Successful treatment of recalcitrant malar rash in a patient with cutaneous lupus erythematosus with efalizumab

In a recent issue of Clinical and Experimental Dermatology, Lim and Foo reported a patient with chronic plaque psoriasis who developed disseminated molluscum contagiosum (MC) after methotrexate treatment. We agree with the authors suggestion that the diagnosis of MC should be considered in patients taking methotrexate who develop suspicious papules and speculate that the occurrence of MC in these patients may be a common, yet under-recognized phenomenon. A 69-year-old woman was referred with a 3-month history of slightly pruritic lesions on the face and neck. She had a 13-year history of disabling rheumatoid arthritis (RA) and had been on oral methotrexate 17.5 mg ⁄ week for 1.5 years and salazopyrin 1.5 g ⁄ day for 13 years. Clinical examination showed multiple discreet, flesh-coloured, crateriform papules, 2–5 mm in size, on the eyelids, cheeks and neck (Fig. 1). Few of these papules were excoriated. Haematological investigations including white cell and differential count were normal. A clinical diagnosis of MC was confirmed on histology. Owing to the disabling nature but reasonable control of her RA, and the rather localized and benign nature of the MC, her immunosuppressive treatment has not been interrupted. A trial of topical hydrogen peroxide 1% cream (Crystacide ; Bioglan, Hampshire, UK) is underway. MC is a benign eruption of umblicated papules caused by the molluscipox virus of the Poxviridae family, which is transmitted by direct contact. Although commonly selflimiting and usually occurring in children, difficult to treat and widespread MC infection can be encountered occasionally in patients with impaired cellular immunity. A few cases of disseminated MC infection occurring in patients immunosuppressed with azathioprine and mycophenolate mofetil have been described. There are several possible explanations for the relative paucity of reports of milder MC infection in iatrogenically immunosuppressed patients. As most cases are mild, these may not be brought to medical attention. Furthermore, iatrogenic immunosuppression is more commonly used as a therapeutic strategy by nondermatologists, who may not be familiar with this diagnosis. Finally, MC may subside without intervention even in the setting of immunosuppression. However, to avoid the risk of disseminated infection, MC in immunosuppressed patients should be actively treated.