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Three GPs share their approach to a clinical problem

Case history

Mrs Hermon has brought three-year-old Tommy to see you. Four weeks ago Mrs Hermon harangued a locum into referring Tommy to a private paediatrician for his mild case of molluscum contagiosum. Tommy isn't worried by the lesions on his abdomen, but his mum thinks they are unsightly and embarrassing when Tommy goes for his swimming lessons.

Mrs Hermon is clutching a private prescription for cimetidine, which the paediatrician has recommended as an off-licence treatment for molluscum. The locum is now in New Zealand and Mrs Hermon would like you to prescribe cimetidine on the NHS for Tommy's unsightly lumps.

Dr Rachel McKenzie

'Her apparent over-reaction could be an indicator of how she's coping with motherhood'

I have concerns about prescribing any medication off licence, especially for a young child. Cimetidine has a number of well-reported adverse effects and interactions, and I'm not happy to prescribe it under these circumstances. I would tell Mrs Hermon this, explaining that I don't feel the potential benefits of prescribing this drug outweigh the risks.

There's no need to prescribe any medication at all because the molluscum lesions aren't causing Tommy distress, they are of no clinical consequence and will eventually fade if left alone.

I can, however, understand Mrs Hermon's concerns; any lesion that is noticeable at Tommy's swimming lessons will invite comment. Other parents will wonder whether their children could become infected and may think the lesions are a sign of an underlying condition. Molluscum contagiosum in adults can be sexually transmitted and is associated with HIV infection.

I can't stop Mrs Hermon getting cimetidine from her private prescription, but I'd suggest that she at least waits until I have explored the issue further. Molluscum can be treated topically, but for such a young child I would like to avoid freezing, cautery or cryotherapy. Topical retinoid gel is another option, but I'm not sure about this for a three-year-old. I'd prefer to discuss the options with a paediatrician or dermatologist and follow Tommy up once I've got more information.

I would also take the opportunity to explore any other anxieties that Mrs Hermon might have. Her apparent over-reaction to this condition could be an indicator of how she is feeling in general or how she is coping with motherhood. How she relates with her son and me could unearth maternal mental health problems. If it becomes apparent that she needs more support I would arrange for our health visitor to get in touch.

It may not be possible to maintain a good therapeutic relationship if Mrs Hermon has a history of haranguing health professionals until she gets her way, but I hope that we can manage to reach a consensus.

Rachel McKenzie completed the VTS in August 2000 –she is now a GP in Dunvegan, Isle of Skye

Dr Ian James

'It's important to explain that I won't have indemnity from the drug's manufacturer if Tommy develops any problems'

This illustrates how using locums and sessional doctors fragments patient care. A satisfactory outcome to this consultation will depend on the strengths of the relationship built up by Mrs Hermon's regular doctor.

It's helpful that Tommy isn't worried about his lesions and I could build on this. I'll stress that molluscum contagiosum is benign, self-limited and caused by a virus. Tommy is likely to develop immunity to the virus with time, and then it will disappear spontaneously.

It's not going to be easy to win Mrs Hermon round, although I'd hope that the locum and paediatrician would have given similar advice. But as Mrs Hermon has probably paid to see the specialist she may be determined for Tommy to take the cimetidine.

Cimetidine is known to stimulate T-lymphocytes, which are important for controlling viral infections. But a literature search doesn't produce any convincing evidence for benefit in molluscum contagiosum.

It's important to explain that the paediatrician is suggesting I prescribe cimetidine off licence, so I won't have indemnity from the manufacturer if Tommy develops any problems. Clinical experience in children is limited and cimetidine can't be recommended for patients under 16 unless the benefits outweigh risks – doubtful in this case.

If Mrs Hermon is still reticent, I could review Tommy to chart his lesions and hopefully reassure her that they are clearing. But the bottom line is to insist Mrs Hermon obtains the cimetidine on a private prescription from the specialist.

Ian James is a GP in Bolton, Lancashire, with more than 20 years' experience in practice

Dr Sarah Humphery

'The paediatrician who originally prescribed the treatment to Tommy should take responsibility for it – not me'

I would probably start the consultation looking bemused, because I haven't heard of using cimetidine to treat molluscum contagiosum. I'd be honest with Mrs Hermon and tell her this. I would ask Mrs Hermon what her concerns are about the lumps and try to address these issues. I would also check how Tommy felt about them.

I'd discuss the natural history of molluscum contagiosum, how the lumps disappear after a time and how they don't usually need treatment. I'd recommend that Tommy doesn't pick at them because they could become infected. If that happens I have occasionally given antibiotics to patients in the past. I'd explain how to avoid transmitting the condition, by giving Tommy his own flannel and towel.

I would explain that I'm not comfortable giving an NHS script for a treatment I don't feel is necessary, that isn't licensed for this use and that could have side-effects. She probably won't be happy. She may become insistent, but I'd hold my ground. I would also explain that I'm responsible for any prescription I write and I feel the paediatrician who originally prescribed the treatment should take responsibility for it.

I'd offer to speak to the paediatrician; I'd like to know what the evidence and rationale is for using cimetidine in a three-year-old with molluscum contagiosum. Mrs Hermon could get the drug privately, but I'd emphasise that I think it's an unnecessary treatment. Afterwards I would ask my colleagues whether they have heard of this use of cimetidine and do a literature search on the internet.

Sarah Humphery is a GP retainer in north London – she completed the VTS in 1997

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