Novel Approaches to Molluscum and HPV-Related Dermatologic Conditions
Insights into managing molluscum contagiosum, HPV-related warts, and other infections took center stage at the Midwinter Clinical Hawaii Derm Conference.
Elizabeth Swanson, MD
Photo courtesy of dermsquared
At the 2025 Winter Clinical Dermatology Conference, Elizabeth Swanson, MD, of Ada West Dermatology and St. Luke’s Children’s Hospital in Boise, Idaho, shared key insights and clinical pearls on the management of molluscum contagiosum, human papillomavirus (HPV)-related warts, and other viral dermatologic conditions. Her presentation, Going Viral! Pearls in Molluscum, HPV, and Beyond, provided updates on both emerging and established treatment strategies.
Molluscum Contagiosum: Treatment Updates and Considerations
Molluscum contagiosum, a common pediatric skin infection, remains a topic of debate regarding the necessity of treatment. Dr Swanson reassured clinicians that treatment is not mandatory and that lesions, while distressing in appearance, do not pose an increased danger when located on the face or genital region.
For those seeking intervention, Dr Swanson highlighted 3 primary treatment options:
- Candida Antigen: Intralesional injection (0.3 mL) every 3-4 weeks for 3-5 sessions is well tolerated and can induce resolution through immune stimulation.
- Cantharidin (Ycanth 0.7%): Recently FDA-approved, this topical therapy led to complete clearance in 50% of patients after 4 applications.
- Berdazimer Gel: Shown to achieve significant lesion reduction with daily use over 12 weeks.
She also emphasized that pseudofurunculoid molluscum, often mistaken for secondary infection, represents a sign of impending resolution (the “BOTE sign” or Beginning of the End), requiring no incision or drainage. Instead, clinicians should manage inflammation with topical steroids and, if necessary, oral antibiotics.
Advances in Wart Management: HPV Vaccine and Topical Therapies
Dr Swanson reviewed emerging data on the use of HPV vaccines for recalcitrant warts. A 2020 study in the Journal of the American Academy of Dermatology showed that intralesional quadrivalent HPV vaccine led to 90% wart clearance, outperforming both bivalent vaccine (30% clearance) and saline placebo (0% clearance). While quadrivalent vaccine is unavailable in the US, clinicians can substitute the 9-valent formulation.
She also presented a simple but highly effective wart treatment: salicylic acid combined with 5-fluorouracil (5-FU) in a proprietary medium, applied under occlusion. This approach demonstrated a 98% success rate with minimal discomfort, providing a promising alternative to destructive modalities.
Perianal Warts in Pediatrics: Addressing Parental Concerns
Dr Swanson reassured clinicians that perianal warts in children under 5 years of age are most commonly due to in utero HPV exposure rather than abuse. Preferred treatments include:
- Imiquimod 5% cream (applied 3 times weekly at bedtime)
- Podofilox 0.5% gel (applied twice daily for 3 days, repeated weekly for 4 weeks)
- 5-FU/salicylic acid combination (with modified instructions for pediatric use)
Emerging Viral Dermatologic Trends
Beyond molluscum and HPV, Dr Swanson discussed evolving presentations of other viral dermatoses:
- Hand, Foot, and Mouth Disease (HFMD): Coxsackie A6 has surpassed A16 as the dominant strain, causing more severe rash presentations, particularly in the diaper area.
- Eczema Coxsackium: A widespread, eczema-like eruption seen in children with underlying atopic dermatitis who contract HFMD, requiring aggressive eczema management.
- Herpes Zoster in Children: A rise in cases among vaccinated children may be due to waning immunity. While often asymptomatic, pediatric zoster cases require antiviral therapy in high-risk patients.
Takeaways for Clinicians
Dr Swanson’s talk underscored the importance of individualized treatment approaches for viral dermatologic conditions. While many infections are self-limiting, targeted therapies—particularly immunomodulatory strategies like Candida antigen for molluscum and intralesional HPV vaccine for warts—offer promising results. Clinicians should also remain vigilant for evolving viral presentations and optimize management strategies accordingly.
