In my last column, I suggested that it might be useful for the members of different specialties to discuss how each sees and does things. I had a recent chance to try this out myself when visiting the online Dermatology Forum (www.medhelp.org).
The issue that I raised was in relation to molluscum contagiosum (MC). Often, molluscum doesn't act so contagiosum. Though MC is called an STD, many adults who get mollusca in the groin seem to have no contacts who have them, and kids, who tend to get it on the thorax, often don't either.
Below is one of the responses:
Dr. Handsfield (HHH) responds: I knew that someone would point out the differences between me and Dr. Rockoff about MC. The STD literature makes it clear that MC of the genital area in adults generally is sexually acquired. According to the main textbook on STDs, "The suspicion that genital MC is sexually transmitted is supported by lesion location, a frequent history of contact with multiple sexual partners, the presence of other STDs, genital lesions in sexual partners, and peak ages of occurrence (20–29 years) [as is the case for] other STDs."
Our differing perspectives might relate mostly to "genital area" infection. Many adults with MC involving other areas of the body may show up in a dermatology office and not STD clinics. Perhaps it is right that sex doesn't account for the majority of adult MC cases, but the case seems pretty clear for genital area infection.
That said, I'm sure there are exceptions—some genital and lower abdomen cases not sexually acquired. The main point is that such persons' sex partners should be examined, and people with genital MC should be routinely tested for other common STDs.
Dr. Rockoff (ASR) responds: I often have difficulty applying epidemiologic evidence to specific patients. Last Thursday, for instance, an 18-year-old boy came in with his father. He had two penile mollusca but denied ever having any sexual partners.
Today a 30-year-old with suprapubic mollusca told me he's had the same partner for 8 months, a woman with no genital lesions. I always ask, but men with pubic mollusca rarely tell me their partner has any, while men with warts often report a partner's HPV (human papillomavirus).
Patients may fib or just be wrong about their partners' status (though mollusca are easy enough to see when looked for). Still, telling an 18-year-old virgin that he has an STD is troubling. Likewise, saying this to a monogamous person raises questions of fidelity that perhaps needn't be raised. Failing to alert female partners of HPV exposure might lead to cervical cancer; less clear are the negative consequences of failing to detect a partner's molluscum.
If it's OK to admit that we have no idea why just one kid in the family gets MC on the thorax, why not say the same to an adult with groin lesions when there's nobody around to implicate?
I do agree that in adults with genital lesions, it's necessary to look into sexual history and contacts, as with any potential STD. In the MedHelp Forum, I'll make that clearer.
HHH responds: Thanks for your thoughtful comments. Clearly, sex doesn't explain all cases, and the difference in our perspectives obviously lies largely in which patients go where. People who show up in STD clinics obviously are biased in one direction; presumably those in private offices, the other way.
We also don't see many people who refer partners found to have MC, but it happens sometimes. Source partners are probably asymptomatic much of the time, especially women, who have greater anatomic opportunity for hidden lesions. Secondary (spread) contacts probably are mostly resistant/immune from their childhood infections.
MC might better be characterized not as a sexually transmitted disease but as a sexually transmissible one. Clearly, sex doesn't explain all cases. My main concern is that MC warrants at least asking patients about sexual risks and often screening them for common STDs. It may be confusing for MedHelp users to read overtly conflicting advice on different forums. For my part, I will pay more attention to terminology that leaves options open.
ASR responds: Thanks. And for my part, I'll emphasize the need to look into the possibility of sexual transmission and concurrent STDs. Your formulation, "not a sexually transmitted disease but a sexually transmissible one," seems just right.
One condition, two perspectives—the result of seeing somewhat different patient populations and of focusing on two aspects of the same problem: protecting the public health and addressing the individual patient. It can be helpful for each of us to see things the other's way.