HIV-Associated Molluscum Contagiosum

There is occasional tenderness or inflammation.
Lesions are often a great cosmetic concern to patients.
Papules may be dome-shaped or, more commonly, are atypical in appearance.
Size may be up to, or greater than, 1 cm (giant molluscum contagiosum) (Fig. 33.6).
Lesions may lack central umbilication or may have several umbilications.
Lesions on hairy areas tend to penetrate hair follicles.
Lesions may be extensive (hundreds to thousands in number) in patients with advanced AIDS.
Patients receiving HAART tend to have rare molluscum, with the more typical morphology seen in immunocompetent hosts.
The appearance of new lesions may follow a downward fluctuation in immunity caused by a concurrent infection, such as influenza.

Distribution of Lesions

All areas of the body may be affected, but lesions are most common on the face and genitals (Fig. 33.7).
In men, possible extensive involvement of the beard area may result from shaving.

Differential Diagnosis

Disseminated Cryptococcosis

Cutaneous lesions may be clinically identical to those of molluscum contagiosum (Fig. 33.8).
Affected patients are usually systemically ill, although cutaneous involvement may be the first sign of illness.
Crush preparation with India ink shows encapsulated yeast.
When in doubt, lesions can be identified by biopsy.
Patients with cutaneous dissemination have neurologic involvement, and a faster diagnosis can be made by cerebrospinal fluid examination.

Disseminated Histoplasmosis

This is a less common cause of molluscum contagiosum-like lesions than cryptococcosis.
Cutaneous histoplasmosis is always indicative of systemic infection.

Management

Treatment is individualized for each patient. No specific treatment is universally more effective than any other.
Topical tretinoin is a useful adjunctive treatment in cases of molluscum contagiosum of the beard.
Surgical treatment is with curettage or liquid nitrogen cryosurgery.
Trichloroacetic acid 25% to 75% may be applied to individual lesions.
Podofilox (Condylox) 5% may be applied to lesions twice per day, 3 days per week.
Imiquimod 5% (Aldara) cream may be effective and should be used daily if possible.
Treatment is long term and is unlikely to eradicate all lesions unless the patient's immunity improves. Lesions may remit spontaneously after the patient is started on HAART, and knowing this will sometimes influence a reluctant patient to start and adhere to treatment for HIV infection.

Point to Remember

Cutaneous lesions of disseminated cryptococcosis and histoplasmosis may look identical to lesions of molluscum contagiosum.