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What's Your Diagnosis? Inflamed Vulvar Papules in a 7-Year-Old Girl
J Pediatr Adolesc Gynecol (2005) 18:179–182
Pedi-Gyn Derm What’s Your Diagnosis? Inflamed Vulvar Papules in a 7-Year-Old Girl Section Editor and Author: Jonathan D.K. Trager, MD The Mount Sinai Medical School, New York, New York, USA
Introduction A 7-year-old girl presents with painless, nonpruritic vulvar lesions of several weeks’ duration. The lesions have a white core and an inflamed base and at first appear to be pustules (Fig. 1). However, when you gently try to express material for a culture you discover that the lesions are papules rather than pustules. It is not until you notice the smooth pink papules on her left upper inner thigh that the diagnosis becomes apparent.
Questions for the Clinician What’s your diagnosis? What tests would you perform? What treatment would you prescribe?
Diagnosis: Molluscum Contagiosum The key to making this diagnosis is recognizing that molluscum contagiosum (MC) may become inflamed and look more like folliculitis. The typical smooth, umbilicated papules of MC may not always be present to help make the diagnosis. Common causes of inflamed (erythematous) vulvar papules in young girls are molluscum contagiosum, folliculitis (e.g., from Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa), scabies, insect bites, and papular eczema. Condylomata may also become inflamed but generally have a more typical wart-like appearance. Vulvar syringomas1 are usually not inflamed. Address correspondence to: Jonathan D.K. Trager, MD, Adolescent-Young Adult Medicine of Great Neck, LLC, 212 Middle Neck Road, Suite #5, Great Neck, NY 11021; E-mail: [email protected]
쑖 2005 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
Clinicians should be aware of the variety of clinical appearances of MC (see Key Features of Molluscum Contagiosum).
Tests No tests are necessary in this patient as the diagnosis is apparent clinically.
Treatment Several treatment options, reviewed below, may be offered. This girl’s lesions resolved after several sessions of topical treatment with cantharone.
Clinical Pearls and Pitfalls
•
•
Young siblings of girls with vulvar (or any) MC should be checked by parents or clinicians since spread among young siblings is common. This patient’s sister had MC of her upper inner thighs which were also successfully treated with cantharone. MC can occur on the vulva, suprapubic area, perineum, perianal area, and upper inner thighs; a careful examination will determine the extent of clinical lesions. The extent of subclinical infection cannot be determined; only visible lesions can be diagnosed. A full skin examination should be performed since lesions may have spread (especially to the trunk and axillae) by autoinoculation. Similarly, the presence of extra-genital MC should prompt a genital skin examination since lesions may spread by autoinoculation to the genital area. 1083-3188/05/$22.00 doi:10.1016/j.jpag.2005.03.013
180
Trager: Inflamed Vulvar Papules
Fig. 1. Seven-year-old girl with inflamed vulvar papules. Note the smooth pink papules on the left upper inner thigh.
•
•
•
MC may spread locally by shaving pubic hair. It is not uncommon to see multiple lesions of MC throughout a shaved pubic area. It is also not uncommon for a young woman to shave her pubic hair to get a better look at the bumps she has noticed, only to spread the lesions further. Remind young women that MC can be transmitted to sexual partners by intimate skin-to-skin contact, even without sexual intercourse, and that condoms obviously won’t prevent spread of MC to or from areas not protected by the condom. “Inflamed” MC is not necessarily “secondarily infected” MC. In this patient, the lesions were inflamed but not secondarily infected. Inflammation of MC papules can occur as part of the lesions’ natural course, from picking or scratching, or from friction related to the anatomic area or the rubbing of clothing. Signs that MC is secondarily infected with bacteria include a larger area of surrounding erythema or frank cellulitis, with or without lymphangitis, tenderness, and a purulent or fluctuant center. Regional lymphadenopathy may or may not be present. It may sometimes be difficult to differentiate between inflamed MC and secondarily infected MC; in
•
that case, empiric treatment with an oral antistaphylococcal and anti-streptococcal antibiotic may be prescribed. Great care should be given to individualizing treatment. An adolescent girl with multiple genital MC lesions may want them all removed by curettage in one setting, despite the potential discomfort; however, the same approach may be inappropriate for a timid 5-year-old. Parents frustrated by the extent and duration of genital MC in their daughter may demand immediate removal of all lesions without fully understanding the implications of that demand. It is the clinician’s duty to review the pros and cons of all treatment methods, including no intervention. Do not make the treatment worse than the problem. Remind parents and older patients that: 䊊 No treatment is perfect or risk-free 䊊 Some clinician-administered treatments may hurt or scar 䊊 Topical agents may cause irritation 䊊 Lesions may become secondarily infected 䊊 New lesions may occur for months despite appropriate treatment
Trager: Inflamed Vulvar Papules
•
While genital MC in young girls may be acquired by sexual contact, the mere presence of genital MC in a young girl is neither sensitive nor specific enough to justify a clinician’s reporting suspected sexual abuse.2 However, the clinician evaluating genital skin lesions in a child should always be alert to clinical or behavioral signs of sexual abuse that would warrant further evaluation.
Key Features of Molluscum Contagiosum
• •
•
•
•
Definition 䊊 MC is a viral infection of the epidermal layer of the skin. Pathogenesis3 䊊 Infection is caused by the Molluscipoxvirus of which there are three subtypes (MCV-1, MCV-2, and MCV-3); all present similarly without localization to a particular body area. 䊊 Transmission can occur by: ■ Casual contact ■ Fomites ■ Auto-inoculation ■ Sexual contact 䊊 The incubation period ranges from 14 to 50 days. Epidemiology3 䊊 The incidence of MC is not known with certainty. 䊊 MC accounts for approximately 1% of all diagnosed dermatologic conditions. Clinical Presentation 4 䊊 Most children are asymptomatic. However, one third of children may experience symptoms from, or secondary reactions to the infection, including pruritus, erythema, inflammation and pain.4 䊊 Lesions may present as single or multiple papules. 䊊 Papules range in size from 1–5 mm; giant MC (⬎ 1 cm) may occur and are more common in HIV-infected individuals. 䊊 Lesions may be white, pink, erythematous, or skin-colored 䊊 MC papules may become secondarily infected 䊊 Lesions may take on a skin tag-like appearance Diagnosis 䊊 The diagnosis is usually straightforward on clinical examination 䊊 If the diagnosis is in doubt, remove a lesion by curettage, place it on a glass side, apply potassium hydroxide and a cover-slip, gently press the cover-slip to distribute the
•
181
material evenly, and examine microscopically for molluscum bodies (virally infected keratinocytes) 䊊 Laboratory Tests ■ A lesion removed by curettage may be sent for histopathologic examination for molluscum bodies Treatment3–5 䊊 No treatment – or watchful waiting ■ Lesions of MC will eventually resolve on their own; however, several issues make watchful waiting problematic: • It may take weeks to months for individual lesions to resolve and months to years for the entire eruption to resolve. • Lesions may spread by autoinoculation, to other siblings, or to sexual partners while waiting for the eruption to clear spontaneously. • Parents may feel uncomfortable, even guilty, for not treating their daughter’s genital bumps; later, parents may become upset when they find out that lesions could have been treated effectively. • Sexually active adolescents and young adults do not want to wait for genital bumps to clear up on their own and will seek out clinicians who will treat them promptly. 䊊 Topical treatment ■ At home treatments are often preferred by parents and children but are generally not as effective nor work as rapidly as clinicianperformed treatments.4 None are approved by the U.S. Food and Drug Administration (FDA) for the treatment of MC. • Tretinoin. Likely works by inciting an irritant/inflammatory reaction. Use with caution in the genital area due to skin irritation. • Imiquimod. Effective for treating MC in children but may cause skin irritation.6,7 • Cidofovir. This antiviral agent has been used topically to treat MC in HIVinfected children.8 ■ Clinician-performed treatment • Curettage. Individual lesions are removed with a curette. The procedure is highly effective with immediate results. Application of a topical anesthetic cream beforehand helps reduce pain. Scarring may result. • Cryotherapy. Individual lesions are frozen for approximately 15 seconds with liquid nitrogen on a cotton-tipped applicator. As with curettage, pain can be
182
䊊
䊊
•
Trager: Inflamed Vulvar Papules
reduced by prior application of a topical anesthetic cream. May cause scarring and pigmentary changes. • Cantharone (not available in the USA; may be purchased from Canada). A small drop of cantharidin 0.7% (Cantharone) is applied with a toothpick or the blunt end of a cotton-tipped applicator to each lesion and allowed to dry. The medication is washed off after 4 hours and a topical antibiotic such as mupirocin ointment is applied twice a day for 1 to 2 weeks to decrease inflammation and prevent secondary infection. Cantharone acts by inciting a blistering reaction in the individual lesion which leads to its resolution. It is painless when applied, but may cause significant blistering and irritation. This is a very effective treatment9 but should be used carefully in the genital area. • Trichloroacetic acid. May be used if only a few lesions are present. Pain, inflammation, and scarring may result. Generally not used in young children due to irritation. Systemic treatment ■ Cimetidine. Oral treatment with cimetidine has been used with variable results.10–12 It is not FDA-approved for the treatment of MC. Other considerations ■ An eczematous eruption may develop around lesions of MC due to scratching; lesions of MC also tend to proliferate in areas of preexisting eczema. ■ Application of a low-potency topical steroid daily or twice daily for a week, with a moisturizer, should allow the eczematous reaction to resolve without worsening the MC infection. Clinical Course and Prognosis 䊊 Infection is self-limited; however, the entire eruption may take 6 months to 5 years to clear spontaneously.3 䊊 HIV-infected individuals have difficulty clearing lesions, even with treatment. 䊊 How quickly a treated eruption of MC resolves varies depending on the number of lesions and the treatment method used. 䊊 Monitor for side effects and complications of treatment as noted above (skin irritation, pain,
•
blistering, secondary infection, scarring, and pigmentary changes). Psychosocial support 䊊 The level of distress for girls and young women with genital MC can vary; treatment should be made as comfortable as possible. 䊊 For sexually active adolescents and young women, counseling should focus on the benign nature of the infection, the mode of transmission, and the generally excellent prognosis of MC. Appropriate screening for other sexually transmitted diseases should be performed.
References 1. Trager JD, Silvers J, Reed JA, et al: Neck and vulvar papules in an 8-year-old girl. Arch Dermatol 1999; 135:203 2. McIntyre L: Reply to Bargman H: Genital molluscum contagiosum in children: evidence of sexual abuse? CMAJ 1986; 135:432 3. Tyring SK: Molluscum contagiosum: the importance of early diagnosis and treatment. Am J Obstet Gynecol 2003; 189:S126 4. Silverberg N: Pediatric molluscum contagiosum: optimal treatment strategies. Pediatr Drugs 2003; 5:505 5. Trager JDK: Sexually transmitted diseases causing genital lesions in adolescents. Adolesc Med Clin 2004; 15:323 6. Bayerl C, Feller G, Goerdt S: Experience in treating molluscum contagiosum in children with imiquimod 5% cream. Br J Dermatol 2003; 149(Suppl 66):25 7. Theos AU, Cummins R, Silverberg NB, et al: Effectiveness of imiquimod cream 5% for treating childhood molluscum contagiosum in a double-blind, randomized pilot trial. Cutis 2004; 74:134 8. Toro JR, Wood LV, Patel NK, et al: Topical cidofovir: a novel treatment for recalcitrant molluscum contagiosum in children infected with human immunodeficiency virus 1. Arch Dermatol 2000; 136:983 9. Silverberg NB, Sidbury R, Mancini AJ: Childhood molluscum contagiosum: experience with cantharidin therapy in 300 patients. J Am Acad Dermatol 2000; 43:503 10. Dohil M, Presdiville JS: Treatment of molluscum contagiosum with oral cimetidine: clinical experience in 13 patients. Pediatr Dermatol 1996; 13:310 11. Cunningham BB, Paller AS, Garzon M: Inefficacy of oral cimetidine for nonatopic children with molluscum contagiosum [Letter]. Pediatr Dermatol 1998; 15:71 12. Yashar SS, Sharmiri B: Oral cimetidine treatment of molluscum contagiosum [Letter]. Pediatr Dermatol 1999; 16:493
Pedi-Gyn Derm What’s Your Diagnosis? Inflamed Vulvar Papules in a 7-Year-Old Girl Section Editor and Author: Jonathan D.K. Trager, MD The Mount Sinai Medical School, New York, New York, USA
Introduction A 7-year-old girl presents with painless, nonpruritic vulvar lesions of several weeks’ duration. The lesions have a white core and an inflamed base and at first appear to be pustules (Fig. 1). However, when you gently try to express material for a culture you discover that the lesions are papules rather than pustules. It is not until you notice the smooth pink papules on her left upper inner thigh that the diagnosis becomes apparent.
Questions for the Clinician What’s your diagnosis? What tests would you perform? What treatment would you prescribe?
Diagnosis: Molluscum Contagiosum The key to making this diagnosis is recognizing that molluscum contagiosum (MC) may become inflamed and look more like folliculitis. The typical smooth, umbilicated papules of MC may not always be present to help make the diagnosis. Common causes of inflamed (erythematous) vulvar papules in young girls are molluscum contagiosum, folliculitis (e.g., from Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa), scabies, insect bites, and papular eczema. Condylomata may also become inflamed but generally have a more typical wart-like appearance. Vulvar syringomas1 are usually not inflamed. Address correspondence to: Jonathan D.K. Trager, MD, Adolescent-Young Adult Medicine of Great Neck, LLC, 212 Middle Neck Road, Suite #5, Great Neck, NY 11021; E-mail: [email protected]
쑖 2005 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
Clinicians should be aware of the variety of clinical appearances of MC (see Key Features of Molluscum Contagiosum).
Tests No tests are necessary in this patient as the diagnosis is apparent clinically.
Treatment Several treatment options, reviewed below, may be offered. This girl’s lesions resolved after several sessions of topical treatment with cantharone.
Clinical Pearls and Pitfalls
•
•
Young siblings of girls with vulvar (or any) MC should be checked by parents or clinicians since spread among young siblings is common. This patient’s sister had MC of her upper inner thighs which were also successfully treated with cantharone. MC can occur on the vulva, suprapubic area, perineum, perianal area, and upper inner thighs; a careful examination will determine the extent of clinical lesions. The extent of subclinical infection cannot be determined; only visible lesions can be diagnosed. A full skin examination should be performed since lesions may have spread (especially to the trunk and axillae) by autoinoculation. Similarly, the presence of extra-genital MC should prompt a genital skin examination since lesions may spread by autoinoculation to the genital area. 1083-3188/05/$22.00 doi:10.1016/j.jpag.2005.03.013
180
Trager: Inflamed Vulvar Papules
Fig. 1. Seven-year-old girl with inflamed vulvar papules. Note the smooth pink papules on the left upper inner thigh.
•
•
•
MC may spread locally by shaving pubic hair. It is not uncommon to see multiple lesions of MC throughout a shaved pubic area. It is also not uncommon for a young woman to shave her pubic hair to get a better look at the bumps she has noticed, only to spread the lesions further. Remind young women that MC can be transmitted to sexual partners by intimate skin-to-skin contact, even without sexual intercourse, and that condoms obviously won’t prevent spread of MC to or from areas not protected by the condom. “Inflamed” MC is not necessarily “secondarily infected” MC. In this patient, the lesions were inflamed but not secondarily infected. Inflammation of MC papules can occur as part of the lesions’ natural course, from picking or scratching, or from friction related to the anatomic area or the rubbing of clothing. Signs that MC is secondarily infected with bacteria include a larger area of surrounding erythema or frank cellulitis, with or without lymphangitis, tenderness, and a purulent or fluctuant center. Regional lymphadenopathy may or may not be present. It may sometimes be difficult to differentiate between inflamed MC and secondarily infected MC; in
•
that case, empiric treatment with an oral antistaphylococcal and anti-streptococcal antibiotic may be prescribed. Great care should be given to individualizing treatment. An adolescent girl with multiple genital MC lesions may want them all removed by curettage in one setting, despite the potential discomfort; however, the same approach may be inappropriate for a timid 5-year-old. Parents frustrated by the extent and duration of genital MC in their daughter may demand immediate removal of all lesions without fully understanding the implications of that demand. It is the clinician’s duty to review the pros and cons of all treatment methods, including no intervention. Do not make the treatment worse than the problem. Remind parents and older patients that: 䊊 No treatment is perfect or risk-free 䊊 Some clinician-administered treatments may hurt or scar 䊊 Topical agents may cause irritation 䊊 Lesions may become secondarily infected 䊊 New lesions may occur for months despite appropriate treatment
Trager: Inflamed Vulvar Papules
•
While genital MC in young girls may be acquired by sexual contact, the mere presence of genital MC in a young girl is neither sensitive nor specific enough to justify a clinician’s reporting suspected sexual abuse.2 However, the clinician evaluating genital skin lesions in a child should always be alert to clinical or behavioral signs of sexual abuse that would warrant further evaluation.
Key Features of Molluscum Contagiosum
• •
•
•
•
Definition 䊊 MC is a viral infection of the epidermal layer of the skin. Pathogenesis3 䊊 Infection is caused by the Molluscipoxvirus of which there are three subtypes (MCV-1, MCV-2, and MCV-3); all present similarly without localization to a particular body area. 䊊 Transmission can occur by: ■ Casual contact ■ Fomites ■ Auto-inoculation ■ Sexual contact 䊊 The incubation period ranges from 14 to 50 days. Epidemiology3 䊊 The incidence of MC is not known with certainty. 䊊 MC accounts for approximately 1% of all diagnosed dermatologic conditions. Clinical Presentation 4 䊊 Most children are asymptomatic. However, one third of children may experience symptoms from, or secondary reactions to the infection, including pruritus, erythema, inflammation and pain.4 䊊 Lesions may present as single or multiple papules. 䊊 Papules range in size from 1–5 mm; giant MC (⬎ 1 cm) may occur and are more common in HIV-infected individuals. 䊊 Lesions may be white, pink, erythematous, or skin-colored 䊊 MC papules may become secondarily infected 䊊 Lesions may take on a skin tag-like appearance Diagnosis 䊊 The diagnosis is usually straightforward on clinical examination 䊊 If the diagnosis is in doubt, remove a lesion by curettage, place it on a glass side, apply potassium hydroxide and a cover-slip, gently press the cover-slip to distribute the
•
181
material evenly, and examine microscopically for molluscum bodies (virally infected keratinocytes) 䊊 Laboratory Tests ■ A lesion removed by curettage may be sent for histopathologic examination for molluscum bodies Treatment3–5 䊊 No treatment – or watchful waiting ■ Lesions of MC will eventually resolve on their own; however, several issues make watchful waiting problematic: • It may take weeks to months for individual lesions to resolve and months to years for the entire eruption to resolve. • Lesions may spread by autoinoculation, to other siblings, or to sexual partners while waiting for the eruption to clear spontaneously. • Parents may feel uncomfortable, even guilty, for not treating their daughter’s genital bumps; later, parents may become upset when they find out that lesions could have been treated effectively. • Sexually active adolescents and young adults do not want to wait for genital bumps to clear up on their own and will seek out clinicians who will treat them promptly. 䊊 Topical treatment ■ At home treatments are often preferred by parents and children but are generally not as effective nor work as rapidly as clinicianperformed treatments.4 None are approved by the U.S. Food and Drug Administration (FDA) for the treatment of MC. • Tretinoin. Likely works by inciting an irritant/inflammatory reaction. Use with caution in the genital area due to skin irritation. • Imiquimod. Effective for treating MC in children but may cause skin irritation.6,7 • Cidofovir. This antiviral agent has been used topically to treat MC in HIVinfected children.8 ■ Clinician-performed treatment • Curettage. Individual lesions are removed with a curette. The procedure is highly effective with immediate results. Application of a topical anesthetic cream beforehand helps reduce pain. Scarring may result. • Cryotherapy. Individual lesions are frozen for approximately 15 seconds with liquid nitrogen on a cotton-tipped applicator. As with curettage, pain can be
182
䊊
䊊
•
Trager: Inflamed Vulvar Papules
reduced by prior application of a topical anesthetic cream. May cause scarring and pigmentary changes. • Cantharone (not available in the USA; may be purchased from Canada). A small drop of cantharidin 0.7% (Cantharone) is applied with a toothpick or the blunt end of a cotton-tipped applicator to each lesion and allowed to dry. The medication is washed off after 4 hours and a topical antibiotic such as mupirocin ointment is applied twice a day for 1 to 2 weeks to decrease inflammation and prevent secondary infection. Cantharone acts by inciting a blistering reaction in the individual lesion which leads to its resolution. It is painless when applied, but may cause significant blistering and irritation. This is a very effective treatment9 but should be used carefully in the genital area. • Trichloroacetic acid. May be used if only a few lesions are present. Pain, inflammation, and scarring may result. Generally not used in young children due to irritation. Systemic treatment ■ Cimetidine. Oral treatment with cimetidine has been used with variable results.10–12 It is not FDA-approved for the treatment of MC. Other considerations ■ An eczematous eruption may develop around lesions of MC due to scratching; lesions of MC also tend to proliferate in areas of preexisting eczema. ■ Application of a low-potency topical steroid daily or twice daily for a week, with a moisturizer, should allow the eczematous reaction to resolve without worsening the MC infection. Clinical Course and Prognosis 䊊 Infection is self-limited; however, the entire eruption may take 6 months to 5 years to clear spontaneously.3 䊊 HIV-infected individuals have difficulty clearing lesions, even with treatment. 䊊 How quickly a treated eruption of MC resolves varies depending on the number of lesions and the treatment method used. 䊊 Monitor for side effects and complications of treatment as noted above (skin irritation, pain,
•
blistering, secondary infection, scarring, and pigmentary changes). Psychosocial support 䊊 The level of distress for girls and young women with genital MC can vary; treatment should be made as comfortable as possible. 䊊 For sexually active adolescents and young women, counseling should focus on the benign nature of the infection, the mode of transmission, and the generally excellent prognosis of MC. Appropriate screening for other sexually transmitted diseases should be performed.
References 1. Trager JD, Silvers J, Reed JA, et al: Neck and vulvar papules in an 8-year-old girl. Arch Dermatol 1999; 135:203 2. McIntyre L: Reply to Bargman H: Genital molluscum contagiosum in children: evidence of sexual abuse? CMAJ 1986; 135:432 3. Tyring SK: Molluscum contagiosum: the importance of early diagnosis and treatment. Am J Obstet Gynecol 2003; 189:S126 4. Silverberg N: Pediatric molluscum contagiosum: optimal treatment strategies. Pediatr Drugs 2003; 5:505 5. Trager JDK: Sexually transmitted diseases causing genital lesions in adolescents. Adolesc Med Clin 2004; 15:323 6. Bayerl C, Feller G, Goerdt S: Experience in treating molluscum contagiosum in children with imiquimod 5% cream. Br J Dermatol 2003; 149(Suppl 66):25 7. Theos AU, Cummins R, Silverberg NB, et al: Effectiveness of imiquimod cream 5% for treating childhood molluscum contagiosum in a double-blind, randomized pilot trial. Cutis 2004; 74:134 8. Toro JR, Wood LV, Patel NK, et al: Topical cidofovir: a novel treatment for recalcitrant molluscum contagiosum in children infected with human immunodeficiency virus 1. Arch Dermatol 2000; 136:983 9. Silverberg NB, Sidbury R, Mancini AJ: Childhood molluscum contagiosum: experience with cantharidin therapy in 300 patients. J Am Acad Dermatol 2000; 43:503 10. Dohil M, Presdiville JS: Treatment of molluscum contagiosum with oral cimetidine: clinical experience in 13 patients. Pediatr Dermatol 1996; 13:310 11. Cunningham BB, Paller AS, Garzon M: Inefficacy of oral cimetidine for nonatopic children with molluscum contagiosum [Letter]. Pediatr Dermatol 1998; 15:71 12. Yashar SS, Sharmiri B: Oral cimetidine treatment of molluscum contagiosum [Letter]. Pediatr Dermatol 1999; 16:493