Summary

Molluscum contagiosum is a Common, Benign, Self-Limiting Viral Skin Infection caused by the Molluscum Contagiosum Virus (MCV), a member of the Poxviridae family. It is characterised by Discrete, Dome-Shaped, Umbilicated Papules with a central dimple (Umbilication) containing a white, waxy core. The condition is extremely common in Children aged 1-10 years, spread by Direct Skin-to-Skin Contact, Autoinoculation, and Fomites. Lesions typically appear on the Face, Trunk, Axillae, and Limbs in children. In Immunocompetent patients, molluscum is Self-Limiting, resolving spontaneously within 6-18 months (Sometimes up to 2-4 years) without scarring. Treatment is often Unnecessary but may be considered for cosmetic reasons, To prevent spread, Or if lesions are symptomatic. Options include Physical Destruction (Cryotherapy, Curettage), Topical Agents (Potassium Hydroxide, Imiquimod), and Watchful Waiting (Preferred). In Immunocompromised patients (HIV/AIDS), molluscum can be extensive, Giant, And recalcitrant, serving as a marker of disease. [1,2,3]

Key Facts

Fact	Value
Definition	Viral skin infection with umbilicated papules
Causative Agent	Molluscum Contagiosum Virus (MCV), Poxviridae
Peak Age	1-10 years
Transmission	Direct contact, Autoinoculation, Fomites
Incubation	2-6 weeks (Up to 6 months)
Duration (Untreated)	6-18 months (Range 6 months - 4 years)
Diagnosis	Clinical (Characteristic appearance)
Treatment	Watchful waiting (First-line)

Clinical Pearls

"Umbilicated Papules with Central Dimple": Pathognomonic appearance.

"Leave Them Alone": Self-limiting in immunocompetent. Watch and wait is first-line.

"BOTE Sign": Beginning Of The End – Inflammatory reaction around lesions signals immune clearance.

"Extensive or Giant Molluscum = Consider Immunodeficiency": Screen for HIV if appropriate.

"Molluscum Dermatitis": Eczematous reaction around lesions – Treat with emollients/Mild TCS.

Why This Matters Clinically

Molluscum contagiosum is one of the most common viral skin infections in children and a frequent presentation in primary care and paediatric dermatology. Although benign and self-limiting, it causes significant parental anxiety and school exclusion debates. Understanding the natural history is essential to avoid unnecessary, Potentially scarring interventions. Recognition of atypical or extensive molluscum is important as it may indicate underlying immunodeficiency. This condition is commonly examined due to its characteristic clinical appearance and management decision-making.

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Overview

Purpose	Approach
Confirm Diagnosis	Identify characteristic umbilicated papules
Assess Severity	Count and map lesions
Identify Complications	Secondary infection, Molluscum dermatitis
Exclude Red Flags	Giant/Extensive (Immunodeficiency), Atypical features
Plan Management	Watchful waiting vs Treatment indicated

Structured Approach

Step 1: General Inspection

Element	What to Look For
General Health	Child appears well (Systemically well)
Skin Overview	Distribution of lesions, Number
Associated Skin Conditions	Atopic dermatitis (Predisposes), Other infections
Scarring	Previous lesions or treatments
Signs of Scratching	Linear marks, Excoriations

Step 2: Lesion Characterisation

Feature	Expected Finding in Molluscum	Red Flag
Shape	Dome-shaped, Hemispherical	Irregular = Consider other diagnosis
Size	1-5mm (Up to 10mm)	Greater than 15mm = Giant molluscum
Colour	Flesh, Pink, Pearly, White	Very red = Infection or BOTE
Surface	Smooth, Shiny, Waxy	Rough = Consider wart
Umbilication	Central dimple present	Absent rare, Use magnification
Number	Variable (1 to hundreds)	Greater than 50-100 = Consider immunodeficiency
Grouping	May cluster, Satellite lesions	Widespread = Screen for immune issues

Step 3: Distribution Mapping

Site	Tick if Involved	Number	Notes
Face	☐
Eyelids	☐		Ophthalmology referral if symptomatic
Trunk	☐
Axillae	☐
Arms	☐
Legs	☐
Genital/Perineal	☐		Note if child or adult
Other	☐

Step 4: Assessment of Complications

Complication	Signs to Look For
BOTE Sign	Red, Swollen, Tender lesions (Good sign = Resolution)
Secondary Infection	Spreading erythema, Warmth, Pustules, Crusting, Pus
Molluscum Dermatitis	Eczematous changes around lesions (Not infection)
Scarring	From previous treatment or infection

Step 5: Examination of Surrounding Skin

Feature	Finding	Significance
Eczema	Dry, Scaly, Erythematous patches	Associated condition. Predisposes. Treat.
Excoriations	Scratch marks	Autoinoculation risk. Counsel on scratching.
Pigment Changes	Hypo/Hyperpigmentation	Post-inflammatory. Usually temporary.

Dermoscopy Findings

Feature	Description	Significance
Central White-Yellow Structure	Amorphous, Homogeneous	Core of molluscum (Virus-laden cells)
Crown/Clover Leaf Vessels	Peripheral radiating vessels	Characteristic pattern
Polylobular Pattern	Multiple lobules	Seen in established lesions
Orifice	Central opening	May express core

Lesion Expression/Testing

Test	Technique	Expected Finding
Gentle Squeeze	Apply lateral pressure to lesion	White, Cheesy, Waxy core may be expressed
Core Examination	Examine expressed material	Contains molluscum bodies
Note	This is diagnostic but not necessary	Clinical diagnosis usually sufficient

Other Examination Components

Element	What to Examine	Findings in Uncomplicated MC
Lymph Nodes	Regional lymphadenopathy	Absent (Unless secondary infection)
Eyes (If Eyelid Lesions)	Conjunctival injection, Discharge	May have chronic follicular conjunctivitis
General Examination	Signs of immunodeficiency	Normal in typical cases

Documentation

Record the Following:

Item	Example Documentation
Number	"Approximately 15-20 lesions"
Size Range	"2-5mm in diameter"
Distribution	"Predominantly trunk and upper limbs"
Morphology	"Dome-shaped, Umbilicated papules"
Complications	"No signs of BOTE or secondary infection"
Associated Conditions	"Background atopic dermatitis noted on flexures"
Diagnosis	"Clinical diagnosis: Molluscum contagiosum"

Special Tests Summary

Test	Technique	Positive Finding	Significance
Dermoscopy	Examine with dermatoscope	White-yellow central structure, Crown vessels	Confirms diagnosis
Expression of Core	Gentle squeeze or curettage	White cheesy material	Characteristic
Wood's Lamp	UV examination	Not specific	Exclude tinea
Biopsy	Rarely needed	Henderson-Patterson bodies	If diagnosis uncertain

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Natural History - Detailed

Phase	Duration	Description
Incubation	2-6 weeks (Up to 6 months)	Virus acquired. No visible lesions yet.
Early Active Disease	Weeks-Months	New lesions appearing. May spread via autoinoculation.
Peak Disease	Variable	Maximum number of lesions. Waxing and waning.
BOTE Phase	1-4 weeks per lesion	Lesions become inflamed. Immune recognition.
Resolution	Weeks per lesion	Individual lesions resolve. May have new ones appearing simultaneously.
Complete Clearance	6-18 months (Up to 4 years)	All lesions gone.
Post-Resolution	Weeks-Months	Any pigment changes fade. Scarring rare.

Outcomes by Population

Population	Typical Outcome	Notes
Immunocompetent Children	Complete resolution in 6-18 months (90%+)	Excellent prognosis
Children with Eczema	May have more lesions, Longer duration	Usually still resolves
Immunocompromised	May not resolve spontaneously. Extensive.	Requires treatment and management of underlying condition.
Adults (Genital)	Similar resolution	STI considerations. Partner notification.

Outcomes with Different Approaches

Approach	Outcome	Scarring Risk	Notes
Watchful Waiting	Greater than 90% complete resolution. Average 12-18 months.	Very Low	Preferred for most children.
Cryotherapy	Clears treated lesions. May recur.	Moderate	May not shorten overall course.
Curettage	Clears treated lesions.	Low-Moderate	Quick. May miss some.
KOH Topical	60-70% clearance.	Low	Home treatment option.
Imiquimod	Variable (40-60%)	Low	Prolonged course. Off-label.

Recurrence

Aspect	Details
True Recurrence Rate	Less than 5%
Apparent Recurrence	Often new lesions from autoinoculation or incomplete treatment
Post-Treatment Recurrence	More common if not all lesions treated
Immunity	Most develop immunity. Repeat infections uncommon.

Prognostic Factors - Detailed

Favourable Prognosis:

Factor	Why
Immunocompetent	Immune system will clear virus
Limited Number (Less than 20)	Easier for immune system. Less autoinoculation.
BOTE Sign Appearing	Active immune clearance
No Underlying Eczema	Intact skin barrier. Less scratching.
Single Anatomical Site	Limited spread
Older Child	May have partial immunity. Less scratching.

Unfavourable Prognosis (Prolonged/Extensive):

Factor	Why	Management
Immunocompromised (HIV, Primary, Iatrogenic)	Impaired T-cell immunity. Won't clear spontaneously.	Optimise immunity. Active treatment. Specialist.
Atopic Dermatitis	Impaired skin barrier. More lesions. More autoinoculation.	Treat eczema aggressively. Emollients.
Large Number (Greater than 50)	More sources for spread. Longer to clear.	May consider treatment. Investigate immunodeficiency.
Absence of BOTE Reaction	Suggests poor immune recognition	May need longer.
High Scratching	Autoinoculation. Spread.	Address scratching. Short nails. Bandages.
Young Child (Less than 2 years)	More scratching. Takes longer.	Watchful waiting still appropriate.

Long-Term Outcomes

Outcome	Frequency	Notes
Complete Resolution Without Scarring	Greater than 90% (Untreated)	Expected in most children
Minor Scarring	5-10%	More common with treatment or infection
Significant Scarring	Less than 2%	Usually from repeated traumatic treatments
Permanent Immunity	Most	Repeat infection uncommon
Psychological Recovery	Excellent	Once gone, No lasting impact

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Key Guidelines

Guideline	Organisation	Key Recommendations
BAD Guidelines	British Association of Dermatologists (2017)	Watchful waiting first-line. Treatment options if indicated.
AAD Position	American Academy of Dermatology	Self-limiting. Treatment for specific indications.

Evidence Summary

Watchful Waiting vs Treatment (Cochrane 2017)

• Systematic review
• Result: No single treatment proven clearly superior to no treatment
• Most lesions resolve spontaneously within 12-24 months
• Quality of evidence: Low for most interventions
• PMID: 28643307

Potassium Hydroxide (Metanalysis)

• Multiple studies
• Result: Effective, Comparable to cryotherapy
• Less painful than cryotherapy when used correctly
• PMID: Various

Evidence Strength

Intervention	Level	Notes
Watchful Waiting	2a	Cochrane supports. First-line.
Cryotherapy	2b	Effective but painful
Curettage	2b	Effective. Skilld required.
KOH Topical	2a	Multiple RCTs support.
Imiquimod	2b	Off-label. Variable results.

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What is Molluscum Contagiosum?

Molluscum contagiosum is a very common and completely harmless viral skin infection that causes small, raised bumps on the skin. It is caused by a virus related to the chickenpox virus family.

Key Points:

• Extremely common in children aged 1-10 years
• Completely harmless – causes no internal illness
• Will go away on its own without treatment
• Not a sign of anything serious

What Do The Spots Look Like?

Feature	Description
Size	Small – usually 2-5mm (about the size of a pencil eraser)
Shape	Round, Dome-shaped bumps
Colour	Flesh-coloured, Pinkish, or Pearly white
Surface	Smooth and shiny
Special Feature	Often have a tiny dimple or dent in the centre (Like a belly button)
Number	Can range from just a few to dozens or more
Location	Can appear anywhere – Face, Arms, Trunk, Legs, Armpits

What They're NOT:

• Not usually red (Unless healing or infected)
• Not painful (Unless infected)
• Not usually itchy (Though surrounding skin may become dry)

How Did My Child Get This?

The virus spreads by:

Method	How it Happens
Direct Touch	Skin-to-skin contact with someone who has the spots
Self-Spreading (Scratching)	If your child scratches one spot and then touches another area, They can spread the virus to themselves
Sharing Things	Sharing towels, Clothes, Bath toys with someone who has molluscum
Swimming/Bathing	Possibly through sharing pool surroundings (Not proven to be from the water itself)

Who is at Risk?

• Children aged 1-10 (Most common)
• Children with eczema (Dry skin makes it easier for the virus to spread)
• Anyone who has close contact with an infected person

Does It Need Treatment?

Usually NO – And Here's Why:

Reason	Explanation
Self-Limiting	The spots WILL go away on their own – Your child's immune system will fight off the virus
Duration	Usually within 6-18 months, Sometimes up to 2 years
Treatment Can Be Painful	Freezing, Scraping, Or chemicals can hurt – This is hard for young children
Treatment May Scar	The treatments can leave permanent marks. The spots usually heal without any scarring if left alone.
Treatment Doesn't Speed Up Resolution Significantly	Evidence shows treatments mainly remove visible spots. The virus may still cause new spots.

When Treatment Might Be Considered:

Situation	Why Treat
Very distressing	If the spots are really bothering your child or the family
Near the eyes	If spots are on the eyelids and causing eye irritation
Spreading rapidly	If new spots appear frequently despite care
Weak immune system	Children with immune problems may need treatment
Significant concern	After understanding the pros and cons, Some families still prefer treatment

The 'Beginning of the End' (BOTE Sign)

This is GOOD NEWS!

[!TIP] If the spots become red, Swollen, And a bit tender – Don't panic!

This is called the "Beginning of the End" or BOTE sign. It means your child's immune system has finally recognised the virus and is fighting it. These inflamed spots will heal and disappear within 1-4 weeks.

This is NOT an infection. It's the body's natural healing response.

How to tell the difference:

BOTE (Normal Healing)	Infection (Need to See Doctor)
Spots become red and puffy	Spreading redness beyond the spot
May be slightly tender	Increasing pain and tenderness
No pus or discharge	Yellow/Green pus or weeping
Child otherwise well	Child unwell, Fever
Spots start shrinking	Spots getting bigger

What Can I Do At Home?

Practical Tips:

Action	Why It Helps
Don't pick or scratch	Scratching spreads the virus to new areas
Keep nails short	Less damage if accidental scratching
Separate towels	Each family member should have their own towel
No shared baths	Bathe children separately if possible
Use moisturiser	Especially if dry skin or eczema – Healthy skin is more resistant
Cover if swimming	Optional – Waterproof plaster or rash guard for peace of mind
Reassure your child	Avoid making them feel embarrassed – It's very common

School and Activities

Activity	Guidance
School/Nursery	NO exclusion required. Can attend normally.
Swimming	Can still swim. Consider covering spots.
Sports	Can participate. Cover spots if contact sport.
Playdates	Can socialise. Avoid direct contact with spots.

When to See a Doctor

Routine Appointment:

• If you want to discuss treatment options
• If spots are spreading very rapidly
• If you're unsure about the diagnosis
• If eczema around spots is difficult to control

See Doctor Sooner if:

• Spots look infected (Red spreading, Pus, Warmth)
• Spots near the eyes are causing irritation or discharge
• Your child has a known immune system problem
• Spots are causing significant distress

Emergency (Rare):

• Signs of severe skin infection (Large area of spreading redness, Your child is unwell with fever)

Frequently Asked Questions

Q: How long will these spots last? A: Usually 6-18 months. Sometimes up to 2 years. They will go away eventually.

Q: Will they scar? A: If left alone, They rarely leave scars. Treatment is more likely to cause scarring than the spots themselves.

Q: Are they contagious? A: Yes, The virus can spread by touch. However, Many children are exposed and never get it. It's not highly contagious like chickenpox.

Q: Can my child go to school? A: Yes! There's no need to stay off school or nursery. Guidelines say no exclusion is required.

Q: Can my child go swimming? A: Yes. You can cover the spots with a waterproof plaster or rash guard if you prefer. There's no strong evidence that pools spread the virus.

Q: Should we treat them? A: Usually no. Treatment options exist but are often painful and may scar. Since they go away on their own, We generally recommend waiting.

Q: Why are they spreading? A: Likely from scratching (The virus spreads from one spot to another). Try to discourage scratching and keep nails short.

Q: Is it related to hygiene? A: No! Molluscum is very common in healthy children. It has nothing to do with being clean or dirty.

Q: Can adults get it? A: Yes, But it's less common. In adults, Especially if on the genitals, It may be sexually transmitted.

Q: Will my child be immune after this? A: Generally yes. Most people develop immunity after an infection and don't get it again.

Psychological and Social Support

For Your Child:

• Reassure them it's very common ("Lots of children get this")
• Don't make a big deal of the spots
• Explain they will go away
• If other children ask, A simple "It's just a skin thing that will go away" is enough

For Parents:

• It can be frustrating waiting for them to go – This is normal
• Other parents may worry about contagion – You can explain it's not highly contagious
• If you feel pressured to keep your child home, Guidelines say this is not necessary

Visual Guide

What to Look For:

Stage	Appearance
New Spot	Small, Flesh-coloured papule. May not have central dimple yet.
Established	Classic dome-shape with central dimple. Shiny.
BOTE (Healing)	Red, Swollen, Tender. About to go away.
Resolving	Shrinking, Crusting, Disappearing.
Healed	May be slight temporary discolouration. Usually no scar.

Support Resources

Resource	Details
NHS Website	www.nhs.uk – Search "Molluscum contagiosum"
BAD Patient Information	www.bad.org.uk – British Association of Dermatologists
Your GP/Health Visitor	First point of contact for concerns
Dermatology	If referral needed for complex cases

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High-Yield Facts for Exams

Category	Key Points
Definition	Benign, Self-limiting viral infection (MCV, Poxviridae)
Pathognomonic Feature	Umbilicated (Central dimple) dome-shaped papules
Histology	Henderson-Patterson bodies (Molluscum bodies)
Peak Age	1-10 years
Duration	6-18 months (Up to 4 years)
First-Line Management	Watchful waiting
BOTE Sign	Beginning Of The End - Inflammation signals resolution
Red Flag	Giant/Extensive molluscum = Consider immunodeficiency

Common Exam Questions

Short Answer Questions:

1. Clinical Scenario: "A 5-year-old presents with multiple small, Dome-shaped, Umbilicated papules on the trunk. What is the diagnosis and management?"

   • Answer: Molluscum contagiosum. Management: Watchful waiting (Self-limiting). Reassure parents.

2. Pathognomonic Finding: "What is the characteristic histological finding in molluscum contagiosum?"

   • Answer: Henderson-Patterson bodies (Large eosinophilic intracytoplasmic inclusion bodies).

3. BOTE Sign: "What is the BOTE sign in molluscum contagiosum?"

   • Answer: Beginning Of The End – Inflammation around lesions indicates immune response and impending resolution.

4. Red Flag: "When should you be concerned about molluscum contagiosum?"

   • Answer: Giant molluscum (greater than 1cm), Extensive disease, Recalcitrant lesions → Suggests immunodeficiency (e.g., HIV).

5. Treatment Options: "What are the treatment options for molluscum if intervention is required?"

   • Answer: Cryotherapy, Curettage, Potassium hydroxide topical, Imiquimod.

MCQ-Style Questions:

6. Best Answer: "A 4-year-old has 15 flesh-coloured papules with central dimples on his arms. Parents ask about treatment. What is the best advice?"

   • A) Prescribe imiquimod
   • B) Arrange curettage under general anaesthetic
   • C) Reassure and advise watchful waiting ✓
   • D) Urgent referral to dermatology
   • E) Prescribe oral aciclovir

7. Diagnosis: "Which of the following best describes the causative organism?"

   • A) Herpesvirus
   • B) Papillomavirus
   • C) Poxvirus ✓
   • D) Retrovirus
   • E) Adenovirus

8. Complication: "A child with molluscum develops red, swollen, tender lesions. What is the most likely explanation?"

   • A) Secondary bacterial infection
   • B) Beginning Of The End (BOTE) ✓
   • C) Allergic reaction
   • D) HSV superinfection
   • E) Impetigo

OSCE Stations

Station 1: Clinical Examination

Component	Required Content
Introduction	Introduce self, Confirm patient identity, Explain examination
Consent	Obtain consent for skin examination
Inspection	Describe: Dome-shaped papules, Central umbilication, Distribution, Number, Colour
Dermoscopy	Describe clover-leaf/Crown vessel pattern if asked
Surrounding Skin	Comment on molluscum dermatitis if present, Eczema
Red Flags	Comment on size (Giant?), Number (Extensive?), Suggest immunodeficiency if applicable
Summary	"This child has multiple dome-shaped, umbilicated papules consistent with molluscum contagiosum"

Station 2: History and Counseling

Question Area	Key Points
History Taking	Duration, Spread, Treatments tried, Eczema history, Symptoms, School concerns
Counseling	Explain diagnosis, Benign nature, Self-limiting (6-18 months), BOTE sign reassurance, Treatment options (Pros and cons), School guidance (No exclusion)

Station 3: Parent Communication

Scenario	Approach
"Parent requests treatment"	Acknowledge concern. Explain natural history. Discuss treatment risks (Pain, Scarring). Shared decision if still want treatment.
"Parent worried about contagion"	Explain transmission. Not highly contagious. Practical advice (Separate towels). School attendance OK.
"Parent worried about scarring"	Reassure: Untreated lesions rarely scar. Treatment more likely to scar.

Viva Points

Opening Statement:

"Molluscum contagiosum is a common, Benign, Self-limiting viral skin infection caused by the Molluscum Contagiosum Virus, A poxvirus. It is characterised by dome-shaped, Umbilicated papules and is most common in children aged 1-10 years. It typically resolves spontaneously within 6-18 months, And therefore watchful waiting is the first-line management."

Key Facts to Mention:

Fact	Details
Virus	Poxviridae family, MCV-1 most common in children
Transmission	Direct contact, Autoinoculation, Fomites
Appearance	Umbilicated papules – Central dimple is pathognomonic
Prognosis	Self-limiting in immunocompetent (6-18 months)
BOTE	Inflammation = Resolution imminent
First-Line	Watchful waiting
Histology	Henderson-Patterson bodies

Classification to Quote:

• "MCV has subtypes: MCV-1 (Children) and MCV-2 (Adults, Sexually transmitted)"

Evidence to Cite:

• "A Cochrane review (2017) found no single treatment clearly superior to watchful waiting in immunocompetent children"
• "PMID 28643307"

Common Mistakes

What Fails Candidates:

Mistake	Why It's Wrong
❌ Over-treating	Recommending cryotherapy for every child. First-line is watchful waiting.
❌ Not knowing BOTE	Missing this high-yield sign that signals resolution
❌ Forgetting Henderson-Patterson bodies	Classic histology finding
❌ Missing immunodeficiency link	Extensive disease warrants HIV testing
❌ Confusing with warts	Warts have rough surface, No umbilication
❌ Saying "treatment shortens disease"	Evidence doesn't strongly support this

Dangerous Errors:

• ⚠️ Missing immunodeficiency in extensive/Giant molluscum
• ⚠️ Aggressive treatment causing scarring in a self-limiting condition
• ⚠️ Prescribing aciclovir (Wrong virus family)

Outdated Practices:

• Routine treatment of all cases – Now watchful waiting preferred
• School exclusion – Not required

Examiner Follow-Up Questions

Question	Model Answer
"What if the lesions are on the eyelid?"	May cause conjunctival irritation. Consider ophthalmology referral if symptomatic. Treatment may be indicated.
"What is molluscum dermatitis?"	Eczematous reaction around lesions. Not infection. Immune response. Treat with emollients and HC 1%.
"Can children go to school?"	Yes. No exclusion required. Cover lesions if swimming (Optional).
"What if an adult presents with genital molluscum?"	Likely sexually transmitted. Consider STI screening. Partner notification.
"What is the evidence for treatment?"	Cochrane 2017: No single treatment clearly superior to watchful waiting. Low quality evidence for most.
"How would you counsel a parent who insists on treatment?"	Explain risks and benefits. If they still want treatment, Discuss options (KOH, Curettage). Shared decision. Document discussion.
"What is the incubation period?"	2-6 weeks, Can be up to 6 months.
"What is the difference between MCV-1 and MCV-2?"	MCV-1: Children, Non-sexual. MCV-2: Adults, Often sexually transmitted.

Differential Diagnosis Discussion

If Asked...	Answer
"What else could this be?"	Warts (Rough surface), Milia (No umbilication), Folliculitis (Pustular), Insect bites, Keratosis pilaris
"How would you exclude warts?"	Warts: Rough, Keratotic, No central dimple. May have black dots (Thrombosed capillaries).
"What if immunocompromised?"	Consider Cryptococcosis, Histoplasmosis (Systemic symptoms in HIV). Biopsy if uncertain.

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Last Reviewed: 2025-12-25 | MedVellum Editorial Team

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and current guidelines.