REPORTS

The epidemiology of molluscum

contagiosum in children
Magdalene A. Dohil, MD,a Peggy Lin, MD,b James Lee, MD, PhD,c Anne W. Lucky, MD,d
Amy S. Paller, MD,b and Lawrence F. Eichenfield, MDa
San Diego, California; Chicago, Illinois; St Paul, Minnesota; and Cincinnati, Ohio

Molluscum contagiosum (MC) is a viral disorder of the skin and mucous membranes characterized by
discrete single or multiple, flesh-colored papules. Although MC as a clinical entity is well defined and
commonly observed, few data regarding its epidemiology in the pediatric population exist. Our purpose was
to collect epidemiologic data on children with MC with regard to age, gender, ethnicity, degree of
involvement, relation to pre-existing atopic dermatitis (AD), and immune status. A retrospective chart review
was conducted. All subjects were seen at 3 tertiary pediatric dermatology referral centers with two of the sites
based at a Children’s Hospital. A total of 302 patient charts with the Current Procedural Terminology code
diagnosis of MC seen over a 6- to 8-month period were reviewed. Approximately 80% of the patients were
younger than 8 years old. The majority of patients (63%) had more than 15 lesions. All but one patient were
otherwise healthy, as determined by history and clinical examination. Approximately 24% of the patients
presented with a history of previous or active coexistent AD. However, children with AD were at risk for an
increased number of lesions. These data provide valuable updated information on the demographics
and clinical presentation of MC in pediatric patients in the United States. Limitations include that this was a
retrospective study with a population limited to tertiary pediatric dermatology referral centers. ( J Am Acad
Dermatol 2006;54:47-54.)

M olluscum contagiosum (MC) is a viral dis-
order of the skin and mucous membranes
characterized by discrete, single or multi-
ple, flesh-colored papules.1 The causative virus be-
longs to the family Poxviridae subgenus molluscipox
virus, which comprises 4 genetically subdivided but
clinically indistinguishable MC viral types.2 MC viruses
(MCVs) replicate in the cytoplasm and show the
typical poxvirus brick-shaped morphology. Despite
these similarities, they lack the ability to cross-hybrid-
ize with or be reactivated by other poxviruses.3-5
From the Division of Pediatric and Adolescent Dermatology,
Children’s Hospital and the Departments of Pediatrics and
Medicine (Dermatology), University of California, San Diego
School of Medicinea; the Division of Dermatology, Children’s
Memorial Hospital; Departments of Dermatology and Pediat-
rics, Northwestern University’s Feinberg School of Medicine,
Chicagob; 3M Pharmaceuticals, St. Paulc; and Dermatology
Associates of Cincinnati and The Cincinnati Children’s Hospital.d
Funding sources: Study was sponsored by an unrestricted educa-
tion grant provided by 3M Pharmaceuticals.
Conflicts of interest: None identified.
Accepted for publication August 3, 2005.
Reprint requests: Lawrence Eichenfield, MD, 8010 Frost St, Suite
602, San Diego, CA 92123. E-mail: leichenfield@chsd.org.
Published online November 21, 2005.
0190-9622/$32.00
ª 2005 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2005.08.035
The MCV infection is specific to humans and has
been reported worldwide. The MCV genotype 1 pre-
dominates and represents 98% of cases in the United
States.3,6 Other genotypes are significantly more
common in immunocompromised and specifically
in HIV-infected persons, as well as in countries
outside the United States. None of these genotypes
shows any difference clinically, and most patients
typically present with multiple lesions.
MCV is passed directly by skin contact to produce
the typical cutaneous and, rarely, mucosal lesions.
Transmission via fomites on bath sponges and bath
towels, in beauty parlors, school swimming pools,
and Turkish baths have been implicated as a source
of infection.7-9
The diagnosis of MC is made clinically, but when
necessary, a biopsy can be performed to confirm
the clinical diagnosis or a microscopic examination
of a crush preparation of a lesion can be confirma-
tory.6,10,11 Although MC lesions can involve any
anatomic site, the most commonly reported locations
include the trunk, axillae, antecubital and popliteal
fossae, and crural folds.4,6,10,12
The prevalence of MC in sexually active adults
and participants in skin contact sports has been well
documented.4,5,13-17 The incidence of MC infection
in the United States has been increasing since the
1960s, particularly as a sexually transmitted disease.

47
48 Dohil et al J AM ACAD DERMATOL
JANUARY 2006

Table I. Association of epidemiologic factors of 302 pediatric patients with clinical involvement of molluscum
contagiosum
No. of molluscum contagiosum lesions
Epidemiologic factors \15 15-30 [30 Total
Age (mo)
0-36 60 (31.4%) 22 (24.2%) 3 (15.8%) 85 (28.1%)
37-60 40 (20.9%) 27 (29.7%) 8 (42.1%) 75 (24.8%)*
61-96 53 (27.8%) 24 (26.4%) 5 (26.3%) 82 (27.2%)
[96 38 (19.9%) 18 (19.8%) 3 (15.8%) 59 (19.5%)
Gendery
Male 89 (46.8%)z 47 (51.7%) 9 (47.4%) 145 (48.0%)
Female 101 (53.2%) 44 (48.4%) 10 (52.6%) 155 (51.3%)*
Anatomic location§
Trunk 132 (69.5%) 71 (78.0%) 16 (84.2%) 219 (72.8%)
Trunk only 60 (31.6%) 20 (22.0%) 2 (10.5%) 82 (27.2%)
Extremities 92 (48.4%) 66 (72.5%) 13 (68.4%) 171 (56.8%)*
Extremities only 33 (17.4%) 15 (16.5%) 2 (10.5%) 50 (16.6%)
Face 46 (24.2%) 18 (19.8%) 6 (31.6%) 70 (23.2%)
Face only 20 (10.5%) 2 (2.2%) 1 (5.3%) 23 (7.6%)
Coexistence of atopic dermatitis
Yes 43 (22.5%) 23 (25.3%) 7 (36.8%) 73 (24.2%)
No 148 (77.5%) 68 (74.7%) 12 (63.2%) 228 (75.5%)*

*Number of molluscum contagiosum lesions were not reported for one patient from center 2.
y
Gender information was missing for one patient from center 1.
z
Denominator for calculation of percentage is the total number of patients within category of molluscum contagiosum lesions.
§
Anatomic location information was missing from one patient from center 3.

Results from a survey involving two clinics for sexu-
ally transmitted disease during the period 1966-1983
indicated that the most commonly affected age group
was 15 to 29 years of age.18
It is estimated that fewer than 5% of children in
the United States show clinical evidence of MCV
infection. An Australian study evaluated the seropre-
valence of MCV antibodies in 357 patients consid-
ered representative of the Australian population. The
results of this study suggested a high incidence of
very mild or subclinical MC cases in the general
community.19 A study performed in the Netherlands
found the cumulative incidence of the childhood
form of MC to be 17% of 15-year-old persons.20
As with other cutaneous viral infections, the cell-
mediated immune system appears to play an impor-
tant role in the resolution of the infection. In adults
an increase in the number of MC cases has paralleled
the rise of AIDS cases during the 1980s,21-23 with a
prevalence of 5% to 18% of patients infected with
HIV showing clinical evidence of infection. Atypical
clinical findings are often seen in HIV-positive
patients, predominantly with facial involvement, a
tendency for bacterial superinfection, and resistance
to various treatment modalities. Since the introduction
of highly active antiretroviral therapy, the number
of MC cases in AIDS patients has decreased sub-
stantially.24-28
MC has also been reported to be more common
and to spread more extensively in patients with
atopic dermatitis (AD).29,30 The increased pre-
valence and severity of MC in this patient popula-
tion have been linked to the relative suppression of
the helper T-cell type 1 responses in acute skin
lesions of AD.31-34 MC has also been associated with
systemic iatrogenic immunosuppression from admi-
nistration of corticosteroids and chemotherapy.35
The epidemiology and features of clinical presen-
tation of MC infection in children and the association
of MC to immunosuppression and AD are poorly
understood. Previous studies that have assessed the
prevalence and clinical presentation of MC in chil-
dren have involved only small sample sizes, gener-
ally in small, defined populations.8,12,36,37 In an effort
to better define and update the epidemiology of MC
infection in children in the United States, a retro-
spective chart review of pediatric patients with the
diagnosis of molluscum at 3 pediatric dermatology
tertiary referral centers was conducted.
METHODS
A total of 302 charts were reviewed of patients
with the Current Procedural Terminology code
diagnosis of MC seen in the preceding 6 to 8 months
at 3 pediatric dermatology practices (Children’s
Hospital of San Diego, Calif [center 1]; Children’s
J AM ACAD DERMATOL
VOLUME 54, NUMBER 1
Fig 1. Summary of demographic data associated with MC in 302 pediatric patients reflecting
age and number of patients per study site. CH, Chicago (center 2); CN, Cincinnati (center 3);
SD, San Diego (center 1).
Memorial Hospital, Chicago, Ill, [center 2]; and a
group dermatology practice in Cincinnati, Ohio
[center 3]). Data on age, gender, number and ana-
tomic location of MC lesions, association with AD,
concomitant use of topical immunosuppressive
medication, and medical history of current immuno-
suppression were collected. For purposes of the ana-
lysis, anatomical location was subcategorized into
the following:
d Face (included ear and scalp)
d Trunk (included neck and groin)
d Extremities
The number of patients with MC was tabulated
across the following demographic variables:
d Age (0-36, 37-60, 61-96, [96 months)
d Ethnicity (Caucasian, Hispanic, Asian, African-
American, other)
d Gender
Ethnicity data were collected only from patients at
study center 2 (100 patients). Epidemiologic factors
summarized included the number of MC patients
with a history of AD. The systemic and topical
immune status of each patient was evaluated by
determining the number of patients diagnosed with
an immunosuppressive condition or patients report-
ing the use of topical immunosuppressive medica-
tion. The number of patients presenting with less
than 15, 15 to 30, and more than 30 MC lesions was
also tabulated. All data analyses and summarizations
were performed using proc FREQ in SAS (SAS
version 8.1, SAS Institute, Cary, NC, 1999).
Access to the patients’ charts was limited to the
principal investigator and subinvestigator. There was
Dohil et al 49
no direct patient contact and the use of the informa-
tion did not involve any perceivable risk to the
person. No identifiable patient data were recorded
from the chart and no such data will be published.
Institutional review board approval was obtained at
each institution before the chart review.
RESULTS
Age. Four age groups were analyzed: 0-36, 37-60,
61-96, and more than 96 months. Eighty-five patients
(28.1%) were in the 0- to 36-month-old group, 75
patients (24.8%) in the 37- to 60-month-old group, 82
patients (27.2%) in the 61- to 96-month-old group,
and 59 patients (19.5%) in the older than 96-month
group (Table I). There was a statistically significant
association between clinic and age group (x 2 5
18.85; P 5 .0044). The age distribution for the 37- to
60-month and 61- to 96-month groups was very
similar at all 3 centers. MC presented less commonly
in the older than 96-month group. Fig 1 summarizes
the demographic data associated with MC with
regard to age and number of patients per study site.
Ethnicity. Because of privacy concerns, ethnic-
ity data were only collected from patient charts at
study center 2. Of the 100 patients, 68% were
Caucasian, 27% were Hispanic, 3% were Asian, and
2% were African American (data not shown). The
ethnicity distribution is representative of the profile
seen at study center 2.
Gender. Gender distribution analysis of patients
revealed an equal distribution, with 48.0% and
51.3% of patients being male and female, respec-
tively (Table I). There was no statistically significant
association between clinic and gender (x 2 = 0.21;
P = .9022).
50 Dohil et al
Fig 2. Summary of epidemiologic factors associated with MC in 302 pediatric patients
reflecting number of lesions per study site. CH, Chicago (center 2); CN, Cincinnati (center 3);
SD, San Diego (center 1).
Degree of involvement. Of the 301 patients
whose physicians reported number of MC lesions,
191 (63.5%) had fewer than 15 lesions, 91 (30.2%)
had 15 to 30 lesions, and 19 (6.3%) had more than
30 lesions (Table I; Fig 2). No gender differences in
clinical involvement were noted. Within the group of
patients who presented with more than 30 lesions, a
slightly higher percentage (42.1%) were in the 37- to
60-month-old group compared with the other age
groups (15.8%-26.3%). For patients with more than
30 lesions, the trunk was the most common anatomic
location involved (84.2%).
Anatomic location of lesions. Approximately
50% of the patients had lesions in more than one
anatomic region (data not shown). Trunk lesions
were the most common, with 219 patients (72.8%)
observed to have MC lesions in this location (Table I;
Fig 3). In 82 patients (27.2%), the trunk was the only
anatomic region involved. Lesions were noted on the
extremities in 171 patients (56.8%); lesions on only
the extremities were reported for 50 patients (16.6%).
Lesions on the face, scalp, and ears were reported in
70 patients (23.2%). Of the 23 patients (7.6%) who
presented with facial lesions only, 20 (10.5%) had
fewer than 15 lesions. The relation between demo-
graphic factors and anatomic location of MC lesions
is summarized in Table II. Overall, there were no
clinically meaningful differences in anatomic loca-
tion of lesions by gender. Trunk lesions were more
common in the 0- to 36-month, 37- to 60-month,
and 61- to 96-month-old groups than in the older
than 96-month group (25.6%-29.2% vs 16.9%). In
contrast, lesions only on the extremities were more
common in patients older than 61 months of age
J AM ACAD DERMATOL
JANUARY 2006
(66%) compared with patients 60 months of age or
younger (34%).
Relation to AD. Seventy-three patients (24.2%)
were concomitantly diagnosed with AD (Table III).
Of these patients, 71 (97.3%) had a history of AD as
reported by a parent. The percentage of patients with
AD was higher in patients with more than 30 lesions
than in patients reporting fewer than 15 lesions
(36.8% vs 22.5%-25.3%) (data not shown). The pre-
valence of AD was lower in the older than 96-month
group compared with the younger age groups
(15.1% vs 27.4%-30.1%) (data not shown).
Immune status. One patient with a history of
IgE deficiency was considered immunosuppressed
and had 15 to 30 lesions. There were no patients that
were known to be HIV positive or receiving systemic
immunosuppressive therapy. Approximately 21%
of patients were using topical immunosuppressive
medication and all of these patients had coexistent
AD (Table III).
DISCUSSION
This retrospective chart review provides informa-
tion on the demographics, clinical presentation, and
immune status of children with MC. Previous studies
from New Guinea,37 Japan,7 and the Netherlands20
found the peak prevalence of MC in patients 2, 8,
and 6 to 10 years of age, respectively. Results from a
molecular epidemiological study conducted in Spain
indicated that 66% of the MCV-infected population
were younger than 10 years old.38 The results from
this chart review showed that two thirds of the
patients were younger than 8 years old. The reason
J AM ACAD DERMATOL Dohil et al 51
VOLUME 54, NUMBER 1

Fig 3. Summary of epidemiologic factors associated with MC in 302 pediatric patients

reflecting location of lesions.

Table II. Association of demographic factors with anatomic location of molluscum contagiosum lesions
Anatomic location of molluscum contagiosum lesionsy
Demographic factors* Trunk Trunk only Extremities Extremities only Face Face only
Gender
Male 110 (50.2%) 46 (56.1%) 77 (44.8%) 21 (42.0%) 31 (44.3%) 10 (45.5%)
Female 109 (49.8%) 36 (43.9%) 95 (55.2%) 29 (58.0%) 39 (55.7%) 12 (54.6%)
Age (mo)
0-36 64 (29.2%) 29 (35.4%) 38 (22.1%) 11 (22.0%) 23 (32.4%) 8 (34.8%)
37-60 62 (28.3%) 23 (28.1%) 42 (24.4%) 6 (12.0%) 18 (25.4%) 6 (26.1%)
61-96 56 (25.6%) 16 (19.5%) 58 (33.7%) 16 (32.0%) 15 (21.1%) 5 (21.7%)
[96 37 (16.9%) 14 (17.1%) 34 (19.8%) 17 (34.0%) 15 (21.1%) 4 (17.4%)

*Demographic factors were not reported for one patient.

y
Denominator for calculation of percentage is the total number of patients with molluscum contagiosum lesions in given anatomic location.

for the predominant occurrence in primarily younger
children remains unclear.
The results from a recent Australian study indi-
cated an overall seropositivity rate of 23%.19 This
number included patients with clinical and subclin-
ical infection. The lowest antibody response was
seen in children from 6 months to 2 years of age
(3%), increasing to 11% from 2 to 4 years of age, and
20% from 5 to 9 years of age. The value reached 39%
in patients older than 50 years. Thirty-one percent
of children younger than 6 months showed sero-
positivity to MCV, which likely reflects maternally
acquired antibodies. The prevalence was highest
(91%) in the group of HIV-positive patients with
clinically apparent MCV infection. In the Australian
study no relationship was found between the sero-
logic responses and the number of lesions or the
duration of infection.
To examine the possible differences in the sus-
ceptibility or transmission patterns of MC between
male and female patients, the patient’s gender was
examined. The gender distribution was similar across
the 0- to 36-month-old, 37- to 60-month-old, and
61- to 96-month-old groups (approximately 1:1,
male/female). The older than 96-month group con-
sisted of more female children compared with the
younger age groups (61% vs 50%). The overall 1:1
gender ratio was consistent with the distribution seen
in the Netherlands study,20 but differs from the 3:2
(male/female) ratio seen in the Japanese study.7,16,17
The distribution of anatomic location appears to
be consistent with previously published reports.12
The trunk was the most frequently reported location
with lesions occurring less commonly on the ex-
tremities and rarely on the face. Approximately 50%
of the patients presented with lesions in more than
one anatomic region. Patients younger than 60
months were more likely to present with truncal
lesions, whereas children older than 60 months
were more likely to present with lesions on the
52 Dohil et al J AM ACAD DERMATOL
JANUARY 2006

Table III. Summary of epidemiologic factors associated with molluscum contagiosum in 302
pediatric patients
No. of patients
Epidemiologic factors Center 1 (n = 102) Center 2 (n = 100) Center 3 (n = 100) Total (N = 302)
Age (mo)
0-36 36 (35.3%) 33 (33.0%) 16 (16.0%) 85 (28.1%)
37-60 23 (22.6%) 26 (26.0%) 27 (27.0%) 76 (25.2%)
61-96 30 (29.4%) 26 (26.0%) 26 (26.0%) 82 (27.2%)
[96 13 (12.8%) 15 (15.0%) 31 (31.0%) 59 (19.5%)
Gender*
Male 48 (47.5%) 47 (47.0%) 50 (50.0%) 145 (48.2%)
Female 53 (52.5%) 53 (53.0%) 50 (50.0%) 156 (51.8%)
Anatomic locationy
Trunk 76 (74.5%) 81 (81.0%) 62 (62.6%)y 219 (72.8%)
Trunk only 16 (15.7%) 43 (43.0%) 23 (23.2%) 82 (27.2%)
Extremities 66 (64.7%) 46 (46.0%) 60 (60.6%) 172 (57.1%)
Extremities only 12 (11.8%) 10 (10.0%) 28 (28.3%) 50 (16.6%)
Face 31 (30.4%) 18 (18.0%) 22 (22.2%) 71 (23.6%)
Face only 9 (8.8%) 7 (7.0%) 7 (7.1%) 23 (7.6%)
History of atopic dermatitis
Yes 21 (20.6%) 26 (26.0%) 24 (24.0%) 71 (23.5%)
No 81 (79.4%) 74 (74.0%) 76 (76.0%) 231 (76.5%)
Coexistence of atopic dermatitis
Yes 21 (20.6%) 30 (30.0%) 22 (22.0%) 73 (24.2%)
No 81 (79.4%) 70 (70.0%) 78 (78.0%) 229 (75.8%)
Immunosuppressed
Yes 0 (0.0%) 0 (0.0%) 1 (1.0%) 1 (0.3%)
No 102 (100.0%) 100 (100.0%) 99 (99.0%) 301 (99.7%)
Topical immunosuppressive medications
Yes 20 (19.6%) 12 (12.0%) 32 (32.0%) 64 (21.2%)
No 82 (80.4%) 88 (88.0%) 68 (68.0%) 238 (78.8%)
No. of lesionsz
\15 76 (74.5%) 57 (57.6%) 58 (58.0%) 191 (63.5%)
15-30 24 (23.5%) 35 (35.4%) 32 (32.0%) 91 (30.2%)
[30 2 (2.0%) 7 (7.1%) 10 (10.0%) 19 (6.3%)

*Gender information was missing for one patient from center 1.

y
Anatomic location information was missing for one patient from center 3.
z
Clinical involvement information was missing for one patient from center 2.

extremities. Approximately two thirds of the patients
had fewer than 15 lesions; 6.3% of patients presented
with more than 30 lesions. There was no association
between the anatomic location of lesions, number of
lesions, gender, or extent of clinical involvement.
In clinical practice, the therapeutic approach for
treating patients presenting with only a few lesions
often differs from the approach used in treating
patients with many lesions. This is especially true for
younger patients who do not tolerate painful proce-
dures. Although application of topical anesthetic
cream and curettage may be appropriate therapy
for treating patients with few lesions, the findings
relating to number and location of lesions emphasize
the need for relatively nonpainful, nonfrightening
options such as the application of cantharidin or
topical imiquimod, both commonly utilized agents,
though not approved by the Food and Drug Admin-
istration for this purpose. In addition, the results from
this study confirm the importance of performing a
thorough examination when MC lesions are identi-
fied, to ensure that as many lesions as possible can be
eliminated by treatment. Since most patients will
have lesions in several anatomic locations and rein-
fection via autoinoculation may prolong the clinical
course of MC, simultaneous treatment of all the MC
lesions is ideal.
MC has been reported to be more common in
patients with AD.30,31,34 However, the extent of this
association has not been quantified clinically, and
different studies come to different conclusions. In
this study, 24.2% of the patients were diagnosed with
concomitant AD at the time of diagnosis of the MC.
These results were similar to an earlier study that
J AM ACAD DERMATOL
VOLUME 54, NUMBER 1
found the prevalence of AD in schoolchildren in
Oregon was as high as 17.2%.38 The percentage of
patients with MC and AD was reported as high as
49% in a study conducted in Spain.39 The results of
the Spanish study also showed a relation between
patients with concurrent AD and large lesions, al-
though these patients had no other distinguishing
clinical finding. Overall, the small increase in the
percentage of reported MC-infected children with
AD as compared with AD in the general population
may simply reflect referral bias and the tendency
of patients with AD to more readily seek care for
skin problems and to be examined regularly by a
physician.
The findings in this study suggest some relation-
ship between immune status and the development
of clinical MC lesions, although the exact interaction
is still unclear. MCV is considered one of the cuta-
neous manifestations of HIV infection before highly
retroactive antiretroviral therapy, and HIV-infected
patients appear to represent a defined subgroup of
MCV cases. None of our patients had known HIV
infection, which indicates that HIV infection has little
impact on the overall epidemiology of MC in children.
Immunosuppression was rare in our population of
children with MC. As tertiary, hospital based pediat-
ric dermatology centers, we would have expected to
capture cases associated with immunosuppression,
if this association was predominant in the epidemi-
ology of MCV infection in children.
One limitation of this cross-sectional study is the
selection bias of the analyzed patient population.
Although we cannot be certain that the results would
be dissimilar if the study had been carried out in a
primary care pediatric office setting, we believe the
results are indicative of the general pediatric popu-
lation infected with MC. The data could be biased
toward more severe cases of MC or a higher repre-
sentation of patients with immunosuppression or
AD. The potential for reporting errors such as mis-
diagnosis of AD exists. This source of bias, however,
is minimized by the fact that pediatric dermatologists
are more likely to diagnose common pediatric skin
conditions accurately than either adult dermatolo-
gists or pediatricians.
CONCLUSIONS
The results of this retrospective chart review
provide valuable information on the demographics,
clinical presentation, and immune status of children
infected with MC. The majority of our patient pop-
ulation with MC presented with fewer than 15 le-
sions and were healthy children younger than 8 years
of age. Contrary to common belief, there is a low
prevalence of immunosuppression in children with
Dohil et al 53
MC. This finding is even more significant given the
fact that all study sites were tertiary referral centers
where more serious cases would be expected to
present. Although approximately 25% of the patients
also had AD, the slight increase above the overall
prevalence of this disorder in the United States likely
reflects referral bias and the tendency for careful skin
examination of children with AD by both parents and
physicians.
We thank Kurt Stromberg for his statistical support and
Elizabeth Lisowski for her editorial contribution to this
manuscript.
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