Molluscum contagiosum

Aetiology

Localised dermal infection caused by a poxvirus
Commonest in:

• children up to the age of 14 years, with the highest incidence in the age range 1-4 years in the UK
  • prevalence approx. 7% in immunocompetent children
• immuno-compromised adults
  • up to 18% in adults with the human immunodeficiency virus (HIV)

Transmitted by skin-to-skin contact; mildly contagious

Lesions on the lid margins may shed viral toxins into the conjunctival sac, causing:

• follicular conjunctivitis 
• uncommonly, corneal involvement

Predisposing factors

Epidemiological studies have shown separate associations with attendance at swimming pools, and with eczema\

Recent increases in the incidence of the condition in adults have been strongly associated with acquired immune deficiency syndrome (AIDS)

Symptoms

Presence of skin lesion(s)
Ocular symptoms: redness, watering, photophobia, blurring of vision (all mild)

Signs 

Skin nodule(s) (typically 2-3 mm diam), often with a central depression (‘umbilicated’)
No visible inflammation
Central core has cheese-like or waxy material which may discharge spontaneously
May be single or multiple on the lid(s) and/or elsewhere on the body
Ocular signs (usually unilateral):

• hyperaemic conjunctiva
• conjunctival follicles
• corneal involvement including punctate keratopathy, subepithelial opacities and pannus
• watery discharge

No lymphadenopathy

Differential diagnosis

Other lesions of the lids which may be skin-coloured:

• basal cell carcinoma, neurofibroma, sebaceous adenoma, non-pigmented intradermal naevus, squamous cell papilloma, chalazion, cutaneous horn, sebaceous carcinoma

Other causes of follicular conjunctivitis:

• viral: herpes simplex, adenovirus, chicken pox lesions around eye
• chlamydia
• topical medication (conjunctivitis medicamentosa)
• Parinaud’s oculo-glandular syndrome

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

Usually self-limiting (weeks or months) without scarring or other long term sequelae.  Although no reliable evidence-based recommendations can be given for the treatment of molluscum contagiosum at present, clinical consensus would support active intervention for lesions of the lid margin causing follicular conjunctivitis
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

If lesion is quiet (dry central core) and no ocular symptoms or associated follicular conjunctivitis:

• leave alone
• advise on need for hygiene to prevent reinfection and spread to others

(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

Pharmacological

Artificial tears and lubricating ointment may relieve symptoms in follicular conjunctivitis
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Management category

B2: Alleviation / palliation: normally no referral
B1: Routine referral to ophthalmologist if:

• multiple peri-ocular lesions
• lesions on the lid margin
• follicular conjunctivitis

Possible management by ophthalmologist

Possible destruction of lesion by shave excision, cautery, cryotherapy or incision and curettage

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Chen X, Anstey AV, Bugert JJ. Molluscum contagiosum virus infection. Lancet Infect Dis. 2013;13(10):877-88

Olsen JR, Gallacher J, Piguet V, Francis NA. Epidemiology of molluscum contagiosum in children: a systematic review. Fam Pract. 2014;31(2):130-6

Schornack MM, Seimsen DW, Bradley EA, Salomao DR, Lee HB. Ocular manifestations of molluscum contagiosum. Clin Exp Optom. 2006;89(6):390-3

van der Wouden JC, van der Sande R, Kruithof EJ, Sollie A, van Suijlekom-Smit LWA, Koning S. Interventions for cutaneous molluscum contagiosum. Cochrane Database of Systematic Reviews 2017;5(5):CD004767. 

Plain language summary

Molluscum contagiosum is a viral infection of the skin that occurs commonly in children. It usually consists of a single or a small group of fluid-filled pimples which have an obvious central depression. These can appear on the eyelids or surrounding skin. If molluscum is close to the eye, it may cause a type of conjunctivitis. Since the condition gets better by itself, the usual advice in patients with this condition is to watch it carefully and allow natural healing. However, molluscum removal may be recommended if there are several pimples near the eye, or if it occurs on the rim of the eyelid, or when there is conjunctivitis. Various surgical and medical treatments are available but there is no evidence that one type of treatment is better than another.

Molluscum contagiosum

Version 9
Date of search 15.10.20
Date of revision 28.10.20
Date of publication 20.08.21
Date for review 14.10.22
© College of Optometrists 

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