The Bay Area Reporter - April 22, 1996
Matthew Sharp ACT UP/Golden Gate Writer's Pool

Two strains of molluscum have been identified with no clinical difference between them. The center of each lesion holds the active virus, which must be completely removed or the molluscum will spread. Molluscum are seen in non-HIV infected children and adults with sexually transmitted diseases, and in other diseases of altered immunity including HIV/AIDS. Nine to 18 percent of people with HIV and AIDS have molluscum. (Goodman DS et al: J Am Acad Dermatol., and Matis WL et al: J Am Acad Dermatol.)

Children who get molluscum in a public setting usually are not treated - the molluscum go away on their own. However, due to altered immunity in people with HIV or AIDS, molluscum can be quite severe and the lesions need to be aggressively treated. There are often more of them than in non-infected individuals and they can grow to enormous size. Although molluscum are never life-threatening, they can affect quality of life in that their appearance can be quite frightening. Also, poor treatments and misdiagnosis can cause further scarring, and pain, leading to a poorer quality of life.

In HIV, molluscum are limited to the epidermis (the outer layer of the skin) and are seen on the face, upper shoulders, chest, and back. They occasionally appear in mucous membranes; they are never internal. There are rare cases where molluscum can cause conjunctivitis, an eye irritation, when they grow on the eyelid. In people with HIV who let their molluscum go, the appearance can be misleading in the beard area and have sort of a flat cobblestone effect.

Sometimes the molluscum can look like skin manifestations of cryptococcus, histoplasmosis, and even basal cell carcinoma. Seen in the genital area, they can look like genital warts. Molluscum, however, can always be diagnosed in a dermatalogical setting where appropriate equipment is available.

Get aggressive

Early aggressive therapy is a message we have heard many times in HIV treatment, but must not be underestimated in eliminating molluscum. Sanford Schnoll, MD, a local dermatologist who specializes in HIV-related skin disorders, stated, "I feel very strongly that people should be treated extremely aggressively, using modalities that will cause the least amount of scarring and provide the best cosmetic result. Some of the repercussions of some cosmetic results can affect general health and well-being."

Schnoll treats patients upon diagnosis, usually on their first visit. He aggressively goes after the lesion to completely destroy it. Opportunities for destruction of the molluscum include 1) chemical modalities such as TCA (trichloroacetic acid, skin peel), podophllyum, Condylox, cantharidine, and Retin A; 2) physical interventions such as liquid nitrogen, electrodessication (burning with a needle), curettage (scraping with a surgical instrument) and laser.

According to Schnoll, "...in HIV-positive patients only the very destructive methods work; such as aggressive liquid nitrogen, which can have a high relapse rate, but I don't think that is the best way. Some of my patients express their frustration at this method, having been treated with liquid nitrogen by other doctors for years with recurrence and spread." Schnoll will anesthetize each lesion and then electrodessicate it, following by scraping out the viral body. According to him this is the most effective method.

Pain involved in these treatments is usually minimal unless multiple lesions are involved. Schnoll uses an experimental application of Efudex (5-luorouracil - a topical therapy used in cancer), as an extra precaution to keep the spread of molluscum at bay. He warns that it should not be applied to open or healing sores.

Trial and error

Since MCV (molluscum contagiosm I virus) cannot be grown in culture, more effective treatments will probably not be found except by trial and error in the clinical setting. The most effective treatment in the future will probably be stimulating the immune system to work as it should. Schnoll stated that he has seen molluscum go away with AZT therapy, so it may follow that the more powerful antiviral combinations with protease inhibitors will work even better. Systemic prophylaxis for molluscum will not be a reality, due to lack of research and the relative ease of treating lesions right now.

There is debate about how molluscum is spread. Reactivation of latent MCV which occurs as people lose the ability to fight infection seems to be the cause. Ninety percent of people in the normal population have antibodies to molluscum (Smith KJ et al: Arch Dermatol.).

Acquiring molluscum through new infections by sexual contact is a reality.

Shaving is thought to be the worst cause of the spread of molluscum in HIV-positive males. Schnoll recommends growing a beard, but for those who don't like the bear look, certain precautions with shaving should be heeded. Shave with disposable razors. Thoroughly wash the razor of all residue before applying the razor to the face again. Shave the area that has had molluscum on it last. Finally, there is no research to show if electric razors slow the spread of molluscum.

Any possible mode of scraping the skin and using unclean razors is a means for contacting MCV.

Schnoll expressed a concern of dermatologists who treat molluscum with electrodessication, over the possible spread of the HIV virus in smoke plumes resulting from this procedure. There is little research however, to show that HIV can be spread in this way. Dermatologists should heed universal precautions anyway, and understand fully that the likelihood of transmission in the smoke plume is nil.

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Always watch for outdated information. This article first appeared in 1996. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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