Molluscum Contagiosum - Melbourne Sexual Health Centre

Molluscum Contagiosum
Competency Package for
Nurses
Introduction
This is an educational and pictorial competency training package for the diagnosis and management of Molluscum Contagiosum (MC). MC is a common condition seen within sexual
health centres, it is easily diagnosed and treated.
The information and assessment represents the level of
educational preparation and supervised clinical practice required by nurses at Melbourne Sexual Health Centre (MSHC)
to competently and confidently perform MC diagnosis,
treatment and management.
The information contained in this material is derived from a
critical analysis of a wide range of authoritative evidence. Any
treatment decisions based on this information should be made
in the context of the clinical circumstances of each client.
Inside
Clinical
Manifestations
Clinical photos
Management
Treatment
Case study
Assessment
Principles to guide nursing scope of practice decisions
The following principles help guide MSHC nurses as they expand their scope of practice
to include the management of new conditions and to encourage accountable and
collaborative practice. 1
Principle 1:
The primary motivation for any decision about a care activity is to meet the consumers
health needs or to enhance outcomes.
Principle 2:
Nurses are accountable for making professional judgements about when an activity is
beyond their own scope of practice and for initiating consultation and referral to other
members of the health care team.
Principle 3:
Nurses are accountable for making decisions about who is the most appropriate person
to perform the clinical activity.
Principle 4:
Nurses practice decisions are best made in a collaborative context of planning, risk
management and evaluation.
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Molluscum Contagiosum Competency Package for Nurses
Target population
Clients presenting with Molluscum Contagiosum (MC)
Exclusion Criteria
Clients with pre-existing dermatological conditions
Clients with MC lesions on the face
Clients with immunosuppressive illness including diabetes and
Human Immunodeficiency Virus (HIV)
Clients who are pregnant or breast feeding
Clients with ongoing symptoms including multiple lesions of MC
Clients with secondary bacterial infection
Objectives and anticipated outcomes
Provide diagnosis and treatment for clients with MC
Identification of individual STI risk and provision of appropriate screening
Identify public health risks to control infections by:
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Provision of STI education and information
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Identification and exploration of sexual risk taking behaviours
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Partner notification and treatment as required
Definition and History
MC is a benign papular condition of the skin. The causative agent is Molluscum Contagiosum virus (MCV). Although most common as a childhood infection, MC is usually
sexually transmitted in young adults. Non sexual transmission can also occur.1,2,3 MC is
part of the poxvirus family and with the eradication of smallpox remains the only human
specific poxvirus. The virus is passed on by direct skin to skin contact and can affect any
part of the body 1
Biology
Many pox viruses encode proteins that help evade host immune defences, this
accounts for the persistent duration of the MC lesions. The infection is restricted to the
epidermis and this location helps the virus evade immune response and subsequent
clearance. 4,5 Four genomic subtypes have been identified for MC. The most common
types seen in adults are MCV 1 and MCV 2.MVC 2 is seen more commonly in adults
than in children. Incubation period is between two to three months (1 week to 6 months).5
Epidemiology
As MCV is self limiting and causes few complications many people do not seek treatment
resulting in minimal population data being available. UK studies report an annual
Incidence of MC for all ages of 2.4/1000.5 People who are HIV positive have estimated
prevalence rates from 1.7 to 4%. MCV 1 occurs more commonly than MCV 2. There is
no association between subtype and anatomical site. 5
Transmission
Transmission occurs primarily by skin to skin contact and is enhanced by warmth and
humidity with lesions usually occurs on the genital region.1,2,3,4 Fomite transmission includes baths, gym equipment, swimming pools and towels.
Sexual Contact
The location of MC in the genital areas of sexually active adults supports the sexual
transmission of the virus. The peak age of occurrence of MC is 20-29 years which is
similar to other sexually transmitted infections.8
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Molluscum Contagiosum Competency Package for Nurses
Non Sexual Contact
The non sexual form occurs in children and usually involves the face, trunk, and upper
extremities. Infection has been associated with procedures causing skin trauma, shaving,
waxing, tattooing and piercing.9,10
Pathogenesis, Pathology Immunology
MC has a limited range of tissue infectivity. The infection only occurs in the epidermis
and dissemination does not occur as in other viruses. 5,10 MC has a predilection for follicular epithelium and is uncommon on non hair bearing sites. Transmission is a result of
skin inoculation following microscopic abrasions. Further spread is thought to occurs
though autoinoculation with infected sites. Reactivation of subclinical infection is seen in
clients with immunosuppression.5,8,9,10
Clinical Manifestations
The typical lesion is a papule with central
umbilication and in HIV infection lesions may be
more widespread and atypical.2,3,4
Lesions consist of focal areas of hyperplastic
epidermis surrounding cyst shaped lobules that
are filled with keratinized debris and
degenerating molluscum bodies.5
Normally clients present with 10-20 lesions.
The duration of infection for untreated MC is reported to be 2 years (range; 2 weeks to 4 years).
Individual lesions usually resolve within 2
months. Recurrences after clearance occur in
15-35% of cases, often it is difficult to distinguish
between a new infection or an exacerbation of
subclinical infection in clients representing after
MC clearance. 4
Investigations
There is no specific laboratory tests required to
diagnose MC at MSHC.7
Lesions begin as tiny papules and
grow over several weeks to 3-5
mm. The flesh coloured papules
are smooth, firm and dome
shaped with a high characteristic
central umbilication from which
material can be expressed.
Diagnosis
Diagnosis is based on the characteristic clinical appearance of MC observed
during the genital examination.7,8
The use of magnification may assist in the diagnosis of MC. Normal
variations in the genital area include pearly penile papules,
parafrenular glands, normal glands, sebaceous cysts and fordyce
spots. These variations are often found on the penile shaft, glands
and the vestibular area of the vulva.9
It is important to remind clients that recent skin changes, colour variations and new lumps on genital skin will continue over the life span
and are generally not clinically significant.
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Molluscum Contagiosum Competency Package for Nurses
Differential Diagnosis 5,10
Genital warts
Keratoacanthomas
Lichen planus
Sebaceous adenomas
Atopic dermatitis
Infection with HSV and varicella zoster
Skin tags
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Treatment
The aim of therapy is to hasten the resolution of lesions as autoinoculation may cause
persistent infection in some clients. Cryotherapy is recommended for the treatment of
MC. 7,8 Cryotherapy causes mechanical destruction and local epidermal inflammation. No
treatment is an important option for clients who have poor tolerance to cryotherapy.
Clients at increased risk of keliod and hypertrophic scarring from ablative techniques
should be informed the MC will clear without treatment. 12
Frequency of treatment depends on the number of MC. Retreating at two week intervals
is recommended as this allows for lesion healing and resolution.12
Complications 5,10
Molluscum dermatitis: eczematoid reaction
Lesions of the eyelid can cause unilateral conjunctivitis
Folliculitis can be a common presentation with MC
Wide spread involvement with clients with atopic dermatitis
Use of topical steroids may impair wound healing
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In Summary
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Molluscum Contagiosum is caused by a pox virus
The virus is passed on by direct skin to skin contact
Sexual contact may lead to the appearance of lesions in the
genital area
Incubation period is between two to three months (1 week to 6
months)
MC are pearly papular umbilicated lesions
Complications occur in the immunocompromised, lesions may
be larger and more widely spread
Secondary infection may be present
Diagnosis is based on characteristic clinical appearance
Spontaneous regression of lesions is common
Treatment is cosmetic and aims to reduce lesion duration and
further spread
Cryotherapy is the recommended treatment
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Molluscum Contagiosum Competency Package for Nurses
Case Study
A 23 year old male attends MSHC with new lumps on the shaft of his penis. They have
been present for 2 weeks. He is currently in a relationship of 2 years duration. His female
partner has no signs or symptoms. He has no allergies to medications and is currently taking Sertraline 50 mg per day for depression which was diagnosed in 2008. This is his first
sexual health check up. On examination you see numerous small lumps on the shaft of his
penis. They are painless raised lumps.
Clinical Manifestations
Clinical Questions
1. What characteristics are typical of MC lesions?
2. How would you explain this condition to the client?
3. What treatment options would you discuss with this client?
4. What would you advise regarding sexual contact with his partner?
5. The client reveals that he is also a diabetic, how would this change your management?
6. What would the client expect to happen to the lesions over the next week after liquid
nitrogen treatment?
7. When should the client return for further treatment?
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Molluscum Contagiosum Competency Package for Nurses
Clinical Supervision
Competency is assessed by successful completion of the case study questions and by
observed and supervised practice for a total of four MC consultations. Following up
clients is highly recommended to improve learning outcomes and facilitate continuity of
care.
On completion of this competency nurses will demonstrate
competency and confidence in the diagnosis, treatment and
management of Molluscum Contagiosum.
Discussed
Demonstrated
Explain the infection, transmission and clinical
manifestations of MC
Recognise and accurately diagnose MC
Accurately list differential diagnosis
Identify common anatomical variations
Describe MC presentations which would require referral
Describe appropriate treatment options
Demonstrate competency in liquid nitrogen treatment
Discuss evaluation of treatment and further management
Clinical Log
Date of
consultation
Role of nurse
(observed/supervised)
Presentation description
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Molluscum Contagiosum Competency Package for Nurses
Author
References:
Mr Matiu Bush
Sexual Health Nurse Practitioner
Any correspondence regarding content should
be directed to mbush@mshc.org.au
Reviewers
Ms Rosey Cummings
Nursing Services Manager
Dr David Lee
Sexual Health Nurse Practitioner
1.Nurse Board of Victoria. Guidelines: Scope of Nursing
& Midwifery Practice. June 2006.
REFERENCE:
2. Franklin R. Genital lumps and bumps. In: Russell D,
Bradford D, and Fairley C, editors. Sexual health medicine. Melbourne: IP Communications; 2005. p.119-128.
3. Denham I, Bowden F. Genital and sexually transmitted infections. In: Yung A , McDonald M, Spelmen D,
Street A, Johnson P, Sorrell T, McCormack J, editors.
Infectious diseases a clinical approach. 2nd ed. Melbourne: IP Communications; 2005. p. 372-387.
4. McMillan A, Ogilvie M M. Other sexually transmissible
viruses. In: McMillan A, Young H, Ogilvie M M, Scott G
R, editors. Clinical practice in sexually transmissible infections. London: Saunders; 2002. p. 251-277.
Ms Lorna Moss
Sexual Health Nurse
5. Douglas J M. Molluscum contagiosum. In: Holmes K
K, Sparling P F, Mardh P A, Lemon S M, Stamm W E, et
al, editors. Sexually transmitted diseases. 3rd ed. New
York: McGraw Hill; 1999. p.385-389.
6. Venereology Society of Victoria. National management guidelines for sexually transmissible infections.
Melbourne: Venereology Society of Victoria; 2002.
7. Melbourne Sexual Health Centre. Treatment guidelines: molluscum contagiosum. Melbourne: Bayside
Health; 2005.
8. Queensland Health. Queensland clinical practice
guidelines for advanced sexual and reproductive health
nursing officers. Public Health Service Branch. Queensland Government. 2007.
9. Valentine CL, Diven DG, Treatment modalities for
molluscum contagiosum. Dermatologic Therapy
2000;13: 285-289.
10. Epstein WL. Molluscum Contagiosum. Dermatology
1992;11: 184-189.
11. Janniger CK, Schwartz RA. Molluscum Contagiosum
in children. Cutis 1993; 52: 194-196.
12. Arndt KA. Manual of dermatologic therapeutics, 5th
ed. Boston: Little Brown, 339-340, 1995.
Sexual Health Nurse
Competency Package
This competency package was supported by the
2009 June Allen Practice Enhancement
Fellowship, Nurse Board of Victoria.
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