The mother of an 11-year-old boy noted a skin lesion on the child’s ankle and requests a teledermatology consultation. The parent emailed a photo of the lesion (Figure). She states that her other son, aged 9 years, has a similar lesion on his arm. Both children are on the wrestling team at school. She is concerned because the lesion is surrounded by redness, although it has remained asymptomatic and is not warm to the touch. Examination of the photo reveals an approximately 0.2 cm lesion representing either a papule or pustule surrounded by a zone of well-defined erythema. As the etiology is clinically uncertain, an office visit is arranged for the next day.
Submit your diagnosis to see full explanation.
Store-and-forward teledermatology is defined as a telecommunication transmission of digital images to a medical provider.1 Patient-initiated teledermatology is readily accomplished with a smartphone as long as images are of good resolution and in focus. Use of teledermatology soared during the COVID-19 pandemic prompting regulatory and policy changes both at the state and national levels.2 In general, evaluation accuracy of teledermatology ranges from moderate to high.3,4
In the case presented, the quality of the transmitted image was excellent; however, the photograph did not permit adequate differentiation of a pustule with surrounding cellulitis from molluscum contagiosum accompanied by inflammation, which is a sign of impending resolution.5,6 Recognition of the BOTE sign (beginning of the end) of molluscum contagiosum avoids undue parental consternation and the need for antibiotic therapy.
Regardless of visible inflammatory response, molluscum contagiosum will spontaneously resolve; although individual lesions may persist for months. Two new topical preparations that target this disorder are in phase 3 development.7
Michelle Boniscavage, CRNP, is on the staff of the DermDox Dermatology Centers in Leola and Wyomissing, Pennsylvania. Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
1. Kaliyadan F, Ramsey ML. Teledermatology. StatPearls [Internet]. StatPearls Publishing. Updated October 3, 2022. Accessed February 1, 2023. www.ncbi.nlm.nih.gov/books/NBK459382/
2. Yeboah CB, Harvey N, Krishnan R, Lipoff JB. The impact of COVID-19 on teledermatology: a review. Dermatol Clin. 2021;39(4):599-608. doi:10.1016/j.det.2021.05.007
3. Giavina-Bianchi M, Sousa R, Cordioli E. Part I: accuracy of teledermatology in inflammatory dermatoses. Front Med (Lausanne). 2020;7:585792. doi:10.3389/fmed.2020.585792
4. Giavina-Bianchi M, Azevedo MFD, Sousa RM, Cordioli E. Part II: accuracy of teledermatology in skin neoplasms. Front Med (Lausanne). 2020;7:598903. doi:10.3389/fmed.2020.598903
5. Butala Niraj, Siegfried E, and Weissler A. Molluscum BOTE sign: a predictor of imminent resolution. Pediatrics. 2013;131(5):e1650-e1653. doi:10.1542/peds.2012-2933
6. Gross I, Ben Nachum N, Molho-Pessach V, et al. The molluscum contagiosum BOTE sign—infected or inflamed? Pediatr Dermatol. 2020;37(3):476-479. doi:10.1111/pde.14124
7. Lacarrubba F, Micali G, Trecarichi AC, Quattrocchi E, Monfrecola G, Verzì AE. New developing treatments for molluscum contagiosum. Dermatol Ther (Heidelb). 2022;12(12):2669-2678. doi:10.1007/s13555-022-00826-7