Treating A Child With Multiple, Mildly Pruritic Papules

By Gary “Dock” Dockery, DPM, FACFAS

An 11-year-old boy presents to the clinic with a chief complaint of multiple bumps on his right leg and foot. He reports the lesions have been present for almost two months and appear to be increasing in number and size. The boy did not see his pediatrician or family physician for this condition.

   The patient says the lesions started as very small bumps and they itched but not too badly. After scratching one of the bumps, the boy says the bump got bigger and new bumps occurred around the area in a few days or so. After further questioning, the patient and his mother stated that he had no known exposure to any chemicals, paints, toxins, irritants or other potential allergens and was taking no medications, vitamins or supplements. The patient also has no known allergies to any medications or environmental agents. No one else in his household or within his family had any similar skin conditions.

What Does The Physical Examination Reveal?

The physical examination revealed a large number of small, firm, dome-shaped, centrally umbilicated papules on the right lower leg. These epidermal papules have a smooth and waxy appearance and are flesh-colored. The patient has a similar papule on the second toe. The lesions ranged in size from 2 mm to 4 mm in diameter and the largest one was on the toe. There were no skin color changes or edema. At the time of the visit, none of the lesions was symptomatic. However, they were occasionally mildly pruritic.

   Careful examination found no other similar appearing lesions on the upper extremities or torso region. There were no other obvious dermatological findings other than the ones noted on the initial examination. There were no other positive findings during the rest of the physical examination.

Key Questions To Consider

1.    What essential question does one still need to ask in order to help make the diagnosis?
2.    What is the tentative diagnosis?
3.    Can you list at least three differential diagnoses?
4.    What features of this condition differentiate it from other conditions in your differential diagnosis?
5.    What is the suitable treatment of this condition?

Answering The Key Diagnostic Questions

1.    Have you had any close contact with other children prior to noticing this condition and do you participate in any organized, close contact sports such as wrestling?
2.    Molluscum contagiosum
3.    Verruca plana (flat warts), verruca vulgaris, keratoacanthosis, papular granuloma annulare, folliculitis, miliaria, varicella and lichen planus
4.    Molluscum contagiosum is characterized by individual papular lesions that are discrete, smooth and distinctly dome-shaped. They are generally skin-colored with an opalescent or slightly transparent quality. The central depression or umbilication is filled with a white, waxy curd-like core.
5.    Cryotherapy, curettage, topical salicylic acid, topical urea or imiquimod. In a few cases, no treatment is necessary.

What You Should Know About Molluscum Contagiosum

Molluscum contagiosum virus (MCV) is a common large, double-stranded DNA poxviridae infection. It presents as small papules, usually ranging from 2 to 6 mm in diameter although they can be up to 15 mm in diameter. The umbilicated, firm and dome-shaped papules may occur in children, most commonly between the ages of 2 and 12, sexually active individuals and patients with human immunodeficiency virus. Children with atopic dermatitis appear to have a slightly higher incidence of molluscum contagiosum infections and more severe reactions, but this relationship is not clear.

   The virus proliferates within keratinocytes and forms intracytoplasmic inclusions called molluscum bodies or Henderson-Patterson bodies. This condition is contagious and about one-third of children have symptoms or secondary reactions such as pruritus, dermatitis, bacterial superinfections or scars. Around 10 to 17 percent of patients develop eczema or inflammation around individual lesions.

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