Molluscum Contagiosum of Vulva

Molluscum contagiosum of the vulva is a skin infection caused by a poxvirus, producing small, firm, dome-shaped papules with a central dimple.

• In adults it is usually sexually transmitted; in children it spreads by skin contact and may occur on the vulva by autoinoculation.
• In healthy people it clears without treatment in 6 to 12 months.
• In HIV infection lesions are numerous, large and persistent.

Multiple 2 to 5 mm skin-coloured, pearly, umbilicated papules on the vulva, pubic area, inner thighs and lower abdomen.

• Mild itching and redness; some lesions become inflamed.
• Differential diagnosis: genital warts, folliculitis, epidermal inclusion cyst, herpes genitalis, skin tags, secondary syphilis, cryptococcosis in advanced HIV.
• Complications: secondary bacterial infection, eczema around lesions, scarring, spread to partners, and extensive disease in immunosuppression.

Diagnosis is clinical, by the umbilicated papule.

• Clinical diagnosis by the umbilicated papule with a cheesy core.
• Biopsy or crush preparation for atypical or large lesions.
• HIV test and screening for other STIs.
• Dermoscopy where available.

Observe in healthy people and treat symptomatic lesions or those at risk of spread.

• Supportive: reassure; avoid scratching, shaving and waxing; cover lesions during intercourse and avoid sexual contact until cleared; wash hands after touching lesions; do not share towels.
• Pharmacological: observation for healthy adults. Topical: potassium hydroxide 10 percent solution applied to each lesion once daily at night until mild inflammation occurs. Infected lesions: flucloxacillin 500 mg oral 6-hourly for 5 to 7 days (child 12.5 to 25 mg/kg 6-hourly, maximum 500 mg per dose). Secondary eczema: hydrocortisone 1 percent cream twice daily for 7 days.
• Procedures: cryotherapy with liquid nitrogen for 5 to 10 seconds per lesion, curettage under 1 percent lignocaine (maximum 3 mg/kg) or topical anaesthetic, repeated every 2 to 3 weeks.
• Special groups: in HIV infection start or optimise antiretroviral treatment because lesions regress with immune recovery. In pregnancy use cryotherapy or curettage. In children use observation or gentle curettage.
• Red flags: very large or numerous lesions in HIV infection, lesions around the eye, atypical lesions, spreading infection.
• Follow-up: review at 4 weeks; repeat treatment as lesions recur; recheck HIV status and STI screen.