Molluscum contagiosum and viral warts — clinical case

Case

A 4-year-old boy presents with a six-month history of small, shiny, pearly papules in both axillae that have gradually increased in number, and a rough, firm grey-brown papule on the side of his right thumb present for four months. He has a history of atopic dermatitis, attends swimming lessons weekly, and has a younger sibling. His mother is anxious that the lesions will scar and spread to his brother, and she asks for them to be frozen off today. He is otherwise well, growing normally, and fully immunised. [2]

Findings

In the axillae there are about a dozen 2 to 5 mm, smooth, dome-shaped, pearly, flesh-coloured papules, several with a glistening central dell; one or two have a faint surrounding eczematous halo. On the right thumb there is a single 6 mm rough, firm, hyperkeratotic papule with tiny black dots visible on the surface; paring reveals pinpoint bleeding. The skin is generally dry, consistent with his atopic dermatitis. There are no giant lesions, no genital involvement, and no systemic features. The working diagnoses are molluscum contagiosum and a common viral wart in an atopic child. [2]

Investigations

Both diagnoses are clinical, and no investigations are needed in this typical case. There are no features (extensive, giant, early-infantile or refractory disease; bleeding or ulceration; systemic illness) to justify a biopsy, skin scraping, or screening for immunodeficiency. I would document the number and distribution of lesions and the atopic background to guide follow-up and the treatment decision. [2]

Management

I would frame the consultation around the natural history and the principle of being kinder than the disease. I would explain that molluscum has a median resolution time of about 13 months with most children clear within two years, and that about two-thirds of childhood warts resolve spontaneously within two years, so expectant care with hygiene advice (no sharing of towels, avoid scratching and picking, cover lesions, hand-washing) is the evidence-based default. I would address the fear of scarring directly: the lesions rarely scar, but over-aggressive treatment can. [3]

If the family choose active treatment on the basis of bother, I would offer salicylic acid 12 to 26 per cent paint applied daily to the soaked and pared thumb wart, moving to cryotherapy with liquid nitrogen every two to four weeks if it persists, and for the molluscum an in-office option (cantharidin 0.7 per cent) or a home topical (potassium hydroxide 10 per cent or berdazimer 10.3 per cent gel). I would not use imiquimod, because randomised trials showed no benefit over placebo. I would give a clear safety-net to return for any lesion that is rapidly growing, bleeding, ulcerated or extensive, or for signs of secondary infection. [8]

Course

At three-month review the thumb wart has partially flattened on salicylic acid and the molluscum is stable with two lesions showing the inflammatory halo of impending resolution. The family is reassured by the explanation and has opted for continued conservative management of the molluscum with a clear action plan. The unifying message — that these are benign, self-limiting, transmissible childhood infections and the goal of treatment is to be kinder than the disease — has been understood and accepted. [2]