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Ep. 27: Molluscum Mayhem

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Ep. 27: Molluscum Mayhem

Jul 08, 2022

While generally harmless, Molluscum is a very common skin condition amongst children ages 2-10. So common that you may know them by their nickname "Water Warts" instead! In today's episode, Skincast hosts Luke Johnson, MD and Michelle Tarbox, MD explain what causes these wart-like bumps, why they're so common, and options for treatment for when you just can't stand them any longer.


Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an academic dermatologist at Texas Tech University Health Sciences Center. And joining me is . . .

Dr. Johnson: Hi, everybody. This is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: Today, we're going to talk about molluscum. Luke, as a pediatric dermatologist, I know you see this condition all the time. So what are molluscum?

Dr. Johnson: I see it so frequently. I usually see multiple cases every day. That's how common it is. But before I became a dermatologist, I didn't even know it existed. So it's kind of shocking that it's so common and yet most people don't seem to know about it, assuming most people are like me and didn't know about it. It is caused by a virus, and it causes little bumps on the skin, little smooth, almost wart-like bumps. The most common ages are ages 2 to 10. And the important thing to know is that it's not dangerous, and it eventually goes away on its own.

Dr. Tarbox: I love that not dangerous part. I like the full name of the condition as well, because it tells people a little bit about potentially how they might acquire it. So we know that it's caused by a virus. What virus causes this?

Dr. Johnson: It's a type of virus called poxvirus. And the virus is just in the skin. Some people sometimes worry that the virus is like in their child, or in their blood, or something, and it's coming out in the skin. But that's not the case. The molluscum virus affects only the skin. And because it's technically a poxvirus, it can leave little tiny scars. Unfortunately, sometimes when the spots go away, there are sort of like pockmark scars. But they're very small and they seem to improve over time a lot more than some other scars. So that's usually not a big deal, even if they show up on the face or some other area where they might be more obvious.

Dr. Tarbox: That's something I've noticed as well, that immediately after they resolve in small children or when it happens in young adults, there are these little slit-like scars. But as the child grows, usually those fade quite significantly. And I've not been able to successfully find old, like, molluscum scars in an adult.

Dr. Johnson: No, I've never seen that either. So if you have a child with molluscum, I wouldn't worry about the scar, though there might be a little scar there for maybe a year or two.

Dr. Tarbox: Now, how do kids get molluscum? Like I think that the easiest way to explain this is to give people the full name of the virus, which is molluscum contagiosum because it is quite contagious. And so like other contagious things, we get it from somebody else, like somebody with molluscum. What's the best way to get it, Luke? If you are going out to get molluscum, how would you do that?

Dr. Johnson: Press your skin against somebody else's molluscum-covered skin.

Dr. Tarbox: Preferably while it's wet.

Dr. Johnson: Preferably while it's wet. While it's wet, it's spreads even easier. So I think this is why it's most common between ages 2 and 10, because kids have to be old enough to kind of be playing with other kids. And by the time you're 10, usually your immune system has already been exposed to it and your immune, or your immune system just takes care of it really quickly. So especially skin-to-skin contacts, usually through play, especially when it's wet, like in a pool or sharing a bath, sharing a towel, stuff like that. Some people refer to these as water warts I think for that reason.

Dr. Tarbox: Yeah. I think that that's one of the simplest ways to pass it. So the summertime is coming up or is already here. If you've got a little one that has these little molluscum, what can you do to kind of like help prevent them to spread?

Dr. Johnson: Unfortunately, not very much. So if you have a couple little kids, and they generally take a bath together, and one of them has molluscum, but the other one doesn't, I suppose you could think about not bathing them together anymore. Though, honestly, both children have probably already been exposed. So you might look at the supposedly molluscum free one very closely, and maybe they just have one or two bumps that you didn't notice before. Plus, I have two kids, if they have a bath together, especially when they were a little bit littler than they are now, it's just nice for the parents to have 30 minutes when the kids are happy and playing in the water for you to do something. And there's only so much we could do to prevent the spread of molluscum anyway. So I'm not sure that it's worth it to bathe them separately and go through all of that. But that's potentially something you can do.

They are quite contagious, so kids can spread them in their own skin by potentially scratching them or something, but they aren't very itchy usually. And they often will spread regardless of a parent's best efforts to tell the kid to stop rubbing it, stop scratching it, keep them covered up. They just spread. I'm sorry, it is what it is. But I am a silver lining kind of guy. So I like to focus on the good news is that they're not dangerous, and they go away on their own.

Dr. Tarbox: So when you were talking about, like, looking at the other kid to see if maybe they have some molluscum, how could they tell if something was molluscum? What would be the characteristic pattern that you would look for?

Dr. Johnson: Well, you can certainly look this up on the internet for some pictures, but they're smooth, dome-shaped, skin-colored or pale bumps. They sometimes have a little dimple in the middle. We call that being umbilicated, like your umbilicus, which is your belly button. So it almost looks like they have a little belly button. And sometimes they don't have that, but they do have an even paler center than the rest of them, like a little pale core. That's actually where the infectious virus is.

Dr. Tarbox: Yeah. When we're looking at these in the clinic, sometimes we'll use a special magnifying device that we call a dermatoscope. And that actually will let us see that little white core that has all of the infectious stuff in the middle. I had one teenage patient that was very industriously using a comedone expresser to kind of pop the little molluscum out. And she was quite enjoying the process of that. Sometimes that can be fun. We had a little possible budding Dr. Pimple Popper there. It was very cute. So sometimes that's a similar thing to a treatment we do in the office. So if we do nothing, what happens?

Dr. Johnson: Well, like I said, they go away. But they can take a long, long time to go away, a frustratingly long time. I'm sorry. Focus on the good news, not dangerous and they will go away. The average length of time they're supposed to stick around is about six months. The longest I have seen is five years. At least the patient's parents told me they had been there for five years. And like I said, it seems that the older you are, the faster your body clears them.

And sometimes when your body starts to clear them, they just sort of start disappearing, which is great. But sometimes when the immune system becomes active against them and finally wakes up, the molluscum can kind of appear different. So sometimes they get a rash around them, almost kind of looks like eczema. They get this itchy pink rash around them. And sometimes the molluscum themselves get inflamed. They can become swollen, big, painful. They can look infected. A lot of times patients, parents, or even other doctors think they're infected. But really, it's just the immune system finally becoming active against this molluscum. Sometimes we call it the beginning of the end sign, and it usually means the molluscum is going to go away in the next two to three months. But I do have some patients where the immune system seems to kind of beat up on the molluscum for a while and then take a little break, and beat up on them some more and then take a break. So if your child has starting to get these inflamed or rashy molluscum, and it's been going on for a month, then you're probably in good shape and they're going to go away. But if that's been happening for like five months, then I'm less optimistic.

Dr. Tarbox: Yeah, I agree. And sometimes that immune response can kind of stutter a little bit. I know you know this about me, Luke, but some of our listeners might not know that I'm a mega dork. And so I've actually written a little book chapter about infectious diseases, one of them being molluscum. And did you know that they have something in common, Luke, with either "Star Trek" or "Harry Potter"?

Dr. Johnson: Please, tell me.

Dr. Tarbox: So molluscum contagiosum can actually hide themselves from the immune system. They make a protein that actually makes it difficult for the immune system to see them, which is the reason why, at first, they tend to be flesh colored, not inflamed at all. So it's either an invisibility cloak or a cloaking device, whichever one you prefer in terms of the metaphor. But when that starts to be able to be seen through by the immune system, that's when we start to get that immune reaction, which is usually a harbinger of success with treatment. So I know they can go away on their own and they're generally harmless, but let's say we have a patient that really can't stand these things, wants them to be gone. How do we take care of these things?

Dr. Johnson: Well, remember, they're going to go away, and they're not dangerous. So because of that reason, I don't like to use treatments that could be uncomfortable, or painful, or could even scar. You know, it's kind of hard for me to justify that medically for something that's going to go away on its own. But reasons to potentially treat. If the child is motivated, for example, if they're motivated to get a shot that might make them go away, then probably we should go ahead and treat them. Usually, that's in the older kids, like the 8, 9, and 10-year-olds. Usually, the 3 and 4-year-olds just don't care that they're there. If the molluscum are spreading all over the face, then that's potentially a reason to do it, especially if it's causing trouble at school. And speaking of schools, occasionally I've had preschools or daycares, who have acted kind of strange about molluscum and have said that your child can't come back until these are gone, which seems absurd. I'm happy to like write a letter saying they should not keep your kid out of school. But sometimes we just have to treat them for that reason.

And then sometimes, I get it. I know my parents . . . This is what I assume they're thinking to themselves when they look at me, and I tell them all of this, "I hear where you're coming from, Dr. Johnson, not dangerous, and they're going to go away on their own. But they've been here for 18 months, and I hate them. I hate them so much. I think about them. I look at my child and I see them, and it just is driving me crazy. And I'm at the end of my rope. Can't we do something?" And if you're at that point, then I also think that they're probably worth doing something about.

Dr. Tarbox: Yeah, I agree with you. You know, sometimes we can do more harm than good if we're too aggressive in treating something that's harmless. So we want to balance those risks. But if it is causing significant distress, there are some things that we can do. So what is your first thing you reach for, Luke?

Dr. Johnson: Well, the first thing I reach for if I'm in clinic is actually a shot that I mentioned. It's called Candida antigen. And it's supposed to inspire your immune system to attack them. So one of the nice things about it is we just inject into the skin under one spot, and it's supposed to inspire your immune system to attack them all. I have seen it work miracles. I've also seen it do nothing. So if you want a dermatologist or somebody like that to do it, usually we plan on three shots each a month apart to see if it works.

But there's stuff you can do at home as well. So there's a little bit of evidence that zinc can help the body fight viral infections. And you can get zinc in over-the-counter pastes. They are, in fact, in diaper pastes, and they're kind of messy. But other than that, they're totally safe. So if you want to do something that might help and is totally safe, you can use one of these diaper pastes. The ones that seem to have the most zinc in them include Desitin Max Strength, Boudreaux's Butt Paste Maximum Strength, and Baby Butz with a Z. We're not sponsored or anything by any of these companies, by the way. Those are just some that might work.

Dr. Tarbox: I love it. I think that those gentle, easy things that people can do at home can be very, very helpful. For some patients we'll also kind of try to cause a little irritation. So we mentioned the fact that the virus can hide itself from the immune system. And our immune system is really how we get rid of this virus. So helping our immune system find the virus is sometimes a useful strategy in treatment. So we can irritate them sometimes with topical retinoids, which can either be over-the-counter products, such as Differin, which contains the active ingredient adapalene, which is a version, kind of a cousin of Retin-A. It's a vitamin A derivative. And tretinoin, which can be prescription.

There are other home remedies or other over-the-counter products that are designed to do something similar. There's something called MolluscumRX. I have no connection to this product. It's a sort of homeopathic treatment that uses a combination of essential oils to sort of irritate the immune system. I think that that's an approach that can work in some patients. There's something called thuja oil that can be used. It's a derivative of sort of a pine plant that has an essential oil that can sometimes cause a little bit of mild irritation that might bring the immune system to the fore. So that's also something that can be useful.

But I think that some of the most concerning things that arise around the issue of molluscum is sometimes people mistake the infection for something much more nefarious. So kids, like you pointed out, tend to pick at the molluscum, even if they're not itchy. And, you know, kids tend to kind of scratch other parts of their body as well. And so, occasionally, you can get spread of the molluscum to the swimsuit area. And occasionally, people can get concerned about a possible STD in a child who has molluscum in that area. But most of the time, that is autoinoculation, meaning the child had molluscum somewhere else, scratched it, and touched the part of their body that is covered by the bathing suit. And then the molluscum is there, not by any kind of abuse but just by auto transfer.

Dr. Johnson: Yeah. They're actually pretty common in the diaper area, especially of like little kids, age 2 to 3 or so on. So don't get worried about that unless, of course, your gut is telling you that something suspicious could be going on. In adults, though, in the genital area, they are considered a sexually transmitted disease. So we take that seriously. In terms of adults getting it, adults are generally immune. I think that almost all of us just see the virus when we're kids and become immune. Though, occasionally, I've had a parent of a child with molluscum, and I've found one or two spots in their forearm or something like that.

Dr. Tarbox: Yeah. I think that, you know, you don't see it so often in adults. They tend to get rid of it faster. It tends to be less persistent. But it can be quite distressing, especially if it occurs in an area that people can see. And I always try to also approach the conversation of the transfer of the virus gently because sometimes adults will also pick it up from like gym equipment or something, you know, sporty, and non-adult in nature. So, of course, being cautious not to cast any aspersions or anything like that. So what other, like, things can look like molluscum?

Dr. Johnson: Well, you probably want to go to a professional if you feel like you might have molluscum, but it's acting funny, especially if there's a problem with your immune system. So there are people out there who have diseases or have to be on medicines that turned their immune system down. And even if they had been immune to molluscum before, their immune system got turned down. Now molluscum might come back, might get worse. And then there's other rare infections that can look like molluscum in people whose immune systems aren't working right. So go see somebody if you think that describes you.

Also, before we finish talking about molluscum, you mentioned earlier about how do you prevent them from spreading. And I said there's not really a great to do it. But if your child has molluscum, I don't think that's a reason to like keep him out of the pool or anything, you know, because you want to be like a good neighbor and prevent it from spreading to other kids. I don't think molluscum should prevent him from playing in the pool. But you might want to like put on some waterproof Band-Aids or have them wear a rash guard or some other kind of swim garment in order to prevent the spread as much as you can.

Dr. Tarbox: Well, and as dermatologists, we love the rash guard because that also provides great sun protection, and you always want to think about that when you're doing outdoor, water-based activities.

Dr. Johnson: Yep. My daughter has a swimsuit that goes neck to wrists to ankle. She's totally covered up. I don't think she has molluscum. But if she did, it wouldn't be spreading to anybody.

Dr. Tarbox: Exactly.

Dr. Johnson: Well, thanks so much for joining us today, listeners. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle. If you feel like you're a dermatology nerd, like we are, you might be interested in our other podcast.

Dr. Tarbox: Our other podcast is called "Dermasphere." It is aimed at dermatology professionals and people who are dermatologically curious. It's a little bit longer and more technical. It's about an hour. And we cover current research in the topics of dermatology and dermatologic disease.

Dr. Johnson: That is correct. So come check us out there if you like. Otherwise, we will see you here next time.