Acne and a Hickey: What is Wrong with Vickie?

The 16-year-old presents with complaints about acne and other zits, the latter of which do not respond to her regular topical retinoic acid treatment.

PMH is significant only for comedonal acne that is well controlled with retinoic acid. No family history of note.

Only finding of note are flesh-colored papules on shoulders, neck, and face; some appear to have central indentation/umbilication.

Cluster of flesh-colored papules on the teen's shoulder.

Papules are seen on the side of the neck and face; also seen is a large eliptical bruise.

Close up of papules and bruise on neck.

Note the umbilication among the papules.

A well adolescent female with two types of lesions: Multiple flesh-colored papules with central umbilication and…an oval bruise on her neck.

What is your diagnosis?

Diagnosis: Molluscum contagiosum, for the papules. As for the bruise, it will be discussed later.

Molluscum contagiosum: pox virus family; double-stranded DNA; most commonly seen in children; transmitted via direct skin contact, sexual contact, fomites.

Molluscum contagiosum: Seen in 5-20% of patients with HIV. Incubation is 2-14 days; resolves without treatment in 6-9 months in immunocompetent hosts .

Diagnosis: typically clinical, straightforward; pink, dome-topped papules with central umbilication/punctum; biopsy reveals acanthomas.

Spontaneous resolution, no scarring in immunocompetent hosts; no definitive evidence of efficacy; clinical evidence supports curettage, cryotherapy, topical agents,

Molluscum treatments supported by clinical evidence: cryotherapy, cantharadin, curettage considered first line; also used topical salicylic and retinoic acid; cimetidine.

Molluscum treatments supported by clinical evidence: Intralesional podofiliox.

Note that there are no FDA-approved treatments, topical or intralesional, for molluscum contagiosum.

Treatment: Curettage most effective, cantharadin has side effects, slightly less effective; keratolytic agent irritating, topical imiquimod is effective but costly.

Giant molluscum seen in a 4-year-old with HIV. You must be suspicious of HIV in a child with giant molluscum or extensive skin involvement.

What about the bruise? The

HEEADS psychosocial inventory

can help engage teens in discussion about areas of their social and emotional lives that may have an impact on physical welbeing.