Your Voice

As a pediatric dermatologist, I read with interest the series on molluscum by Dr. Silverberg, "A practical approach to molluscum contagiosum," Parts 1 and 2. A significant component of my tertiary care patients-or their parents-seek consultation for molluscum. After 23 years of searching for the magic bullet, I would like to advocate for active nonintervention in those children who do not give assent or consent for painful, destructive, frightening treatments.

Dermatologists recognize that molluscum in children is a self-limited infection. It peaks between 2 to 7 years of age, and resolves in healthy individuals within 2 years. Molluscum contagiosum may be associated with a perilesional dermatitis, and occasionally secondary infection.

One to 2% of naturally regressing molluscum heal with shallow pox-like scars. Complications of treatment include pain (cryotherapy, cantharidin), irritant dermatitis (topical retinoids, salicylic acid), recurrence, pox-like scars (in 2% to 10%), hypertrophic scars, keloids, postinflammatory hyper- and hypopigmentation, and secondary infection. Moreover, there are no well-done evidence-based studies that demonstrate a response to therapy better than placebo.

I advocate for children and the 25-minute visit. I require assent or consent for painful, frightening procedures used for the treatment of innocent self-limited dermatologic disorders where there is no evidence that treatment is more effective than observation. I also recommend the following:

Patients usually leave the office with the above instructions, an information sheet on the natural history of molluscum, and a prescription for a topical antibiotic.

P.S. The 25-minute visit for molluscum only works if you are convincingly committed to aggressive nonintervention.

Bernard A. Cohen, MDDirector of Pediatric DermatologyJohns Hopkins Children's Center

In response

Regarding Dr. Cohen's letter, I would like to say that we are both likely correct. Medicine is an art and no two artists paint a canvas in the exact same fashion. Active nonintervention is a practice I advocate for most uncomplicated cases of molluscum contagiosum, which constitutes the majority of children seen in a pediatrician's office. As one practices more years, one develops greater skills at convincing parents to not treat their child's molluscum.

On the other hand, many of the cases I see are complicated by dermatitis, inflammation, and abscesses. This is because I too am a pediatric dermatologist in a tertiary care facility, resulting in a selected group of unusually severe patients. For these patients, very often, therapy is needed to alleviate discomfort. The amount of therapeutic data in the literature attests to the fact that no single therapy is appropriate for each situation.

There is a well-designed study that supports the use of imiquimod 5% cream. Despite the sample size being small, the study shows statistical superiority of the cream (three times weekly) over placebo for lesional molluscum clearance.¹ Unfortunately, the clearance rate is not 100% and the medication is very costly and irritating, making it impractical in many situations requiring therapy.