Case
A 14-year-old girl presents to A&E with recurrent irritation in her right eye. During slit-lamp examination a 2mm lesion on the right upper eyelid is noted.
The lesion has been gradually increasing in size for four to five months and she has several similar small cysts on her face.
The lesion has raised, pearly edges with telangiectasia and an umbilicated centre. There is no associated lash loss – lid eversion reveals follicles on the upper and lower lid tarsal conjunctiva.
The remaining examination is unremarkable with healthy optic discs, no diplopia and no lymphadenopathy. A clinical diagnosis of molluscum contagiosum is made and the patient has an excision biopsy.
The problem
Molluscum contagiosum is a benign viral cutaneous neoplasm. Lesions appear as raised, pearly papules or nodules on the skin or mucous membranes.
The infection is common in children, and it spreads mainly by direct contact or contaminated clothing or towels.
Lesions may occur anywhere on the body except the palms and soles – frequently on the face, arms, armpit, neck, legs and hands.
The virus also spreads by sexual
contact – lesions on the genitalia may be mistaken for herpes or warts but, unlike herpes, these lesions are painless.
Features
- Lesions begin as small, painless papules that develop into pearly, flesh-coloured nodules.
- The papule often has an umbilicated centre.
- Scratching causes the virus to spread in a line or in groups.
- Papules are 2-5mm wide.
- In adults, the lesions are commonly seen on the genitals, abdomen and inner thigh.
- Diagnosis is clinical, but can be confirmed by a skin biopsy.
- A patient with periocular lesions may present with chronic conjunctivitis which is refractory to treatment with antibiotics secondary to viral shedding.
Differential diagnosis
- Basal cell carcinoma – an ulcerating lesion with pearly, rolled edges – usually associated with lash loss – which may bleed on minor trauma
- Warts — often have a rough surface with no central umbilication
- Milia — white keratinous cysts on the face, most frequently around the eyes
- Syringoma (uncommon) — small, pale papules on the lower lids, no umbilication
- Cutaneous cryptococcosis (rare) — umbilicated papules, opportunistic yeast infection only seen in immunocompromised patients.1
Examination
- Check visual acuity.
- Assess lesion – size, shape, ulceration? Pearly edges? Crusting or bleeding?
- Evert lids to assess for presence of any follicles.
- Check for lash loss, diplopia and lymphadenopathy.
- Enquire about any other lesions on the body.
Referral
- Urgent referral is required if there is any suspicion of BCC.
- If a patient with periocular molluscum is asymptomatic and not bothered by the lesion a referral might not be needed.
- But we recommend a routine referral as the lesions can cause chronic conjunctivitis.
Treatment
Treatment of a single or a few periocular lesions will take place in the eye clinic and usually involves excision under local anaesthetic.
In widespread disease, several treatment options are available including cryotherapy, diathermy, topical imiquimod2 and pulsed-dye laser treatment.3
Miss Claire Daniel is a consultant ophthalmic surgeon and Miss Lucy Barker is a specialist registrar at Moorfields Eye Hospital, London
References
1 Smolinski KN and Yan AC. How and when to treat: molluscum contagiosum and warts in children. Pediatric Annals 2005;34:211-21
2 Hengge UR, Esser S, Schultewolter T et al. Self-administered topical 5% imiquimod for the treatment of common warts and molluscum contagiosum. Br J Dermatol 2000;143:1026-31
3 Hammes S, Greve B and Raulin C. Molluscum contagiosum: treatment with pulsed-dye laser. Hautzart 2001;52:38-42
