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A 9-year-old girl is brought to the physician’s office for evaluation of a rash on her left thigh and abdomen. Her parents relate that the girl has developed “clear” bumps in the areas several weeks ago. The parents treated the bumps with an over-the-counter wart remedy. Three days ago, the area around the bumps developed redness. The child complains of slight itchiness but no pain. Examination reveals well demarcated erythematous patches; within the area are scattered papules that match the child’s skin or are erythematous.
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Molluscum contagiosum (MC) is a common skin condition caused by a poxvirus — the Molluscipoxvirus. There are 4 identified subtypes of MC: MC type I (MCV-1), MCV-2, MCV-3, and MCV-4. In the general population, MCV-1 predominates, accounting for up to 97% of cases.1
Primary transmission of MC is through direct contact with someone infected; autoinoculation results in spread.1 Preschool and elementary school children are predominately affected by MCV-1.2 Characteristic lesions are typically the same color as the patient’s skin, or may have a pink tone, with central umbilication.2
In healthy patients, MC is generally self-limited and resolves within several months.3
Treatment with curettage or liquid nitrogen hastens resolution, but ablative therapies may be somewhat traumatic to a child and can result in hyperpigmentation.3,4
An interesting phenomenon associated with MC is the so-called BOTE sign (standing for “beginning of the end”), which was first described in 2013.5 The sign connotes an inflammatory reaction at the site of lesions characterized by erythema that may be severe and extend well beyond the periphery of the papules. The BOTE sign (Figure) is a favorable immune response and usually predicts resolution of the molluscum in short order.5
This viral infection is often misdiagnosed as a secondary bacterial infection. MC infections are usually asymptomatic and the occurrence of tenderness or pain should point to another diagnosis.6
Stephen Schleicher, MD, is director of the DermDox Center for Dermatology in Pennsylvania, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.
References
1. Trčko K, Hošnjak L, Kušar B, et al. Clinical, histopathological, and virological evaluation of 203 patients with a clinical diagnosis of molluscum contagiosum. Open Forum Infect Dis. 2018;5(11):ofy298. doi:10.1093/ofid/ofy298
2. Laxmisha C, Thappa DM, Jaisankar TJ. Clinical profile of molluscum contagiosum in children versus adults. Dermatol Online J. 2003;9(5):1.
3. Nguyen HP, Franz E, Stiegel KR, Hsu S, Tyring SK. Treatment of molluscum contagiosum in adult, pediatric, and immunodeficient populations. J Cutan Med Surg. 2014;18(5):299-306. doi:10.2310/7750.2013.13133
4. van der Wouden JC, van der Sande R, Kruithof EJ, Sollie A, van Suijlekom-Smit LW, Koning S. Interventions for cutaneous molluscum contagiosum. Cochrane Database Syst Rev. 2017;5(5):CD004767. doi:10.1002/14651858.CD004767.pub4
5. Butala N, Siegfried E, 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, Nachum NB, 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
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