A 24 y.o. sexually active woman presents with a rash in the genital area.

What could it be?

Our patient had molluscum contagiosum.

Molluscum  is a viral disease of the skin sometimes called “water warts”. As they grow they may develop a characteristic indentation.  Molluscum contagiosum got its name from the Latin word "molluscum," meaning "soft," and the observation that the lesions released a soft, milky fluid. British physician Thomas Bateman coined the term in 1817 after he noticed the characteristic fluid  he was able to express from the bumps. 

Molluscum is found mainly in children aged two to five but can also be found in sexually active adults and immunocompromised individuals or those with atopic dermatitis. The virus is part of the pox virus family.  Henderson-Patterson bodies can be seen in the epidermis in molluscum. These are inclusions of virions in the cytoplasm in epidermal cells. Local inflammation from immune activity can occur around the lesions that does not represent bacterial infection. This is referred to as BOTE (beginning of the end of the lesion)

Henderson-Patterson bodies in the epidermis of a patient with molluscum

Molluscum is largely a cosmetic problem  and usually resolves spontaneously in 6-12 months but can persist for years and is contagious. It is a problem in those who are immunocompromised. The treatments have evolved over time. The older treatment was topical cantharidin 0.7% applied in a thin film and then allowed to dry The lesions were then taped for two to four hours and then washed off.  This caused a blistering effect similar to liquid nitrogen.. Recently, Zelsuvmi has been approved for topical use at home.  It is a gel that causes the release of nitric oxide  which is an antiviral agent. This antiviral agent can also be used on genital warts.

GENITAL WARTS

While pox virus can cause genital lesions,  the  most common cause of genital warts is the human papillomavirus (HPV)  which is also responsible for warts on other areas of the body. There are 150 types of HPV and in addition to warts on skin some have been linked to cancers.  Cervical cancer, vulvar cancer, vaginal cancer, anal cancer and oropharyngeal cancer have all been linked to HPV.  Condylomata acuminata  or genital warts are one of the most common sexually transmitted diseases with 400,000 new cases reported in the US each year.  On rare occasions they can develop into malignancy which remains localized. This is called  a Buschke-Lowenstein tumor.

Buschke-Lowenstein genital warts

Our patient was given  Zelsuvmi and her lesions resolved.

Many  viruses cause skin infections as listed below.

common and not so common (orf) viral skin infections

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Sil A, Bhanja D, Chandra A, et al. BOTE sign in molluscum contagiosum BMJ Case Rep 2020 Sept 16;13(9):e239142.