available at www.jstage.jst.go.jp/browse/islsm
ORIGINAL ARTICLES
Recalcitrant molluscum contagiosum successfully treated with the pulsed dye laser Tokuya Omi 1,2, Seiji Kawana 2
1: Department of Dermatology, Queens’s Square Medical Center, Yokohama; and 2: Department of Dermatology, Nippon Medical School, Tokyo, Japan
Background and aims: Molluscum contagiosum is caused by the molluscum contagiosum virus (MCV) and is a very common skin disorder mainly involving young children Cryotherapy, curettage or some topical therapies have been applied for MC, but all of these treatments need several sessions, can be somewhat ineffective, and very painful. The present study assessed the impact of a single session of pulsed dye laser treatment of MC lesions which had proved resistant to other approaches Subjects and methods: Fifteen children comprised the study subjects, 11 boys and 4 girls, 3-5 years of age (mean 4.2 yr) with recalcitrant MC. Lesions were counted at baseline, and a single shot from a 585 nm pulsed dye laser was applied to each lesion (3 mm, 300 ms, 8.0 J/cm²). Lesions were counted again at 1 week post-treatment and followed for up to 3 months thereafter. Results: All patients completed the study and no patient dropped out through pain or discomfort. Purpura was seen at each treated lesion immediately after irradiation, but at 1 week after treatment, lesion clearance was virtually complete which was maintained for 1 month, and no recurrence was seen at 3 months in 8 of the 15 patients who remained available for followup. Conclusions: A single treatment of MC lesions with the pulsed dye laser successfully cured even recalcitrant lesions with no recurrence on follow up, and was well tolerated by the young subjects. Key words: Recalcitrant molluscum contagiosum • Poxvirus • Autoinnoculation
Introduction Molluscum contagiosum (MC, popularly known as water warts) is caused by the molluscum contagiosum virus (MCV, mostly MCV-1) that belongs to the poxvirus family and is common in children. 1) Although MC lesions can spontaneously clear up after 6 weeks to 3 months, they tend to be itchy and selfexcoriation of active lesions induces autoinoculation which can start a vicious circle and prolong involvement, in addition to putting other children at risk of catching the disease via skin-skin contact during the prolonged contagious phase. Addressee for Correspondence: Tokuya Omi MD PhD Department of Dermatology Queens’s Square Medical Center 2-3-5 Minatomirai, Yokohama, Japan TEL: +81 45 682 4112 FAX: +81 45 682 4111 [email protected] ©2013 JMLL, Tokyo, Japan
Various treatments have been reported and tried to date, but these treatments have many problems such as safety concerns and particularly pain, which in young children can affect compliance. Most importantly, repeated treatments are necessary. Because MC have a reddish colored cast, we designed the present study to assess the efficacy of a single session of treatment of MC lesions with a pulsed dye laser (PDL), normally associated with the treatment of vascular lesions such as hemangiomas.
Subjects and methods The subjects were 15 children (11 boys and 4 girls) aged 3 to 5 years (average, 4.2 yr) with active MC lesions which had proved resistant to other treatment methods. Lesions were mostly on the extremities with Received Date: February 4th, 2013 Accepted Date: March 6th, 2013
Laser Therapy 22.1: 51-54
51
ORIGINAL ARTICLES some on the trunk, and were not painful but tended to be extremely itchy. The laser used was a 585 nm pulsed dye laser (Chromogenex VIII, Chromogenex, UK). A spot size of 3 mm in diameter was used, at a pulse width of 300 ms delivering 8.0 J/cm² per shot. Each lesion was targeted once only. Clinical photography was taken at baseline, immediately after treatment, then at 1 week and 1 month post-treatment. MC lesions were counted at baseline. Treated lesions were checked at 1 week after the single treatment, then at 1 month post-treatment. As many patients as possible were followed up for a further 2 months. This study was conducted with the permission of the Queens Square Department of Dermatology Ethics Committee, and with the written consent of the parents of the children.
Results Clinical cases are shown in Figures 1 to 3. In Figure 1, lesions before irradiation are marked. Some lesions are erythematous due to scratching. Figure 2 shows lesions immediately after irradiation, in which purpura is seen at the irradiation sites. Figure 3 shows a magnified image of the lesions one week after irradiation, in which slight pigmentation is seen at the lesion sites where purpura has faded, but the molluscum contagiosum lesions have disappeared. Figure 4 shows the results of the 15 patients who were treated in this study. The average number of MC lesions was 29.5 at baseline but was reduced to 0.3
Figure 1: A 2-year-old boy at the first examination in the author’s clinic, where molluscum contagiosum lesions can be seen mainly in the extremities (forearm only shown), and some lesions showed redness due to scratching. 52
available at www.jstage.jst.go.jp/browse/islsm
one week after irradiation, with a residual rate of 1.0%. One month later, the lesions were examined again. No recurrence at the primary sites was seen in all cases, and new lesions were noted at other sites in 3 cases but these lesions also disappeared following a single irradiation at the same parameters as in the first treatment. In addition, there was no recurrence of molluscum contagiosum in any of the 8 patients in whom follow-up observation was possible 3 months later.
Discussion Molluscum contagiosum is common in children, but uncommon in infants aged less than 1 year. This disease has been reported to have a peak incidence at 8 years of age in Japan, and many patients are considered to be infected in swimming pools. 1) MC is often seen particularly in children with atopic dermatitis, and abnormalities in skin barrier function, immunological abnormalities and immune depression due to topical steroids are considered as the causes. 2,3) The MC virus is classified into 2 types, MCV-1 and MCV-2, but no immunological or clinical differences have been found between them. 4) Clinically, characteristic papules make the diagnosis easy. The first choice of treatment in countries outside Japan is to leave the lesions untreated. 5) However, in Japan, patients are often recommended to receive treatment in kindergarten and elementary school for reasons such as “your children cannot enter swimming pools,” and under such pressure from society, parents often take their children to hospital for
Figure 2: Same lesions as in Fig 1 immediately after irradiation with the pulsed dye laser, with purpura visible at the irradiation sites.
Omi T & Kawana S
available at www.jstage.jst.go.jp/browse/islsm
Figure 3: A magnified image of the same lesions as in Figs 1 & 2 one week after irradiation with very mild pigmentation seen at lesion sites where the purpura has faded, but the molluscum contagiosum lesions have disappeared.
prompt treatment. Liquid nitrogen therapy is effective but needs to be given at least 3-4 times. In addition, topical cantharidin, topical 5% imiquimod cream, topical nucleoside/nucleotide analogues and topical phenol are also used, but these treatments have many problems such
Figure 4: Scatter chart of baseline and 1 week post-PDL treatment for the 15 patients in the presents study. The average number of molluscum contagiosum lesions at baseline was 29.5 but was reduced to 0.3 one week after irradiation, with a residual rate of 1.0% and a cure rate of 99%.
PDL for molluscum contagiosum
ORIGINAL ARTICLES as insufficient efficacy and pain. 5) In departments of dermatology, the lesions themselves are generally excised with a small curette and pressure forceps for treatment. However, such a treatment causes pain and feelings of fear in children due to bleeding and pain and thus is associated with many problems. In particular, in patients with a large number of MC lesions, a single treatment session alone is often insufficient, necessitating multiple treatment sessions. In addition, each lesion is painful, possibly promoting “white coat phobia” in affected children. The pulsed dye laser has a peak wavelength of 580-590 nm, which is strongly absorbed by hemoglobin, and is used in the treatment of vascular lesions such as vascular malformations and telangiectasia. In countries outside Japan, the pulsed dye laser has been reported to be effective in the treatment of acne vulgaris, and particularly in recent years, clinical and morphological studies have reported that this laser effectively improves facial skin through non-ablative skin rejuvenation. 6,7,8) Moreover, the pulsed dye laser is considered to be highly effective in hypertrophic scars and keloids, 9) and in our department, striae cutis distensae and other lesions have also been effectively treated. Furthermore, its effect on verruca vulgaris has
Figure 5.: Light absorption in tissue. Tissue chromophores, melanin, hemoglobin and water have wavelength-dependent absorption characteristics over the visible to midinfrared wavebands. The pulsed dye laser has a peak wavelength of 580-590 nm (hatched vertical block in the figure), which is strongly absorbed by hemoglobin.
53
ORIGINAL ARTICLES also been reported. 10) Although the mechanism of treatment of molluscum contagiosum is unclear, marked edema in the dermis and increased immunological activity after pulsed dye laser irradiation 7,8) suggest the involvement of both physical barriers against viruses and immunological mechanisms. In this study, we treated MC lesions using the pulsed dye laser. As a result, follow-up observation showed that a single treatment resulted in a residual rate of 1.0% and a reduction rate of approximately 99.0% one month after treatment. In addition, there was no recurrence of molluscum contagiosum in all the 8 patients in whom follow-up observation was possible 3 months after baseline, suggesting that this treatment is extremely highly effective compared to other treatments currently used. Adverse effects include “pain like being hit by a rubber band” during irradiation and the formation of purpura that remains for 1-2 weeks. In this study, a fluence of 8.0 J/cm2 and a spot size of 3 mm were used. The usual spot size for hemangioma treatment is 5-7 mm, requiring a correspondingly higher irradiance. The irradiance in the present study was much lower than that used in the treatment of hemangioma in children, suggesting that the use of the pulsed dye laser for MC treatment is very safe. In children, the extremities and trunk needed to be held steady during irradiation to secure the laser irradiation field. Among the 15 patients who underwent the operation in this study, 11 patients who had undergone lesion excision at a previous hospital
available at www.jstage.jst.go.jp/browse/islsm
remarked that “laser treatment was less painful” after treatment, and all the 3 patients who had recurrence wished to receive laser treatment again, suggesting that laser treatment causes less feelings of fear in children than lesion excision. For pain during irradiation, the use of a local anesthetic tape (Penles tape®) and a topical cream (EMLA Cream®) should be considered. This pain is reduced by decreasing fluence, and it seems necessary to study the correlation between fluence and therapeutic effect in the future. Purpura disappeared in 2-3 weeks after pulsed dye laser irradiation in almost all cases, but slight pigmentation remained in the occasional lesion. Therefore, adequate informed consent including these factors should be obtained from patients and their families. The treatment of MC lesions investigated in this study was highly effective. The liquid dye used in pulsed dye laser is expensive, however, and needs to be exchanged after a certain period of time. The authors are therefore not suggesting that a clinic should purchase a pulsed dye laser simply for the treatment of MC, but are suggesting such treatment as another string to the bow of pulsed dye lasers already being used in a clinic. Bearing this in mind, it is always necessary to consider the economical and efficient use of laser treatment, including pulsed dye laser treatment, not only from the viewpoint of cosmetic indications but also from the viewpoint of dermatological applications.
References 1: Niizeki K, Kano O and Kondo Y (1984): An epidemic of Molluscum contagiosum; relationship to swimming. Dermatologica, 169: 197-198 2: Pauly CR, Artis WM, and Jones HE (1978): Atopic dermatitis, impaired cellular immunity, and molluscum contagiosum. Arch Dermatol, 114: 391-393 3: Hellier FF (1971): Profuse mollusca contagiosa of the face induced by corticosteroids. Br J Dermatol 1971; 85: 398 4: Porter CD, Blake NW, and Archard LC (1989): Molluscum contagiosum virus types in genital and non-genital lesions. Br J Dermatol, 120: 37-40 5: Epstein E (2001): Molluscum contagiosum. In Common Skin Disorders 2001; 114. W.B. Saunders Company, Philadelphia. 6: Smit JM, Bauland CG, Wijnberg DS, and Spauwen PH: (2005): Pulsed dye laser treatment, a review of
54
indications and outcome based on published trials. Br J Plast Surg, 58: 981-987. 7: Omi T, Kawana S, Sato S et al. (2003): Ultrastructural changes elicited by a non- ablative wrinkle reduction laser. Lasers Surg Med, 32: 46-49 8: Omi T, Kawana S, Sato S et al. Cutaneous immunological activation elicited by a low-fluence pulsed dye laser. Br J Dermatol in press 9: Rochkind S, Kogan G, Luger EG, Salame K, Karp E, Graif M, and Weiss J (2004): Molecular structure of the bony tissue after experimental trauma to the mandibular region followed by laser therapy. Photomed Laser Surg. 2004; 22: 249-253. 10: Park HS and Choi WS: (2008): Pulsed dye laser treatment for viral warts: a study of 120 patients. J Dermatol, 35: 491-498.
Omi T & Kawana S
ORIGINAL ARTICLES
Recalcitrant molluscum contagiosum successfully treated with the pulsed dye laser Tokuya Omi 1,2, Seiji Kawana 2
1: Department of Dermatology, Queens’s Square Medical Center, Yokohama; and 2: Department of Dermatology, Nippon Medical School, Tokyo, Japan
Background and aims: Molluscum contagiosum is caused by the molluscum contagiosum virus (MCV) and is a very common skin disorder mainly involving young children Cryotherapy, curettage or some topical therapies have been applied for MC, but all of these treatments need several sessions, can be somewhat ineffective, and very painful. The present study assessed the impact of a single session of pulsed dye laser treatment of MC lesions which had proved resistant to other approaches Subjects and methods: Fifteen children comprised the study subjects, 11 boys and 4 girls, 3-5 years of age (mean 4.2 yr) with recalcitrant MC. Lesions were counted at baseline, and a single shot from a 585 nm pulsed dye laser was applied to each lesion (3 mm, 300 ms, 8.0 J/cm²). Lesions were counted again at 1 week post-treatment and followed for up to 3 months thereafter. Results: All patients completed the study and no patient dropped out through pain or discomfort. Purpura was seen at each treated lesion immediately after irradiation, but at 1 week after treatment, lesion clearance was virtually complete which was maintained for 1 month, and no recurrence was seen at 3 months in 8 of the 15 patients who remained available for followup. Conclusions: A single treatment of MC lesions with the pulsed dye laser successfully cured even recalcitrant lesions with no recurrence on follow up, and was well tolerated by the young subjects. Key words: Recalcitrant molluscum contagiosum • Poxvirus • Autoinnoculation
Introduction Molluscum contagiosum (MC, popularly known as water warts) is caused by the molluscum contagiosum virus (MCV, mostly MCV-1) that belongs to the poxvirus family and is common in children. 1) Although MC lesions can spontaneously clear up after 6 weeks to 3 months, they tend to be itchy and selfexcoriation of active lesions induces autoinoculation which can start a vicious circle and prolong involvement, in addition to putting other children at risk of catching the disease via skin-skin contact during the prolonged contagious phase. Addressee for Correspondence: Tokuya Omi MD PhD Department of Dermatology Queens’s Square Medical Center 2-3-5 Minatomirai, Yokohama, Japan TEL: +81 45 682 4112 FAX: +81 45 682 4111 [email protected] ©2013 JMLL, Tokyo, Japan
Various treatments have been reported and tried to date, but these treatments have many problems such as safety concerns and particularly pain, which in young children can affect compliance. Most importantly, repeated treatments are necessary. Because MC have a reddish colored cast, we designed the present study to assess the efficacy of a single session of treatment of MC lesions with a pulsed dye laser (PDL), normally associated with the treatment of vascular lesions such as hemangiomas.
Subjects and methods The subjects were 15 children (11 boys and 4 girls) aged 3 to 5 years (average, 4.2 yr) with active MC lesions which had proved resistant to other treatment methods. Lesions were mostly on the extremities with Received Date: February 4th, 2013 Accepted Date: March 6th, 2013
Laser Therapy 22.1: 51-54
51
ORIGINAL ARTICLES some on the trunk, and were not painful but tended to be extremely itchy. The laser used was a 585 nm pulsed dye laser (Chromogenex VIII, Chromogenex, UK). A spot size of 3 mm in diameter was used, at a pulse width of 300 ms delivering 8.0 J/cm² per shot. Each lesion was targeted once only. Clinical photography was taken at baseline, immediately after treatment, then at 1 week and 1 month post-treatment. MC lesions were counted at baseline. Treated lesions were checked at 1 week after the single treatment, then at 1 month post-treatment. As many patients as possible were followed up for a further 2 months. This study was conducted with the permission of the Queens Square Department of Dermatology Ethics Committee, and with the written consent of the parents of the children.
Results Clinical cases are shown in Figures 1 to 3. In Figure 1, lesions before irradiation are marked. Some lesions are erythematous due to scratching. Figure 2 shows lesions immediately after irradiation, in which purpura is seen at the irradiation sites. Figure 3 shows a magnified image of the lesions one week after irradiation, in which slight pigmentation is seen at the lesion sites where purpura has faded, but the molluscum contagiosum lesions have disappeared. Figure 4 shows the results of the 15 patients who were treated in this study. The average number of MC lesions was 29.5 at baseline but was reduced to 0.3
Figure 1: A 2-year-old boy at the first examination in the author’s clinic, where molluscum contagiosum lesions can be seen mainly in the extremities (forearm only shown), and some lesions showed redness due to scratching. 52
available at www.jstage.jst.go.jp/browse/islsm
one week after irradiation, with a residual rate of 1.0%. One month later, the lesions were examined again. No recurrence at the primary sites was seen in all cases, and new lesions were noted at other sites in 3 cases but these lesions also disappeared following a single irradiation at the same parameters as in the first treatment. In addition, there was no recurrence of molluscum contagiosum in any of the 8 patients in whom follow-up observation was possible 3 months later.
Discussion Molluscum contagiosum is common in children, but uncommon in infants aged less than 1 year. This disease has been reported to have a peak incidence at 8 years of age in Japan, and many patients are considered to be infected in swimming pools. 1) MC is often seen particularly in children with atopic dermatitis, and abnormalities in skin barrier function, immunological abnormalities and immune depression due to topical steroids are considered as the causes. 2,3) The MC virus is classified into 2 types, MCV-1 and MCV-2, but no immunological or clinical differences have been found between them. 4) Clinically, characteristic papules make the diagnosis easy. The first choice of treatment in countries outside Japan is to leave the lesions untreated. 5) However, in Japan, patients are often recommended to receive treatment in kindergarten and elementary school for reasons such as “your children cannot enter swimming pools,” and under such pressure from society, parents often take their children to hospital for
Figure 2: Same lesions as in Fig 1 immediately after irradiation with the pulsed dye laser, with purpura visible at the irradiation sites.
Omi T & Kawana S
available at www.jstage.jst.go.jp/browse/islsm
Figure 3: A magnified image of the same lesions as in Figs 1 & 2 one week after irradiation with very mild pigmentation seen at lesion sites where the purpura has faded, but the molluscum contagiosum lesions have disappeared.
prompt treatment. Liquid nitrogen therapy is effective but needs to be given at least 3-4 times. In addition, topical cantharidin, topical 5% imiquimod cream, topical nucleoside/nucleotide analogues and topical phenol are also used, but these treatments have many problems such
Figure 4: Scatter chart of baseline and 1 week post-PDL treatment for the 15 patients in the presents study. The average number of molluscum contagiosum lesions at baseline was 29.5 but was reduced to 0.3 one week after irradiation, with a residual rate of 1.0% and a cure rate of 99%.
PDL for molluscum contagiosum
ORIGINAL ARTICLES as insufficient efficacy and pain. 5) In departments of dermatology, the lesions themselves are generally excised with a small curette and pressure forceps for treatment. However, such a treatment causes pain and feelings of fear in children due to bleeding and pain and thus is associated with many problems. In particular, in patients with a large number of MC lesions, a single treatment session alone is often insufficient, necessitating multiple treatment sessions. In addition, each lesion is painful, possibly promoting “white coat phobia” in affected children. The pulsed dye laser has a peak wavelength of 580-590 nm, which is strongly absorbed by hemoglobin, and is used in the treatment of vascular lesions such as vascular malformations and telangiectasia. In countries outside Japan, the pulsed dye laser has been reported to be effective in the treatment of acne vulgaris, and particularly in recent years, clinical and morphological studies have reported that this laser effectively improves facial skin through non-ablative skin rejuvenation. 6,7,8) Moreover, the pulsed dye laser is considered to be highly effective in hypertrophic scars and keloids, 9) and in our department, striae cutis distensae and other lesions have also been effectively treated. Furthermore, its effect on verruca vulgaris has
Figure 5.: Light absorption in tissue. Tissue chromophores, melanin, hemoglobin and water have wavelength-dependent absorption characteristics over the visible to midinfrared wavebands. The pulsed dye laser has a peak wavelength of 580-590 nm (hatched vertical block in the figure), which is strongly absorbed by hemoglobin.
53
ORIGINAL ARTICLES also been reported. 10) Although the mechanism of treatment of molluscum contagiosum is unclear, marked edema in the dermis and increased immunological activity after pulsed dye laser irradiation 7,8) suggest the involvement of both physical barriers against viruses and immunological mechanisms. In this study, we treated MC lesions using the pulsed dye laser. As a result, follow-up observation showed that a single treatment resulted in a residual rate of 1.0% and a reduction rate of approximately 99.0% one month after treatment. In addition, there was no recurrence of molluscum contagiosum in all the 8 patients in whom follow-up observation was possible 3 months after baseline, suggesting that this treatment is extremely highly effective compared to other treatments currently used. Adverse effects include “pain like being hit by a rubber band” during irradiation and the formation of purpura that remains for 1-2 weeks. In this study, a fluence of 8.0 J/cm2 and a spot size of 3 mm were used. The usual spot size for hemangioma treatment is 5-7 mm, requiring a correspondingly higher irradiance. The irradiance in the present study was much lower than that used in the treatment of hemangioma in children, suggesting that the use of the pulsed dye laser for MC treatment is very safe. In children, the extremities and trunk needed to be held steady during irradiation to secure the laser irradiation field. Among the 15 patients who underwent the operation in this study, 11 patients who had undergone lesion excision at a previous hospital
available at www.jstage.jst.go.jp/browse/islsm
remarked that “laser treatment was less painful” after treatment, and all the 3 patients who had recurrence wished to receive laser treatment again, suggesting that laser treatment causes less feelings of fear in children than lesion excision. For pain during irradiation, the use of a local anesthetic tape (Penles tape®) and a topical cream (EMLA Cream®) should be considered. This pain is reduced by decreasing fluence, and it seems necessary to study the correlation between fluence and therapeutic effect in the future. Purpura disappeared in 2-3 weeks after pulsed dye laser irradiation in almost all cases, but slight pigmentation remained in the occasional lesion. Therefore, adequate informed consent including these factors should be obtained from patients and their families. The treatment of MC lesions investigated in this study was highly effective. The liquid dye used in pulsed dye laser is expensive, however, and needs to be exchanged after a certain period of time. The authors are therefore not suggesting that a clinic should purchase a pulsed dye laser simply for the treatment of MC, but are suggesting such treatment as another string to the bow of pulsed dye lasers already being used in a clinic. Bearing this in mind, it is always necessary to consider the economical and efficient use of laser treatment, including pulsed dye laser treatment, not only from the viewpoint of cosmetic indications but also from the viewpoint of dermatological applications.
References 1: Niizeki K, Kano O and Kondo Y (1984): An epidemic of Molluscum contagiosum; relationship to swimming. Dermatologica, 169: 197-198 2: Pauly CR, Artis WM, and Jones HE (1978): Atopic dermatitis, impaired cellular immunity, and molluscum contagiosum. Arch Dermatol, 114: 391-393 3: Hellier FF (1971): Profuse mollusca contagiosa of the face induced by corticosteroids. Br J Dermatol 1971; 85: 398 4: Porter CD, Blake NW, and Archard LC (1989): Molluscum contagiosum virus types in genital and non-genital lesions. Br J Dermatol, 120: 37-40 5: Epstein E (2001): Molluscum contagiosum. In Common Skin Disorders 2001; 114. W.B. Saunders Company, Philadelphia. 6: Smit JM, Bauland CG, Wijnberg DS, and Spauwen PH: (2005): Pulsed dye laser treatment, a review of
54
indications and outcome based on published trials. Br J Plast Surg, 58: 981-987. 7: Omi T, Kawana S, Sato S et al. (2003): Ultrastructural changes elicited by a non- ablative wrinkle reduction laser. Lasers Surg Med, 32: 46-49 8: Omi T, Kawana S, Sato S et al. Cutaneous immunological activation elicited by a low-fluence pulsed dye laser. Br J Dermatol in press 9: Rochkind S, Kogan G, Luger EG, Salame K, Karp E, Graif M, and Weiss J (2004): Molecular structure of the bony tissue after experimental trauma to the mandibular region followed by laser therapy. Photomed Laser Surg. 2004; 22: 249-253. 10: Park HS and Choi WS: (2008): Pulsed dye laser treatment for viral warts: a study of 120 patients. J Dermatol, 35: 491-498.
Omi T & Kawana S
