Warts, molluscum and things that go bump on the skin: a practical guide

Peter Lio

doi:10.1136/adc.2007.122317

Responses

Dermatophile

Warts, molluscum and things that go bump on the skin: a practical guide

Compose a Response to This Article

Compose Response

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

PLEASE NOTE:

A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.

I agree to and have read the terms and conditions for rapid responses and BMJ Privacy Notice *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

Author's Reply
Peter A Lio
Published on: 23 March 2016
Warts and Molluscum: An impractical guide
Stephen Roberts
Published on: 23 March 2016
Warts, molluscum and things that go bump on the skin: A practical guide
Helen M Goodyear
Published on: 23 March 2016

Published on: 23 March 2016
Author's Reply
- Peter A Lio, Dermatologist
Dear Editor,
Dr Roberts questions the point of treating warts and molluscum which are benign and will often spontaneously resolve, and expresses concern about discussing these methods of treatment at all. In terms of the former, I regret that I did not more explicitly state that the so-called "tincture of time" is, by far, the preferred method of treating these lesions. The focus of the review is on those cas...
Show More

Dear Editor,
Dr Roberts questions the point of treating warts and molluscum which are benign and will often spontaneously resolve, and expresses concern about discussing these methods of treatment at all. In terms of the former, I regret that I did not more explicitly state that the so-called "tincture of time" is, by far, the preferred method of treating these lesions. The focus of the review is on those cases where there is a compelling reason to seek further treatment, with emphasis on sorting through the vast (and often anecdotal) literature on these treatments.
As Dr Roberts notes, the consultant dermatologists carry a heavy load in the UK, and this is perhaps equally true in the US.[1] Ironically, it was the tremendous number of "emergency" consultations that are referred to our practice for warts and molluscum that prompted me to write this article. Many patients are referred by their pediatricians for warts and molluscum that have persisted or are spreading, causing a great deal of anxiety and frustration for all parties. Importantly, many of these patients express anger towards their pediatrician and frequently feel marginalized because they were told the lesions would go away without treatment. Sometimes, the children are ostracized from school, public pools or sporting events, adding psychological stress to the entire family.[2]
Much more concerning, however, is when doctors or the patients themselves feel compelled to treat these lesions and do so in ways that may cause harm. I specifically cautioned against using imiquimod for molluscum, for example, as I have seen many adverse effects when used for this purpose. I have seen patients apply powerful acids and create painful ulcers which scar, and have seen children traumatized by curettage without anesthesia of any sort. The secondary purpose of the paper, then, is to discuss these methods openly and without bias, so that if treatment is deemed necessary, there is some context and experience for choosing an appropriate treatment in a manner that is safe for the patient.
Drs Goodyear and Taibjee raise concern that I impugn evidence-based medicine (EBM). In fact, in my five-page paper with almost 50 references from the peer-reviewed literature including heavy reliance on the Cochrane Database, I sought to explore the area where there is not yet enough evidence to make easy rational choices about treatment of these skin diseases. Indeed, on the British Association of Dermatologists website, the only treatments that were given the strength of evidence D ("There is fair evidence to support the rejection of the use of the procedure") were oral cimetidine and homeopathy.[3] There were no treatments given strength of evidence E ("There is good evidence to support the rejection of the use of the prodedure"). In fact, two of the treatments I discussed (imiquidmod and heat treatment/balneotherapy) were deemed to have insufficient evidence at this time. As a strong proponent of EBM, I try to remain vigilant for the fallacy of argumentum ad ignorantiam in all its forms, which in this case might be best put: "absence of evidence is not evidence of absence."
In sum, I overwhelmingly agree with the comments of Drs Goodyear, Taibjee, and Roberts and appreciate the opportunity to put the review in a proper light.
References:
1. Tsang MW, Resneck JS Jr. Even patients with changing moles face long dermatology appointment wait-times: a study of simulated patient calls to dermatologists. J Am Acad Dermatol 2006;55(1):54-8.
2. Braue A, Ross G, Varigos G, et al. Epidemiology and impact of childhood molluscum contagiosum: a case series and critical review of the literature. Pediatr Dermatol 2005;22:287–94.
3. BAD.org.uk/healthcare/guidelines/cw.
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 23 March 2016
Warts and Molluscum: An impractical guide
- Stephen Roberts, Paediatrician
Dear Editor
The August edition of ADC Education and Practice supplement prominently displays on the front cover an infant receiving treatment for molluscum lesions on the thigh. The associated article on the management of warts and molluscum contagiosum explores available treatment options and the differential diagnosis of these benign skin infections.
What messages are conveyed in this review of Nort...
Show More

Dear Editor
The August edition of ADC Education and Practice supplement prominently displays on the front cover an infant receiving treatment for molluscum lesions on the thigh. The associated article on the management of warts and molluscum contagiosum explores available treatment options and the differential diagnosis of these benign skin infections.
What messages are conveyed in this review of North American practice to Paediatricians and General Practitioners in the UK? The high prevalence of these conditions in school age children is well known, as is the natural history for them to spontaneously resolve without medical intervention. Are we now expected to routinely offer treatment advice or even refer affected children to dermatology clinics? It would be helpful to know if the recommendations contained in Dr Lio’s guide had the general support of the British Association of Dermatologists. (2.)
The questionable benefits to the child of removing warts and molluscum have to be balanced with the disadvantages of discomfort, psychological trauma and the possibility of permanent scarring. Most children prefer not to undergo such procedures if given the choice even though their parents may wish us to adopt a more active cosmetic approach.
In support of the no treatment option, we should also consider the practicalities of providing a clinical service for inessential treatments. Consultant Dermatologists in the UK already carry a heavy patient load and their expertise should perhaps be restricted to the assessment of lesions which cause occasional diagnostic difficulty. Inflamed and irritated lesions are best managed by treatment of the associated eczematisation which can usually be achieved in primary care. Hospital paediatric services do not normally have staff who are trained in minor skin surgery or dermatological procedures so that patients referred for such treatments would perhaps languish on a waiting list for several months until their lesions spontaneously resolved.
Several helpful information leaflets are in general circulation to guide parents and their doctors with general advice on benign dermatological conditions in children. (2.3.4.) this should be the first stage and often the only stage required in management.
Yours sincerely
Dr S Roberts
Consultant Paediatrician
University Hospital of South Manchester NHS Foundation Trust Manchester
M23 9LT
References:
1. ACD 2007; 92:4 EP119-124.
2. www.bad.org.uk/public/leaflets/molluscum.
3. BAD.org.uk/healthcare/guidelines/cw.
4. www.netdoctor.co.uk/diseases/facts/warts
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 23 March 2016
Warts, molluscum and things that go bump on the skin: A practical guide
- Helen M Goodyear, Consultant Paediatrician
- Other Contributors:
  Saleem M Taibjee, Consultant Paediatric Dermatologist Birmingham Childrens Hospital
Dear Editor,
We read this article with concern. Incorrect and potentially harmful messages may be relayed to paediatricians, especially to those in training and other healthcare professionals.
Dr Lio asserts that Evidence-based Medicine (EBM) leads to stagnation in medicine and therapeutic nihilism, and expresses his concerns of EBM as a “philosophy in treating actual human beings”. Unfortunately this is rath...
Show More

Dear Editor,
We read this article with concern. Incorrect and potentially harmful messages may be relayed to paediatricians, especially to those in training and other healthcare professionals.
Dr Lio asserts that Evidence-based Medicine (EBM) leads to stagnation in medicine and therapeutic nihilism, and expresses his concerns of EBM as a “philosophy in treating actual human beings”. Unfortunately this is rather missing the point. The cornerstone of EBM is reviewing the wealth of data and applying this to the individual patient.
In 2006 there were comprehensive Cochrane reviews of treatment of warts and molluscum in otherwise healthy individuals.[1,2] These had simple and easy-to-understand recommendations; firstly, awaiting spontaneous resolution of molluscum and secondly, topical preparations containing salicylic acid are safe and effective for warts. No randomised controlled trials address physical destructive methods for molluscum. Cantharidin causes pain and blistering with multiple treatments often required.[3] Regarding warts, cryotherapy appears to be no more effective than simple topical preparations.[1] Balneotherapy is potentially dangerous due to risk of burns. Up to 85% children using imiquimod have side effects.[4] Doctors registered with the General Medical Council have a duty to provide effective treatments based on best available evidence.[5] In the absence of a clearly demonstrable superior efficacy of a given treatment compared to placebo or no treatment we should not persist with such treatments.
Additionally to physical side effects, we should consider that for a child distressing treatments may lead to longlasting phobias and distrust of healthcare professionals and hospitals. Treatment of molluscum and warts is appropriate when clearly troubling or impairing the child, and in the child’s best interests. However, the front cover picture of August 2007 Education and Practice depicting cantharidin treatment in infants is worrisome. Doctors may feel pressured to offer treatment based on parental anxiety and expectations but frequently all that is required is simple reassurance for common, asymptomatic and self-limiting conditions.
References:
1.Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database of Syst Rev 2006:3:CD001781.
2.Van Dr Wouden JC, Menke J, Gajadin S et al. Interventions for cutaneous molluscum contagiosum. Cochrane Database of Syst Rev 2006;2:CD004767.
3.Hanna D, Hatami A, Powell J et al. A prospective randomised trial compating the efficacy and adverse effects of four recognised treatments of molluscum contagiosum in children. Pediatr Dermatol 2006;23:574-9.
4.Bayerl C, Feller G, Goerdt S. Experience in treating molluscum contagiosum in children with imiquimod 5% cream. Br J Dermatol 2003;149:25-8.
5.The General Medical Council. Good Medical Practice. London, GMC 2006.
Dr Helen M Goodyear
Consultant Paediatrician
Heart of England NHS Foundation Trust
Bordesley Green
East Birmingham
B9 5SS
Dr Saleem M Taibjee
Consultant Paediatric Dermatologist
Birmingham Childrens Hospital
Steelhouse Lane
Birmingham
B4 6NH
Show Less

Conflict of Interest:
None declared.
- Back to top

Main menu

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Log in using your username and password

Main menu

Log in using your username and password

You are here

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Read the full text or download the PDF:

Log in using your username and password