Molluscum contagiosum

Abstract

Molluscum contagiosum, a viral disease of the skin, manifests as a smooth-surfaced, firm, and spherical papule with umbilication of the vertex. It commonly presents as multiple lesions, which may be extensive in immunocompromised patients, and may mimic cutaneous tumors in HIV co-infected patients. Infection usually persists for 6 months to 5 years before resolving naturally. Among immune-impaired persons with HIV infection is generally more persistent. To date, single and combination therapies for such patients have been unsatisfactory. Recent observations from a dermatology practice in which 6 patients with HIV and molluscum contagiosum were treated with 5-aminolevulinic acid (Levulan[R] Kerastick[R]) in conjunction with photodynamic therapy suggest clinical benefits: i.e., substantial reduction in lesional count and severity. Additional research is mandated.

Introduction

Molluscum contagiosum, a viral disease of the skin, is usually limited to children, sexually active adults, and immunocompromised individuals. It manifests as a smooth-surfaced, firm and spherical papule with umbilication of the vertex (1,2). The disease commonly presents with multiple lesions, which may be extensive in 5% to 18% of immunocompromised patients (2-6). Lesions may mimic cutaneous tumors or other infections in HIV coinfected patients (7).

Among individuals in the general population, infection persists for 6 months to 5 years before resolving naturally (8). Among immune-impaired persons with HIV, infection is more persistent unless CD4 counts can be increased with antiretroviral therapy (9). Regardless, many dermatologists prefer to treat the molluscum contagiosum due to its propensity to spread easily (8), and patients generally prefer treatment to remove unsightly lesions and disfigurements.

Treatment of the immunocompromised patient has included cryosurgery, electrocautery, scraping with a curette, topical medications, intravenous pharmacotherapy, and laser therapy. The clinical response to such treatments, alone or in combination, has been unsatisfactory and have led to scientific and clinical experimentation in search of more effective methods of disease control (6,10). This report presents recent observations from a dermatology practice in which 40 patients with either actinic keratosis or molluscum contagiosum virus were treated with a unique delivery system for 5-aminolevulinic acid (Levulan[R] Kerastick[R]) in conjunction with photodynamic therapy. The following evidence documents 6 of those patients with HIV and molluscum contagiosum coinfection.

Study Objective

Evaluate the effectiveness of 5-aminolevulinic acid and photodynamic therapy (PDT) for molluscum contagiosum in persons with HIV.

Methodology

Patients (n=6) with clinically confirmed molluscum contagiosum and clinically documented HIV who met specific study inclusion/exclusion criteria (see Table 1) and signed an informed consent form were selected for PDT. Prior to treatment, lesions were cleaned with acetone to remove excessive oil. A delivery system for 5-aminolevulinic acid (Levulan[R] Kerastick[R]) was prepared properly by thorough mixing and applied twice (5-10 minutes between applications for drying) in a broad manner. Between 14 and 24 hours later, BLU-U[R] light treatment was subsequently directed to facial lesions. Goggles were used to cover the eyes of each patient, and their entire face was placed under the light for a total of 16 minutes and 40 seconds.

Baseline photographs of the lesions were taken at the first visit. Patients were then followed with serial photographs (see Figures) and clinical exams. Evidence of improvement was documented with each subsequent photograph.

[FIGURES OMITTED]

Results

All patients experienced improvement in their lesion count, regardless of lesion locations (see Table 2). In two patients, one treatment produced an improvement in the lesion count of 60%. Furthermore, patients who received 3-5 treatments were found to have a 75-80% reduction in the number of lesions counted.

Treatment with 5-aminolevulinic acid and PDT elicited a phototoxic reaction that included erythema, edema, vesiculation, hyperpigmentation, hypopigmentation, pain, stinging/burning, and itching. The only moderately intense side effect was a burning sensation described by one patient when placed under the BLU-U[R] light.

Conclusion

This method of photodynamic therapy treatment is a viable option for treating molluscum contagiosum virus in HIV patients. A larger study is warranted to better assess this method of treatment for the molluscum contagiosum virus. Although this study used the application of BLU-U[R] light, other light sources (i.e., Intense Pulsed Light (IPL), Long Pulse Dye Laser (LPDL)) can activate the drug, therefore further research should explore these viable options. From this sample of patients, treatment with 5-aminolevulinic acid and PDT elicited superior results compared to other methods of treatment previously used in this practice. Observed cosmetic and psychologic enhancements were noted in patients and likely were related to visual improvements that occurred in a timely manner. All patients voiced preference for 5-aminolevulinic acid and PDT therapy over previous therapies they had received for the molluscum contagiosum virus.

Table I

Patient Inclusion/Exclusion Criteria

Inclusion criteria:

* Male and non-pregnant female outpatients, 18 years and older

* Presence of suspected molluscum contagiosum

* Written informed patient consent

* HIV positive

Exclusion Criteria:

Patients presenting with any of the following were not included in the study:

* A history of cutaneous photosensitization, porphyria, hyper sensitivity to porphyrins, or photodermatoses

* A known sensitivity to the use of Levulan[R] or any of its vehicle components

* Uncorrected coagulation defects

* Pregnant or lactating patients

Prior Therapy Washout:

* No treatment within 1 month: systemic steroid therapy or topical treatment with any other investigational drug

* No treatment within 2 months: laser resurfacing, chemical peels, topical application of 5-flurorouracil for treatment of MCV, systemic treatment with chemotherapeutic agents, psoralens, or immunotherapy

References

(1.) Control of communicable diseases manual. 17th ed. Washington D.C.: American Public Health Association, 2000.

(2.) Lowy DR. Molluscum contagiosum, In: Freedberg IM, Eisen AZ, Wolff K et al, editors. Dermatology in general medicine. New York: The McGraw-Hill Companies, Inc., 1999: 2478-2481.

(3.) Coldiron BM, Bergstresser PR. Prevalence and clinical spectrum of skin disease in patients infected with human immunodeficiency virus. Arch Dermatol 1989; 125(3):357-361.

(4.) Matis WL. Triana A, Shapiro R. et al. Dermatologic findings associated with human immunodeficiency virus infection. J Am Acad Dermatol 1987; 17(5 Pt 1):746-751.

(5.) Goodman DS, Teplitz ED, Wishner A, et al. Prevalence of cutaneous disease in patients with acquired immunodeficiency syndrome (AIDS) or AIDS-related complex. J Am Acad Dermatol 1987:17(2 Pt 1):210-220.

(6.) Schwartz JJ, Myskowski PL. Molluscum contagiosum in patients with human immunodeficiency virus infection. A review of twenty-seven patients. J Am Acad Dermatol 1992; 27(4):583-588.

(7.) Johnson RA. Cutaneous manifestations of HIV disease. In: Freedberg IM. Eisen AZ, Wolff K et al, editors. Dermatology in general medicine. New York: The McGraw-Hill Companies, Inc. 1999:2505-2538.

(8.) Molluscum contagiosum. American Academy of Dermatology Website. 2000. Available at: www.aad.org/pamphlets/molluscum1.html. Accessed January 14, 2003.

(9.) Hicks CB. et al. Resolution of intractable molluscum contagiosum in a human immunodeficiency virus-infected patient after institution of antiretroviral therapy with ritonavir. Clin Infect Dis 1997: 23:1023.

(10.) Gottlieb SL, Myskowski PL. Molluscum contagiosum. Int J Dermatol 1994: 33(7):453-61.

ALI MOIIN MD CLINICAL ASSISTANT PROFESSOR, WAYNE STATE UNIVERSITY MEDICAL DIRECTOR, OF A COMPREHENSIVE DERMATOLOGY CENTER TROY, MICHIGAN

ADDRESS FOR CORRESPONDENCE:

Ali Moiin MD

A Comprehensive Dermatology Center

Medical Square Village

1575 W Big Beaver Rd, Suite C-12

Troy, MI 48084

Phone: (248) 643-7677

Fax: (248) 643-7679

E-Mail: AMoiin@aol.com

COPYRIGHT 2003 Journal of Drugs in Dermatology
COPYRIGHT 2004 Gale Group