Molluscum contagiosum This condition is a benign viral infection that appears as crops of discrete, slightly umbilicated, flesh-colored, or shiny papules. It is extremely common among children and may be seen in several children within a family. The lesions may become inflamed if traumatized or infected and sometimes become inflamed spontaneously as they resolve.

The lesions tend to be grouped, and the average size of a lesion is 2 to 3 mm in diameter and height. The trunk, face, genitalia, and intertriginous areas are the most common sites of infection. Pruritus is an occasional symptom and an eczematous eruption may develop in the area of the molluscum.

Molluscum contagiosum This viral infection is self-limited, but treatment is often required because of discomfort or out of concern for appearance. Treatment should be individualized to the age and extent of involvement in each patient.

As the infection is self-limited, observation is an acceptable option. In the cooperative patient, destruction of lesions with curettage or light cryotherapy may be attempted for treatment of limited lesions. Some dermatologists treat this disorder with the office application of topical cantharidin. The child with numerous lesions poses a particular therapeutic challenge.

Molluscum contagiosum Occasionally, a lesion of molluscum contagiosum may grow to as large as 3 cm in diameter. Two photos of such “giant mollusca” are shown in Figs. 5-5 and 5-6. The diagnosis is usually suggested by the presence of more typical, smaller lesions on adjacent or distant skin surfaces. Note the presence of a central umbilication in Fig. 5-5. Treatment is by surgical removal when possible.

Molluscum contagiosum When molluscum contagiosum appear in the groin or especially the intergluteal cleft area, they may be misdiagnosed as warts. Molluscum in the intergluteal cleft area may appear like “fleshy” skin tags, and upon close examination that can be aided by magnification, a central umbilication can be seen. If the diagnosis is in question, a biopsy would yield the diagnosis.

Some patients with molluscum contagiosum will develop scarring from this viral infection. Large and even small molluscum may scar even without any treatment. Figure 5-8 shows a patient who developed scarring without any treatment given for the molluscum.

Molluscum contagiosum dermatitis Many children with molluscum contagiosum infection develop an eczematous, pruritic dermatitis surrounding the affected area of involvement. Low potency topical corticosteroids can alleviate the dermatitis. At times, the lesions in the involved area may have to be treated in order to permanently clear the dermatitis.

Molluscum contagiosum id reaction Some patients may develop a hypersensitivity eruption as a result of the immune response to the virus. This eruption favors the extremities, particularly the elbows (Fig. 5-11) and knees, with skin colored to erythematous papules and grouped papulovesicles. The buttocks may also be involved. Inflamed molluscum is seen elsewhere. Note the inflamed mollusum on the abdomen in Figs. 5-11 and 5-12. The papules on the elbow and hand in Fig. 5-12 are related to the id reaction and are not inflamed molluscum.

Verruca vulgaris The common wart is a benign growth caused by localized infection with one of the many types of human papillomavirus. These small DNA viruses are part of the papovavirus group. Warts are especially common among children and adolescents and may occur on any mucocutaneous surface. The hands are a particularly frequent location.

The typical wart is a rough-surfaced nodule that may be either lighter or darker than the surrounding skin. Lesions involving the proximal and lateral nail folds are common and present particular treatment difficulties.

Verruca vulgaris Gentle cryotherapy or topical salicylic acid preparations may be of value in the treatment of warts. However, severe warts such as those shown in Fig. 5-15 may require additional therapies, such as injection with intralesional candida antigen.

Figure 5-16 illustrates multiple warts located on the palmar surface of the hand. In general, treatment must be individualized to the age and cooperative abilities of the patient and to the size and location of the warts.

Verruca vulgaris Following the application of cantharidin or liquid nitrogen, blister formation may result. Upon resolution of the blister, a ring wart may develop, as seen in Fig. 5-17.

Multiple ring warts are seen in Fig. 5-18.

Verruca vulgaris Although the hands are the most common location for warts in children, they may occur on almost any part of the skin surface.

Figure 5-20 illustrates the appearance of multiple clustered warts on the knee.

Plantar warts Plantar warts appear as flat areas of firm hyperkeratosis on the soles of the feet. Lesions that occur at points of pressure may be associated with severe pain on walking. Figure 5-21 illustrates solitary and multiple plantar warts. Note the obliteration of skin markings, which does not occur in a callus. The lesions in Fig. 5-22 on the heel are numerous and mosaic. Treatment of plantar warts requires perseverance on the part of both patient and physician.

Attempts at a rapid cure may result in scarring. One practical method involves the daily application of salicylic acid plasters or liquid salicylic acid preparations along with repeated paring of the necrotic surface of the wart. The success of this routine may be hastened by gentle cryotherapy.

Filiform warts The surfaces of common warts are influenced by their position on the body. In general, they have a rough surface. On hands, the surfaces of warts are doomed from wear and tear, so that troughs and crests are shallow; on soles, they are flat and smooth from the weight of the body, but where they are undisturbed, common warts tend to grow with fimbria or fingerlike projections. They are then called filiform or digitate warts.

The face and scalp are the most common sites where warts grow in this fashion Filiform warts may also occur on the lips as shown in Fig. 5-24.

Verruca plana Plane, or flat, warts may be caused by several types of the human papillomavirus. They are common in children. The lesions are slightly raised, flesh-colored papules, and usually 2 to 4 mm in diameter.

The face and hands are the most frequent locations for these multiple small warts. The lesions may be discrete or confluent, and a linear array of flat warts, as shown in Fig. 5-26, may result from autoinoculation in a scratch.

Condyloma acuminatum Warts with this “cauliflower” appearance on the labia (Fig. 5-27), penis, or around the rectum (Fig. 5-28) are termed condylomata acuminata. The presence of lesions of this type in a child should prompt the physician to consider the possibility of sexual abuse, although the true incidence of this association is not known. In very young children, perinatal transmission is probably the most common cause.

In some cases, as well, condylomata acuminata may be the result of innocent contact with another infected individual. The use of topical products containing podophyllum or imiquimod are effective treatments.

Epidermodysplasia verruciformis This rare familial disease usually has its onset during childhood. Patients develop numerous flat warts, initially involving the face and upper trunk. A number of human papillomavirus types have been implicated. As the lesions tend toward confluence, they may mimic the appearance of tinea versicolor. Most patients with epidermodysplasia verruciformis have depressed cell-mediated immunity, and they are also at risk for squamous cell carcinoma. A similar presentation may be seen in children with HIV infection.

Neonatal herpes simplex Neonatal herpes simplex infection is acquired during passage through an infected birth canal. The cutaneous involvement may be as extensive as shown in Fig. 5-30, or it may be subtle. The scalp is the most common site for the typical clustered vesicles.

Because of the very high frequency of concurrent disseminated disease, cutaneous herpes simplex in the newborn must be considered a pediatric emergency. Early treatment with an intravenous antiviral agent minimizes complications and offers the infant the best possibility of survival.

Herpes simplex Herpes simplex infection of the fingers may occur in infants and young children. The first episode may accompany herpetic gingivostomatitis.