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## Complete Summary

#### GUIDELINE TITLE

United Kingdom national guideline on the management of molluscum
contagiosum.

#### BIBLIOGRAPHIC SOURCE(S)

Clinical Effectiveness Group, British Association for Sexual Health and
HIV (BASHH). United Kingdom national guideline on the management of
molluscum contagiosum. London (UK): British Association for Sexual
Health and HIV (BASHH); 2008 Feb 15. 5 p. \[11 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Association for Genitourinary
Medicine (AGUM), Medical Society for the Study of Venereal Disease
(MSSVD). 2002 national guideline on the management of molluscum
contagiosum. London: Association for Genitourinary Medicine (AGUM),
Medical Society for the Study of Venereal Disease (MSSVD); 2002. Various
p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Genital molluscum contagiosum

-   Human immunodeficiency virus (HIV) infection

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Dermatology\
Family Practice\
Infectious Diseases\
Internal Medicine\
Obstetrics and Gynecology\
Urology

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

-   To enable the healthcare practitioner to reassure a patient with
    genital molluscum contagiosum (MC) that their condition is harmless
    and to offer an appropriate plan of management

-   To highlight key clinical features that should allow the diagnosis
    of genital MC to be made with confidence and to outline the
    treatment options

#### TARGET POPULATION

Patients in the United Kingdom with molluscum contagiosum

**Note**: This guideline is aimed primarily at people aged 16 or older
presenting to health care professionals working in departments offering
level 3 care in sexually transmitted infection (STI) management in
England and Wales, tier 5 in Scotland. However, the recommendations are
appropriate in all health care settings.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Diagnosis**

1.  Assessment of clinical features, including signs, symptoms, and
    evidence of secondary infection

2.  Examination of the core of lesions by electron microscopy

**Management/Treatment**

1.  General advice

2.  A full screen for sexually transmitted infections

3.  Human immunodeficiency virus (HIV) testing in patients presenting
    with facial lesions

4.  Cryotherapy

5.  Expression of the pearly core, either manually or using forceps

6.  Piercing with an orange stick, with or without the application of
    tincture of iodine, or phenol

7.  Curettage or diathermy under local anaesthesia

8.  Podophyllotoxin cream (0.5%)

9.  Imiquimod 5% cream for use in men

10. In patients with HIV infection, the introduction of highly active
    antiretroviral therapy

11. Considerations for pregnant and breastfeeding women

12. Follow-up

**Note**: There are no medicines licensed for the treatment of molluscum
contagiosum (MC) in the United Kingdom.

#### MAJOR OUTCOMES CONSIDERED

Safety and efficacy of treatment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A Medline search was undertaken using search terms molluscum
contagiosum, genital and randomised controlled trial (RCT). The Cochrane
database was also searched under molluscum contagiosum (MC). Trials
restricted to children aged \<16 years only were excluded. One systemic
review of treatment of MC in the Cochrane database was also excluded as
it did not consider the treatment of sexually transmitted MC. Two
studies involving the use of podophyllotoxin and imiquimod were
considered. The study on imiquimod used a 1% cream whereas the 5%
preparation is available in the United Kingdom (UK).

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Ia**: Evidence obtained from meta-analysis of randomised controlled
trials

**Ib**: Evidence obtained from at least one randomised controlled trial

**IIa**: Evidence obtained from at least one well designed controlled
study without randomisation

**IIb**: Evidence obtained from at least one other type of well designed
quasi-experimental study

**III**: Evidence obtained from well designed non-experimental
descriptive studies such as comparative studies, correlation studies,
and case control studies

**IV**: Evidence obtained from expert committee reports or opinions
and/or clinical experience of respected authorities

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grading of Recommendations**

**A (Evidence Levels Ia, Ib)**

-   Requires at least one randomised controlled trial as part of the
    body of literature of overall good quality and consistency
    addressing the specific recommendation.

**B (Evidence Levels IIa, IIb, III)**

-   Requires availability of well conducted clinical studies but no
    randomised clinical trials on the topic of recommendation.

**C (Evidence Level IV)**

-   Requires evidence from expert committee reports or opinions and/or
    clinical experience of respected authorities. Indicates absence of
    directly applicable studies of good quality.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Successive drafts of the guideline have been reviewed by the Clinical
Effectiveness Group (CEG) of the British Association for Sexual Health
and HIV (BASHH). The guideline was posted for comment for 3 months on
the BASHH website.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the levels of evidence **(I-IV)** and grades of
recommendation **(A-C)** are defined at the end of the \"Major
Recommendations\" field.

**[Diagnosis]{.underline}**

-   This is usually based on characteristic clinical appearance.

-   The main differential diagnosis is with genital warts, which are
    neither smooth nor umbilicated.

-   The core of lesions can be examined by electron microscopy, under
    which typical poxvirus-like particles will be seen.

**[Management]{.underline}**

**General Advice**

As the natural history is of spontaneous regression of lesions,
treatment is offered for cosmetic reasons only.

**Further Investigation**

-   As other sexually transmitted infections (STIs) may co-exist; a full
    screen for these should be undertaken (**Level of evidence III,
    Grade of recommendation B**).

-   Human immunodeficiency virus (HIV) testing is recommended in
    patients presenting with facial lesions (**Level of evidence III,
    Grade of recommendation B**).

**Treatment**

The aim is tissue destruction, with viral demise accompanying this.
There are no medicines licensed for the treatment of molluscum
contagiosum (MC) in the United Kingdom (UK).

**Recommended Regimens**

-   Cryotherapy -- apply liquid nitrogen until a halo of ice surrounds
    the lesion. Repeat applications may be necessary (**Level of
    evidence IV, Grade of recommendation C**).

-   Expression of the pearly core, either manually or using forceps
    (**Level of evidence IV, Grade of recommendation C**).

-   Piercing with an orange stick, with or without the application of
    tincture of iodine or phenol (**Level of evidence IV, Grade of
    recommendation C**).

-   Curettage or diathermy may be carried out under local anaesthesia
    (**Level of evidence IV, Grade of recommendation C**).

-   Podophyllotoxin cream (0.5%) can be self-applied in men (**Level of
    evidence Ib, Grade of recommendation A**).

-   Imiquimod 5% cream can be self-applied in men (**Level of evidence
    Ib, Grade of recommendation A**).

-   In patients with HIV infection, the introduction of highly active
    antiretroviral therapy may lead to the resolution of lesions
    (**Level of evidence III, Grade of recommendation B**).

*Allergy*

-   Treatments to which there is known hypersensitivity should be
    avoided

*Pregnancy and Breastfeeding*

-   Cryotherapy and other, purely destructive methods are safe.

-   Podophyllotoxin is contraindicated. The British National Formulary
    advises that Imiquimod should be used with caution.

**Sexual Partners**

-   Contact tracing of partners is unnecessary

**[Definitions]{.underline}**:

**Levels of Evidence**

**Ia**: Evidence obtained from meta-analysis of randomised controlled
trials

**Ib**: Evidence obtained from at least one randomised controlled trial

**IIa**: Evidence obtained from at least one well designed controlled
study without randomisation

**IIb**: Evidence obtained from at least one other type of well designed
quasi-experimental study

**III**: Evidence obtained from well designed non-experimental
descriptive studies such as comparative studies, correlation studies,
and case control studies

**IV**: Evidence obtained from expert committee reports or opinions
and/or clinical experience of respected authorities

**Grading of Recommendations**

**A (Evidence levels Ia, Ib)**

-   Requires at least one randomised controlled trial as part of the
    body of literature of overall good quality and consistency
    addressing the specific recommendation.

**B (Evidence levels IIa, IIb, III)**

-   Requires availability of well conducted clinical studies but no
    randomised clinical trials on the topic of recommendation.

**C (Evidence level IV)**

-   Requires evidence from expert committee reports or opinions and/or
    clinical experience of respected authorities. Indicates absence of
    directly applicable studies of good quality.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate diagnosis, treatment and management of patients with
molluscum contagiosum

#### POTENTIAL HARMS

Not stated

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Treatments to which there is known hypersensitivity should be
    avoided.

-   Podophyllotoxin is contraindicated in women who are pregnant or
    breastfeeding.

-   The British National Formulary advises that imiquimod should be used
    with caution in women who are pregnant or breastfeeding.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The study on imiquimod that guideline developers considered used a
    1% cream whereas the 5% preparation is available in the United
    Kingdom.

-   The recommendations in this guideline may not be appropriate for use
    in all clinical situations. Decisions to follow these
    recommendations must be based on the professional judgement of the
    clinician and consideration of individual patient circumstances.

-   All possible care has been undertaken to ensure the publication of
    the correct dosage of medication and route of administration.
    However, it remains the responsibility of the prescribing physician
    to ensure the accuracy and appropriateness of the medication they
    prescribe.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Clinical Effectiveness Group, British Association for Sexual Health and
HIV (BASHH). United Kingdom national guideline on the management of
molluscum contagiosum. London (UK): British Association for Sexual
Health and HIV (BASHH); 2008 Feb 15. 5 p. \[11 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 Aug (revised 2008 Feb 15)

#### GUIDELINE DEVELOPER(S)

British Association for Sexual Health and HIV - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Not stated

#### GUIDELINE COMMITTEE

Clinical Effectiveness Group (CEG)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Author*: Gordon Scott, Lauriston Building, Edinburgh

*Clinical Effectiveness Group (CEG) Members*: Dr Keith Radcliffe,
Whittal Street Clinic, Birmingham (BASHH); Dr Imtyaz Ahmed-Jusuf,
Nottingham City Hospital (BASHH); Dr David Daniels, West Middlesex
Hospital (Chair NAG); Dr Mark FitzGerald, Taunton and Somerset (BASHH);
Dr Neil Lazaro (RCGP); Dr Guy Rooney, Swindon and Oxford (RCP); Dr Gill
McCarthy, Kingston Hospital (BASHH)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Conflict of Interest: None

This guideline was commissioned and edited by the Clinical Effectiveness
Group (CEG) of the British Association for Sexual Health and HIV
(BASHH), without external funding being sought or obtained.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Association for Genitourinary
Medicine (AGUM), Medical Society for the Study of Venereal Disease
(MSSVD). 2002 national guideline on the management of molluscum
contagiosum. London: Association for Genitourinary Medicine (AGUM),
Medical Society for the Study of Venereal Disease (MSSVD); 2002. Various
p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [British Association for Sexual
Health and HIV Web site](http://www.bashh.org/guidelines).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Specifications for the development of UK guidelines on the
    management of sexually transmitted infections (STIs) and closely
    related conditions 2005. London (UK): British Association for Sexual
    Health and HIV (BASHH); 2005. 14 p. Electronic copies: Available in
    Portable Document Format (PDF) from the [British Association for
    Sexual Health and HIV Web
    site](http://www.bashh.org/documents/25/25.pdf).

Additionally, auditable outcome measures can be found in the [original
guideline document](http://www.bashh.org/guidelines).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on December 8, 2000. The information
was verified by the guideline developer on January 12, 2001. This
summary was updated on August 5, 2002. This summary was updated by ECRI
Institute on June 24, 2008. The updated information was verified by the
guideline developer on June 30, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developers and/or BMJ Publishing Group\'s copyright
restrictions. Reproduction and use of this guideline is permitted
provided that (a) the original content is not changed or edited; and,
(b) any content derived from the original guideline is acknowledged as
that of the author(s) and responsible organizations.

Readers wishing to download and reproduce material for purposes other
than personal study or education should contact BMJPG to seek permission
first. Contact: BMJ Publishing Group, BMA House, Tavistock Square, WC1H
9JR, UK.

### DISCLAIMER

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Date Modified: 11/3/2008