curretted specimens( originally, he tried treating them all with EDC, but she wouldnt tolerate it, even with EMLA) for path because they are so characterstic of verruca. SHe has no family history of nevoid basal cell carcinoma ( although I admit that spontaneous mutations are known to occur.) She has no frank deformities of the face, eyes, or skeleton that are known to occur in this syndrome, or pits of the palms or soles. According to Fitz, she is a little young for cutaneous onset because she is prepubescent. I appreciate your suggestion. It is certainly a diagnostic possibility which I did not consider until you mentioned it, but submitt the above as arguments against it in this particular case. Incidentally, I would like to thank everyone thus far who has contributed to this therapeutic and diagnostic dilemma. I can say in all honesty that so far RXDERM has been the single most valuable educational contribution to my education as a resident. I learn a great deal every day. Edward Zabawski -------------------- Rhett, years ago I wrote in the Schock letter tha"any child who can eat peas on a fork is old enough to extract his own mollusca with a # 18 needle". I presume your AIDS patients can pick each molluscum open with the tip of an #18 needle. It doesn't hurt when the patient does his own. Haines Ely -------------------- Haines, do you need to extract the mollusca or just prick the mollusca-gentle unroofing. In non HIV one can just unroof the top very dead skin, without popping out the white debris. Diane thaler -------------------- Double-pulsing molluscum contagiosa with the 585 nm pulsed dye laser (at lower fluences than used for warts) is "easy as pie" and efficacious. I have treated hundreds. I learned this from Dr. Mark McCune, an Overland Park, Kansas dermatologist. I use a viral "smoke evacuator" but have quit wearing a mask, as this is no longer even officially recommended. The current theory is if the evacuator doesn't suck up the particles, they are in your office for days. There are just as many in the air after you take off your mask as there were during the procedure. Actually whether there is any risk with the pulsed dye laser is not known . Also clinical studies have shown no greater incidence of warts in laser surgeons than the general medical population. Philip Hughes, M.D. -------------------- I leave it (35% tca) on mcv until I observe a "frost",prob a min or two, then I wipe the sites down with 70% etoh pledget. finis.Again, it takes 2 or 3 visits.It works. Pierre Jaffe -------------------- Rhett, I think this is an excellent time to let the patient carry the battle for you. Give him a bottle of 5-FU, a bottle of Retin-A liquid and have him use them b.i.d. on every lesion he has as soon as it rears its ugly little head. If he's not making progress, add an h.s. application of a topical acid in colloidion (such as Duofilm or Occlusal (sorry to our international audience for the use of proprietary names). You can still treat the thick/resistant ones with LN2. Mark Naylor, M.D. -------------------- As promised I unearthed my desk today and discovered my notes on antivirals. Cidofovir (CDV) is the nucleotide analog gel for MC, it has a broad DNA scope. It is a 3% gel. There was also mention of Imiquimod, a topical interferon alpha inducer for warts. I am sure our NIH members can update us on this one. Diane Thaler ------- A patient with long-standing HIV (since 1981) has had multiple lesions of molluscum contagiosum over his face -- cantherone, scraping, LN2 have been unsuccessful; current therapy with topical 5-fluorouracil is producing irritation only. Local trauma and attempts at scraping have produced rupture of the lesions, leading to pseudocellulitis from loose keratin in the skin. At this time, the patient has layers of molluscum (one literally on top of the other) covering roughly 20% of his face. Through a 5mm slit in the skin, multiple keratinous plugs are recoverable -- so treatment at surface level is not likely to work. As the patient is very high-functioning and otherwise in good health (he takes meticulous care of himself), he'd like to be rid of these. Does anyone have information about using the 5-FU injectable gel in MC? Any thoughts about using it? Any other suggestions for this patient? Chris Scholes ---------- I had a guy with Hodgkin's who had a lot of mollusca - nothing worked very well, including Grenz ray, Soriatane and Ranitidine 300 mg bid. They were in the genital area, and he didn't want diphenylcyprone contact dermatitis therapy. You could offer that to your guy, or try to get some imiquimod from 3M Pharmaceuticals. Karl Beutner ran one of the condyloma studies with imiquimod - maybe he'd be a good guy to talk to - he'd know who to call at 3M. HPMPC is another antiviral to consider. I wonder if hemtoporphyrin derivative (HPD) or a derivative with phototherapy would knock the mollusca off. Kevin C. Smith MD ----------- Sounds to me like more aggressive, albeit judicious and artful use of LN2 is the way to go. If I had dry ice slurry, I'd consider it. Michael Fetterman ----------- Two suggestions which may be of some help in your patient with the "layers" of molluscum. I have one patient with what I would have guessed at 25 mollusca/cm2 and had him use condylox(podopholytoxin) night;ly to the areas until irritated usually about 5 applications,then rest 4 days. Within one month he was much improved. You might also be able to improve him with sequential glycolic peels in much the way that comedonal acne responds to the peels. I imagine these lesions are a reflection of the Cd4 counts and would improve if the status of his disease improved. L.J. Gregg,M.D. ---------- Cantharone is our drug of choice. Daniel Mark Siegel MD ------------ 585 nm pulsed dye laser treatment is effective in molluscum contagiosum. There are no studies regarding the potential vaporization of the virus, although this is not probable with this laser. Still, I think I would be reluctant since this is a vitally important unknown to the physician operator,office staff and even other patients in a closed office building. Wearing a mask is not helpful, since any virus would still be suspended when you take the mask off. Philip Hughes, M.D. ---------- If you are going to continue to pursue medical therapy, I would add liquid Retin-A to the regimen, since it potentiates the effect of 5-FU and has antiviral activity in its own right. I would suggest bid application of both RA and 5-FU to each lesion applied with a Q-tip. Mark Naylor, M.D. ----------- I will take the liberty of translating DR CARLOS MACHADO'S (from Sao Paulo,Brazil) alternative of treating mollusca in children, idea that has been very much explored and motivated some colleagues over here, in our portuguese speaking dermatologic chat,DERMLIST. He says he's completely stopped screams and cries of young children with molluscum,using this technique: with a toothpick he puts a very tiny drop of cantharidin on top of the lesions, then ocludes them. In a few days they evolve exulcerating, then he recommends daily applications of the so effective iodine, on the lesions - that disappear in a few days! Excellent results and tolerability . George Leal