|Year : 2020 | Volume
| Issue : 1 | Page : 5-8
Clinical Profile and Management Outcomes of Periocular Molluscum Contagiosum
Bipasha Mukherjee1, Harshit Vaidya1, Md Shahid Alam2
1 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya Medical Research Foundation, Chennai, Tamil Nadu, India
2 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya Medical Research Foundation, Kolkata, West Bengal, India
|Date of Submission||09-Nov-2019|
|Date of Decision||28-Nov-2019|
|Date of Acceptance||06-Jan-2020|
|Date of Web Publication||04-Mar-2020|
Dr Bipasha Mukherjee
Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya Medical Research Foundation, No. 18, College Road, Chennai - 600 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Purpose: To study the clinical profile and management outcomes of histopathologically proven cases of eyelid molluscum contagiosum (MC). Materials and Methods: A retrospective analysis of the medical records of patients presenting to a tertiary eye care center between January 1995 and December 2018 was carried out. Of 67 patients clinically suspected of harboring molluscum lesions of the eyelids, 32 were confirmed on histopathology. Results: Mean age of the patients was 7 years (1.3–69). Of 32 patients, 17 (53%) were males and 15 (47%) were females. Eyelid mass lesion was the most common complaint (87.5%). Lower eyelid was the most common site (14/44%). Eighteen (56%) patients had a solitary lesion whereas 14 (44%) had multiple lesions. Characteristic umbilication was seen in 14 (44%) cases. Associated ocular surface findings were observed in 21 (66%) patients, of which most commonly noted were follicles, papillae, and eyelid edema. Lymphadenopathy was observed in two patients. Excision with or without cautery was performed in all patients. One patient had a recurrence after 5 months. None of the patients were immunocompromised. Most common misdiagnosis was sebaceous cyst (5), chalazia (2), and viral warts (2). A positive clinicopathological correlation was found in 59.34% cases. Conclusion: MC is a common infectious eyelid lesion in immunocompetent children. Characteristic central umbilication of the lesion provides a clue to clinical diagnosis; however, it can mimic many other eyelid lesions. Complete excision offers cure in almost all cases.
Keywords: Henderson–Paterson bodies, molluscum contagiosum, poxvirus, umbilication
|How to cite this article:|
Mukherjee B, Vaidya H, Alam MS. Clinical Profile and Management Outcomes of Periocular Molluscum Contagiosum. TNOA J Ophthalmic Sci Res 2020;58:5-8
|How to cite this URL:|
Mukherjee B, Vaidya H, Alam MS. Clinical Profile and Management Outcomes of Periocular Molluscum Contagiosum. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2020 Jun 4];58:5-8. Available from: http://www.tnoajosr.com/text.asp?2020/58/1/5/279993
| Introduction|| |
Molluscum contagiosum (MC) is a common viral infection of the skin, usually seen in children and immunocompromised adults. The lesions typically appear as flesh-colored papules with central umbilication and are usually asymptomatic. At times, however, they can become symptomatic, causing inflammation, pruritus, pain, discomfort, superadded infection, and hypersensitivity reactions. These lesions most commonly appear on the extremities, face, genitalia, and trunk. However, MC may be rarely seen infecting the eyelids and the periocular area.
| Materials and Methods|| |
This is a retrospective case series of patients treated at a single tertiary eye care center. The medical records of 67 patients clinically suspected of harboring molluscum lesions of the eyelids during a period of 24 years (January 1995 to December 2018) were studied. A total of 32 cases with histopathological diagnosis of MC were included in the study. Institutional review board and ethics committee approval was taken, and the study followed the tenets of Declaration of Helsinki.
Demographic details including age, gender, laterality, site of involvement, presenting complaints, and suspected clinical diagnosis were noted. The lesion characteristics and management outcomes were recorded for analysis. All the patients underwent a comprehensive ophthalmic and systemic evaluation. Patients with clinical suspicion of MC of the eyelid with negative histopathological diagnosis were excluded from the study.
| Results|| |
A total of 32 patients (17 males and 15 females) were analyzed. The median age at presentation was 16.6 years (range = 1.3–69 years). The mean duration of complaints was 4.99 ± 7.3 months (range = 0.5–36 months). Eyelid mass was the most common complaint, seen in 87.5% of the patients followed by redness (59%), watering (38%), and mild pain (25%). Lower eyelid was the most common site (14/44%), whereas both eyelids were involved in 7 (22%) patients. Both eyes were involved in 4 (12.5%) patients [Figure 1]. Eighteen (56%) patients had a solitary lesion and 14 (44%) had multiple lesions. Characteristic umbilication was seen in 14 (44%) cases [Table 1]. Associated ocular surface findings were observed in 21 (66%) patients, of which most commonly noted were follicles, papillae, and eyelid edema. Face was the most common site of extraocular lesions (7/22%) [Figure 2]. Lymphadenopathy was observed in two patients.
|Figure 1: Clinical photograph of a patient showing bilateral molluscum contagiosum lesions over the right lower eyelid and over both lids of the left eye|
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|Figure 2: Clinical photograph showing multiple molluscum lesions over the right lower eyelid and face of an adult patient|
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Excision of the lesions with or without cautery was performed in all the patients. One patient had a recurrence after 5 months. None of the patients were immunocompromised. Most common misdiagnoses were sebaceous cyst (5), chalazia (2), and viral warts (2). Of the 32 cases, 19 were clinically diagnosed as molluscum, of which 14 showed the characteristic umbilication. None of the patients had any postoperative complications.
| Discussion|| |
MC is caused by a poxvirus of the Molluscipox genus in the Poxviridae family. MC virus (MCV) is a large brick-shaped, double-stranded deoxyribonucleic acid virus. MCV has four major subtypes: MCV-1 being the most common (75%–96% of cases) followed by, in the order of decreasing frequency, MCV-2, MCV-4, and MCV-3. Virtually, all pediatric cases are caused by MCV-1. On the other hand, MCV-2 affects teenagers and adults and is mainly transmitted sexually. In patients with human immunodeficiency virus infection, MCV-2 accounts for approximately 60% of the infections. MC occurs worldwide but is more common in areas with tropical and humid climates.
The only known host for MCV is humans. It primarily affects children, sexually active adults, and immunosuppressed patient populations. The virus is transmitted by close physical contact, autoinoculation, and occasionally, contaminated fomites (e.g., clothing, bath sponges, and towels), especially if the skin is wet. In adults, the disease may be spread by sexual contact and is typically found in a bathing-trunk distribution. The virus can also be transmitted by tattoos. Swimming in community swimming pools have also been implicated as a source of infection.
The diagnosis is predominantly clinical. A typical molluscum lesion is painless, flesh-colored, dome-shaped papules or nodules with central umbilication. We noted this characteristic feature in 44% of the cases [Figure 3]. While the diagnosis of MC is usually clinical, it might pose a challenge in some patients, whereupon the definitive diagnosis is made after excision biopsy of the lesion [Table 2].
|Figure 3: Typical centrally umbilicated molluscum contagiosum lesion over the lower eyelid|
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On histopathological examination, MC presents as a lobulated crater-like lesion with the epidermis, showing inverted acanthosis containing intracytoplasmic basophilic to eosinophilic viral inclusions known as molluscum bodies or Henderson–Paterson bodies [Figure 4]. Peripherally, the cell nucleus is displaced, resulting in a signet-ring appearance. Although benign, this condition is often a cause for concern among the affected due to its prolonged course, contagious nature, and the cosmetic blemish it confers upon the patients. The condition is known to be self-limited. Most lesions resolve spontaneously without sequelae; the mean duration of spontaneous resolution ranges from 6.5 to 13 months but may occasionally persist for years.
|Figure 4: Microphotograph of molluscum contagiosum lesion (H and E, ×20) containing intracytoplasmic inclusion bodies (Inset: Trichrome, ×40)|
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From the epidemiological standpoint, the mean age of the cases in our study was 7 years compared to 25.5 years in the study by Charteris et al. In the current study, 80% of the patients were under the age of 16 years, concurring that eyelid MC is predominantly a disease of the young.
MC lesions were classified according to six proposed clinical presentations: “umbilicated nodular,” “big/giant,” “conglomerated,” “erythematous,” “inflamed,” and “pedunculated.” Macroscopic appearances of brain-like gyri over the surface of the lesion have been described. Most of the lesions in our series were typically umbilicated (14/44%), followed by vascularized lesions. Molluscum lesions can be cosmetically unsightly. Other complications include secondary bacterial infection, irritation, inflammation, conjunctivitis, and superficial punctate keratitis [Figure 5].
|Figure 5: Slit-lamp photograph showing molluscum contagiosum lesion in the upper eyelid with allergic conjunctivitis showing follicles involving the palpebral conjunctiva|
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To avoid spread of the infection, the importance of avoidance of sharing of bed linen, towels, sponges, and bathtubs cannot be over-emphasized. Swimming in pools and participation in contact sports can spread the virus and should be discouraged. Although natural resolution of MC remains an appropriate line of management, many authors suggest active treatment of lesions for cosmetic reasons, social stigma associated with visible lesions, alleviation of discomfort including itching, or concerns of transmission and autoinoculation. Active treatments may be mechanical, chemical, immunomodulatory, and antiviral. Mechanical methods (e.g., cryotherapy with liquid nitrogen, curettage, and pulsed dye laser therapy) are generally quite effective. Chemical agents (e.g., cantharidin, potassium hydroxide, podophyllotoxin, benzoyl peroxide, tretinoin, trichloro acetic acid, lactic acid, glycolic acid, and salicylic acid) work by producing a local inflammatory response. Although the use of cantharidin is not painful at the time of application, it may lead to later discomfort/pain, pruritus, blister formation, and dyspigmentation, especially in dark-skinned individuals. Immunomodulatory agents (e.g., imiquimod, interferon-alpha, and cimetidine) work by enhancing the local release of cytokines. Topical imiquimod is no longer recommended for the treatment of MC. In fact, many authors have strongly urged dermatologists to refrain from prescribing imiquimod in children as it is neither safe nor effective in the treatment of MC. Oral cimetidine, a H2-receptor antagonist, presumably works by enhancing cell-mediated immunity against MCV. The medication is safe, painless, and well tolerated. However, lesions on the face do not respond as well compared with lesions elsewhere on the body. Antiviral therapy with topical or intravenous cidofovir has been used for immunocompromised patients with severe, refractory lesions. A Cochrane systematic review of 11 randomized controlled trials (n = 495) examined the effects of topical and systemic, as well as homoeopathic interventions, and concluded that there was insufficient evidence to suggest superiority of any particular treatment. Most of those treatments were suggested for other parts of the body and not for the eyelids. All the lesions of the patients in our current study group were treated by surgical excision. We prefer surgical removal because it involves a minor, short procedure with good cosmetic results and definitive confirmation of the diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brown J, Janniger CK, Schwartz RA, Silverberg NB. Childhood molluscum contagiosum. Int J Dermatol 2006;45:93-9.
Mohan RP, Verma S, Singh AK, Singh U. Molluscum contagiosum: Report of one case with overview. BMJ Case Rep 2013;2013. pii: bcr2013008744.
Janniger CK, Schwartz RA. Molluscum contagiosum in children. Cutis 1993;52:194-6.
Molina L, Romiti R. Molluscum contagiosum on tattoo. An Bras Dermatol 2011;86:352-4.
Chen X, Anstey AV, Bugert JJ. Molluscum contagiosum virus infection. Lancet Infect Dis 2013;13:877-88.
Charteris DG, Bonshek RE, Tullo AB. Ophthalmic molluscum contagiosum: Clinical and immunopathological features. Br J Ophthalmol 1995;79:476-81.
Rosner M, Zloto O. Periocular molluscum contagiosum: Six different clinical presentations. Acta Ophthalmol 2018;96:e600-5.
Alam MS, Shrirao N. Giant molluscum contagiosum presenting as lid neoplasm in an immunocompetent child. Dermatol Online J 2016;22. pii: 13030/qt56v567gn.
Örnek K, Onaran Z, Koçak M. Giant eyelid molluscum contagiosum presenting as preseptal cellulitis. J Paediatr Child Health 2014;50:1036.
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:CD004767.
Leung AK, Barankin B, Hon KL. Molluscum contagiosum: An update. Recent Pat Inflamm Allergy Drug Discov 2017;11:22-31.
Katz KA. Dermatologists, imiquimod, and treatment of molluscum contagiosum in children: Righting wrongs. JAMA Dermatol 2015;151:125-6.
Yashar SS, Shamiri B. Oral cimetidine treatment of molluscum contagiosum. Pediatr Dermatol 1999;16:493.
Meadows KP, Tyring SK, Pavia AT, Rallis TM. Resolution of recalcitrant molluscum contagiosum virus lesions in human immunodeficiency virus-infected patients treated with cidofovir. Arch Dermatol 1997;133:987-90.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]