Molluscum Contagiosum

Moles, Warts and Skin Tags Removal

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Molluscum contagiosum is a benign lesion produced by a virus that is a member of the Poxviridae family. Transmission occurs by direct skin contact with an infected individual, and when occurring on anogenital skin, it is generally sexually transmitted. However, genital mollusca in a child do not suggest sexual contact.

Most often, molluscum contagiosum is an asymptomatic infection, although when the immune system mounts an inflammatory reaction itching can occur. Mol-luscum contagiosum in adults primarily affects the genital, perianal, groin, upper thigh, and lower abdomen. The eruption is characterized by multiple pearly lesions, at least some of which show umbilication (Fig. 6). Often these are shiny and appear nearly vesicular, leading to the lay term "water warts.'' The central umbilication contains a white, cord-like core. The lesions vary in size but are generally 1 to 3 mm. Histologically, molluscum bodies are cytoplasmic inclusion bodies within keratino-cytes that contain large numbers of mature virions. The papule consists of acanthotic epithelium with hyperkeratosis. In the immunocompetent host, they often resolve without treatment within one to two years. Immunocompromised individuals may have lesions that are unusually large, numerous, and resistant to treatment.

aEditor's note: Two multivalent vaccines against HPV have recently been approved by the FDA and marketed.

Table 3 Human Papillomavirus Infections

Clinical

Differential

Diagnosis

Symptoms

appearance

diagnosis

Therapy

Genital warts

Usually

Acuminate, flat-

Vulvar/vestibular

Cryotherapy,

asymptomatic

topped,

papillomatosis,

excision,

verrucous, or

sebaceous

podophyllum

cauliflower

hyperplasia,

resin, trichloro-

skin-colored,

nevi,

acetic or

pink, or

condyloma

bichloro-

hyperpigmen-

lata,

acetic acid,

ted papules

molluscum

5-fluorouracil

contagiosum,

injection, laser,

vulvar

electrosurgery,

intraepithelial

podofilox,

neoplasia,

imiquimod,

acrochordons,

a-interferon

fibroepithelio-

mas, verrucous

carcinoma

Vulvar

Usually asymp-

Vulvar intra-

Cryotherapy,

intraepithelial

tomatic but

epithelial

imiquimod,

neoplasia

can produce

neoplasia

laser, local

irritation,

lesions vary in

excision to

burning or

clinical

vulvectomy

itching

appearance,

acetowhite

changes with

acetic acid

Vulvovaginal Papillomatosis
Figure 6 Although the central dell seen on these mollusca contagiosa are classic, most lesions are dome shaped and the dell can be difficult to identify.

Vulvovaginal Infections Table 4 Molluscum Contagiosum

Clinical Symptoms appearance

Diagnosis

Molluscum contagiosum

Generally asymptomatic; occasionally may be pruritic or painful

Well-demarcated, dome-shaped, white, pink, or skin-colored glistening papules. Some with central umbilication; white central core

Differential diagnosis

Condylomata acuminata, varicella, herpes simplex, milia, nevi, basal cell carcinoma, folliculitis, keratoacan-thoma

Therapy

Observation, cryosurgery, expression of the core either by light curettage or with a needle, podophyllin and podofilox, cantharidin, potassium hydroxide, imiquimod, cidovir, tretinoin

Conditions that can resemble mollusca contagiosa include genital warts, fol-liculitis, dermal nevi, milia, and sebaceous hyperplasia. The diagnosis is generally made clinically. However, when the presentation is atypical, the diagnosis can be made when the white central core is expressed and examined microscopically to visualize brick-shaped inclusion bodies. Treatment includes observation, destruction by cryotherapy or cantharidin, and expression of the white molluscum body. More recently, open trials have suggested that topical imiquimod cream applied overnight three nights a week is beneficial, and a controlled trial of 23 children showed that imiquimod used for 12 weeks cleared one-third of patients receiving active medication as compared to one of eleven placebo patients (19). Irritation was tolerable (19,20). Other, less common therapies include podophyllum resin, potassium hydroxide, podofilox, and trichloroacetic and bichloroacetic acid. Mollusca contagiosa are a more recalcitrant problem in the immunosuppressed, and these have been shown to respond well to antiretroviral therapy in women with concomitant mollusca contagiosa and HIV (Table 4) (21).

BACTERIAL INFECTIONS Syphilis

Syphilis is a systemic, sexually transmitted disease caused by Treponema pallidum. This infection initially is manifested by an ulcer at the inoculation site, but secondary skin disease and constitutional symptoms can ensue, followed by latency and late, grave disease. The signs and symptoms vary remarkably, depending upon the stage of the disease. The incidence of syphilis has increased substantially recently, and many clinicians are uncomfortable with dealing with the diagnosis of syphilis, especially obtaining samples for darkfield microscopy and interpreting the preparations.

The incubation period varies from about one week to three months, with an average of three weeks. One or a few small papules occur, and erode into a chancre, an ulcer that classically is painless, with raised, indurated borders and a clean base.

Moist Labia

Figure 7 Condylomata lata are characterized by well-demarcated, white, flat papules when occurring on moist skin, and skin-colored on dry skin.

Local lymphadenopathy follows, and the ulcer resolves even without treatment in several weeks. Most patients then develop latent disease, but about a quarter-progress to secondary syphilis. This stage is manifested by some or all of the following: generalized lymphadenopathy, flat, skin-colored (dry keratinized skin) to moist white (mucous membrane and modified mucous membrane skin) papules of the genital skin (condylomata lata), white mucous patches of the mouth, patchy hair loss, and generalized scaling, inflamed, well-demarcated papules that show a predilection for the palms and soles (Fig. 7). This stage also resolves with or without treatment. Latent infection can ensue, followed much later by tertiary syphilis, manifested by gummas that can be life threatening.

The differential diagnosis of primary syphilis is any ulcerative genital disease, including aphthous ulcers, ulcerative HSV in an immunosuppressed host, chancroid, granuloma inguinale, and lymphogranuloma venereum (LGV). The differential diagnosis of secondary syphilis primarily includes pityriasis rosea and guttate psoriasis. The diagnosis of a chancre is made by a darkfield examination of exudate from the surface of the ulcer, performed at an experienced laboratory. Serology is negative initially. The diagnosis of secondary syphilis is made on the basis of positive serology.

Patients found to have syphilis should be evaluated for infection with the human immunodeficiency virus, because an association has been noted.

First-line treatment of syphilis is intramuscular (IM) benzathine penicillin 2.4 million units in a single dose. This is the current CDC guideline for 1° or 2° syphilis. At least one recent study shows that the combination of penicillin and 1 g of azi-thromycin orally is superior to penicillin alone in patients with high-serology titers, whether or not associated with HIV (22). The treatment of syphilis during pregnancy

Vulvovaginal Infections Table 5 Syphilis

Clinical

Differential

Therapy: primary

Diagnosis

Symptoms

appearance

diagnosis

and secondary

Primary

Usually asymp-

Painless

Herpes simplex

Benzathine

syphilis

tomatic

indurated

virus in

penicillin

genital ulcer

immunosup-

2.4 MU IM,

with clean base

pressed patient,

2 wk of tetra-

chancroid,

cycline or

granuloma

erythromycin

inguinale,

500 mg

lymphogranu-

q.i.d., or

loma venereum

doxycycline

100 mg

b.i.d.

Secondary

Fever, malaise

Generalized, well-

Pityriasis rosea,

Same as above

demarcated,

guttate

pink, scaling

psoriasis

papules, white

mucous

patches,

alopecia

Abbreviation: MU IM, million units intramuscularly.

Abbreviation: MU IM, million units intramuscularly.

is controversial (23). Benzathine penicillin 2.4 MU IM weekly for three weeks has been used, and a recent trial suggests that one dose is effective (24).

Following treatment for syphilis, serology should be followed to ensure (in the case of primary syphilis) that it remains negative, or (in the case of secondary disease) that the titers decrease at least fourfold. Those who are allergic to penicillin can be treated with tetracycline or erythromycin 500 mg q.i.d., or doxycycline 100 mg b.i.d. for two weeks. Treatment in pregnancy for penicillin-allergic patients requires special consideration because of potential impact on the fetus. Bacteriostatic rather than bacteriocidal therapy such as doxycycline should be avoided in immunosup-pressed patients (Table 5).

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