Molluscum Contagiosum is a widespread virus affecting the skin, causing distress for millions worldwide. It is primarily seen in children between the ages of one and ten but also has an incidence spike with young adults, associated with sexual activity. Classified as a pox virus, once the patient develops immunity eruptions will spontaneously involute. The average duration is about nine months, but lesions can last 2-3 years. When medical students ask me “Dr. Meisenheimer, are molluscum contagiosum contagious?” I make them repeat their question word for word slowly until they arrive at the correct answer on their own.
My training in the eighties was old school when it came to molluscum contagiosum. The question was not whether molluscum needed treatment but how aggressive the procedure would be. In my residency program, the preferred method was curettage, which quite frankly worked well. The problem was, curettage on a three-year-old, if observed by an outsider, would somehow suggest that something was being done in violation of the Geneva Convention. Of course, there are other treatments such as cryosurgery, electrosurgery, laser, topical agents such as cantharidin, podophyllotoxin, and imiquimod, etc. but what I have learned with experience in young pediatric cases is the best treatment is doing nothing. There are some of you who will vehemently disagree, and I’m not saying you shouldn’t treat molluscum, so hold the hate mail. I only believe that watchful waiting is another arrow in your quiver of treatment options.
I am a teetotaler, but I will tell you after successfully treating a large number of molluscum on a screaming four year old it is enough to make one consider a quick consult with Dr. Jack Daniels. Decades ago, when I treated by curettage, the parents were usually extremely grateful and often aided in holding the patient down; still, I felt there had to be a better way. When I relayed my treatment dismay to an older, wiser mentor, he responded, “you do not have kids of your own do you?” at that time the answer was no. He then said, “What I did with my own kids was nothing.” As a young physician, the thought had never occurred to me that nothing was an option, and I responded with, “but patients don’t come to me to do nothing?” He replied, “Educating parents about choices is not doing nothing.” It was a bit of an epiphany for me, so I began offering no treatment as an option with what ended up being a high degree of acceptance. And yes, it is okay for these kids to go to school with molluscum it is not a disease that needs to be quarantined.
Now there are some caveats in using observation as your “treatment.” Number one, some kids will get worse while you are waiting for the eruption to clear. Number two, it takes three times as long to explain to the parent why their child does not need any treatment as it does actually to do the treatment. (They need a lot of reassurance that they are not a bad parent for picking the no treatment option, especially if Dr. Grandma intervenes with her sage advice). Number three, some of these moms/dads are not going to believe you, and they may leave your practice (I typically will treat if the parents are adamant about proceeding, and work to help them pick their best option. The interesting fact is many will stop mid-way through treatment to revert to the no treatment option). The true acid test for the no treatment option comes when you have your own children. I have three boys, all of which acquired molluscum contagiosum. My first son was atopic, and his involvement was bad. The Molluscum spread quite heavily in all his areas of eczematization, but we stayed the course, and he cleared. Boy number two had a mild case caught from boy number one. He performed fingernail surgery on himself, regardless of the heavy dressings, and cleared nicely. Boy number three ended up having one of the most extensive cases of molluscum contagiosum I have ever seen in my dermatology practice. He had hundreds over his entire body. As the condition progressed, he began to resemble a miniature human pincushion.
My wife wanted to know what I was going to do, I told her we were going to observe. Lovingly, she responded, “Then I want to take him to a good dermatologist.” Before you question my qualifications as a parent, he was mostly asymptomatic. Save some mild pruritus, he was living the good life of a three-year-old without a care in the world. I was able to convince my wife to wait at least another six weeks before completely trampling my ego. As all things happen in life, he got worse. Fortunately, my colleagues had long waiting lists, and before my wife could get him scheduled his molluscum disappeared. None of my boys remember having molluscum, which I cannot say is true for patients that underwent other treatment options.
Now, what about adults? Young adults can tolerate the curettage quite nicely, especially if you apply a thin coat of topical anesthetic a couple of minutes before the procedure. Since they most likely acquired them secondary to sexual activity, these patients are motivated to have them gone immediately. Young adults are generally grateful for having the molluscum instantly removed. Another difficulty regarding adults with molluscum is what to do with somebody with HIV/ AIDS. These immunosuppressed individuals presented with hundreds of molluscum often on the face. I would treat them, mainly if they were in visible areas, but due to low CD4 counts, the Molluscum always recurred. This was a problem in the late 80s early 90s, but fortunately, the advent of effective HIV therapies made it rare to see someone that is HIV positive with uncontrollable molluscum contagiosum.
Of course, there can always be exceptions found to my no treatment recommendation for the young pediatric population, and there are still going to be those clinicians that insist on treating all molluscum cases aggressively. For those doctors that do continue to use curettage, cryosurgery, laser, or electrosurgery on their young patients with molluscum, I would prescribe one shot of Jack Daniels post-treatment (for the doctor).
By Lucky Meisenheimer, M.D. and John Meisenheimer, VII
Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. He is a former chairman of the Division of Dermatology at ORHS.