Available online at www.sciencedirect.comwww.jdds.org

ScienceDirectJournal of Dermatology & Dermatologic Surgery 20 (2016) 107–114

A comparative study of topical 10% KOH solution and topical25% podophyllin solution as home-based treatments

of molluscum contagiosumq

Nameer K. Al-Sudany a,⇑, Dler R. Abdulkareem b

a Ibn Sina University of Medical and Pharmaceutical Sciences, Department of Dermatology, Baghdad, IraqbAl-Yarmouk Teaching Hospital, Department of Dermatology, Baghdad, Iraq

Received 6 January 2016; accepted 14 February 2016Available online 24 February 2016

Abstract

Background: Molluscum contagiosum is a common self-limiting viral infection of the skin. Many therapeutic agents have been usedwith varying success rates. Objective: To evaluate and compare the effectiveness of topical 10% KOH solution and 25% podophyllin solu-tion as home-based treatments of molluscum contagiosum. Patients and methods: This open randomized comparative therapeutic trialwas conducted in the department of dermatology, Al-Yarmouk Teaching Hospital, Baghdad, Iraq between January and October 2015.The patients were divided randomly into two equal groups. Group A patients were treated with 10% KOH solution and those in group Bwith 25% podophyllin solution. All patients were assessed weekly for 4 weeks for therapeutic response. Results: Fifty-two patients (age:2–34 years) with MC were enrolled in this study, 25 patients in group A and 20 patients in group B completed the study. Sixteen (64%)patients in group A showed complete clearance of lesions versus 14 (70%) patients in group B. No systemic side effects were reported inboth groups and the local side effects were comparable between both groups. Conclusion: Both 10% KOH solution and 25% podophyllinsolution are effective local therapies for the treatment of MC with comparable success rates (64% and 70% respectively).� 2016 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Molluscum contagiosum; KOH solution; Podophyllin solution

1. Introduction

Molluscum contagiosum (MC) is a viral disease causedby molluscum contagiosum virus (MCV) which is classifiedwithin the Poxvirus family (Sterling, 2010). Approximately

http://dx.doi.org/10.1016/j.jdds.2016.02.002

2352-2410/� 2016 The Authors. Production and hosting by Elsevier B.V. on b

This is an open access article under the CC BY-NC-ND license (http://creativec

q The study is an independent one and not funded by any drugcompany, academic institute or any health authority.⇑ Corresponding author. Tel.: +964 7712216414; fax: +964 5410584.E-mail address: nameeralsudany@yahoo.com (N.K. Al-Sudany).

Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

1.8% of the population were affected worldwide by MCwith a higher distribution in the tropical areas (Vos et al.,2012). The disease is more prevalent in children (peak inci-dence between 2 and 5 years) (Sterling, 2010; Hanson andDiven, 2003). A later incidence peak in young adults isattributable to sexual transmission with lesions more com-mon in the genital area (Hanson and Diven, 2003). There isa clinical impression that MC is more common in patientswith atopic eczema (Leslie et al., 2005). MCV is passeddirectly by skin contact with an infected individual toproduce typical cutaneous and, rarely, mucosal lesions(Dohil et al., 2006). The average incubation time is between2 and 7 weeks with a range extending out to 6 months.Infection with the virus causes acanthotic hyperplasia

ehalf of King Saud University.

ommons.org/licenses/by-nc-nd/4.0/).

108 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery 20 (2016) 107–114

and hypertrophy of the epidermis which consists of manylobes, each lobe made up of many lobules separated fromeach other by distinct basement membrane (Sharquieet al., 2015). Clinically the disease produces a papular erup-tion of multiple umbilicated lesions. Individual lesions arediscrete, smooth, and dome shaped (Hanson and Diven,2003). Any cutaneous surface may be involved, but favoredsites include the face, neck, abdomen, arms, thighs, axilla,and genital areas (Bikowski, 2004). MC is a self-limited dis-ease, which, left untreated, will eventually resolve inimmunocompetent hosts (Chen et al., 2013). In general,there are four main therapeutic approaches to MC:

1. Physical therapies: like; cryosurgery (Silverberg, 2007),evisceration (Hanson and Diven, 2003), phenol 10%with pricking (Chen et al., 2013), curettage (Silverberg,2007), tape stripping (Valentine and Diven, 2000), pho-todynamic therapy (Chen et al., 2013), electron beamtherapy (Chen et al., 2013) and laser (Jones andMuram, 1993; Binder et al., 2008).

2. Chemical destructive agents: like; trichloroacetic acid(Chen et al., 2013), cantharidin (Chen et al., 2013), ben-zoyl peroxide 10% (Chen et al., 2013), iodine solutionand salicylic acid (Valentine and Diven, 2000), tretinoin(Rajouria et al., 2011), podophyllotoxin (Piggott et al.,2012), podophyllin (Barefoot, 1951) and potassiumhydroxide (KOH) Romiti et al., 2000, 1999.

3. Immune modulators: like; imiquimod (Piggott et al.,2012), diphencyprone (Chen et al., 2013), cimetidine(Dohil and Prendiville, 1996) and intralesional candidaantigen (Chen et al., 2013).

4. Antiviral agents: like; cidofovir (Chen et al., 2013) andsubcutaneous IFN-a (Piggott et al., 2012).

The best way to prevent the spread of MC is throughgood hygiene. (Centers for Disease Control andPrevention, 2015)

Many therapeutic agents were used for the treatment ofMC with variable results. KOH in different concentrationshas been well studied whereas podophylline solution, toour best knowledge, wasn’t tried in the treatment of MCexcept once. The aim of the present study was to evaluateand compare the effectiveness of topical 10% KOH solu-tion and 25% podophyllin solution as home-based treat-ments of molluscum contagiosum.

2. Patients and methods

An open comparative therapeutic study was conductedin the Department of Dermatology and Venereology inAl-Yarmouk Teaching Hospital, Baghdad-Iraq from 1stof January 2015 to the end October 2015, where a totalnumber of 52 patients with MC were enrolled in thisstudy. The patients enrolled in this study were randomlyallocated into two groups through systematic randomsampling.

A full history was taken from each patient regardingname, age, sex, occupation, marital status, sexual history,duration of the disease, family history of similar condition,past medical history, drug history especially for corticos-teroids and other immune suppressants and any previoustreatment modality received for their MCs.

Every patient was examined to assess the number, sizeand site of lesions; examination was aided by taking severalphotos for each patient using the same digital camera(Canon Power Shot SX260HS Camera 12.1 Megapixel)from approximately the same distance and similar view.

Patients excluded from this study included those withface involvement to avoid any possible side effect especiallyof cosmetic concern, those who were previously treated,pregnant and lactating women, uneducated (unreliable)patient or his/her guardians and children less than 2 yearsold.

An informed consent was obtained from each patient orhis/her parents prior to their inclusion in this study afterfull explanation about the nature of the disease, its courseand prognosis and full information about therapeuticagents intended to be used including the side effects andmethod of application were given. An approval of theEthics Committee of Scientific Council of Dermatologyand Venereology of Iraqi Board for Medical Specializa-tions was also obtained.

2.1. Preparation of the therapeutic agents

A KOH powder (produced by Sinopharm ChemicalReagent Co., Ltd., Shanghai, China) was dissolved in dis-tilled water to produce a 10% w/v solution. A podophyllinresin powder (produced by Baoji Oasier Bio-Tech Co., Ltd.Baoji, China) was dissolved in tincture benzoin to producea 25% w/v solution.

2.2. Method of application

Patients in group A were treated with 10%KOH solutionand those in group B were treated with 25% podophyllinsolution with instructions given to the patients or their guar-dians to apply the agent topically using cotton swab soakedin the solution after covering the surrounding area withpetrolatum, making gentle application to the MC lesionand avoid any spillage over normal skin. First applicationof therapeutic agent was done in the outpatient clinic tryingto learn the patients the correct way of application and howto use it at home. Patients in group A were asked to apply10% KOH solution once daily at night and those in groupB were instructed to apply 25% podophyllin solution everyother night and wash off 4 h after application.

All patients were asked to attend weekly to the outpa-tient clinic for evaluation and to use therapeutic agentsfor 4 weeks or until the lesions are cleared, whichever wasearly. The importance of regular attendance was stressedupon to prevent defaulting.

N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery 20 (2016) 107–114 109

2.3. Evaluation and follow up

All patients were examined at the end of 1st, 2nd, 3rd,and 4th weeks. On each visit the clinical response to treat-ment; total disappearance of lesions, decrease in size andnumber of lesions and any local or systemic side effect wereevaluated and recorded depending on clinical and photo-graphic assessments. Photographs for lesions were takenbefore and after treatment.

The patients were considered as respondent when therewas complete disappearance of the lesion; if there was nochange, the patients were considered as non-respondent;if there was decrease in the number and size of lesions,the patients were considered as partial respondent.

If complete response occurred during treatment period,they were asked to attend one month later to assess for anyrecurrence of the lesion, if no response occurred, they wereconsidered as treatment failure.

2.4. Statistical analysis

Data were coded and fed on a computer. Analysis wasdone on SPSS (Statistical Package for Social Science

Assessed for elig

Randomized

Allocated to intervention A (n=26) Received allocated intervention (n=26) Did not received allocated intervention (n=0)

Alloca

Lost to follow up due to non-compliance (n=1) Discontinued intervention (n=0)

Follow

Analyzed (n=25) Excluded from analysis (n=0)

Analy

Enrollment

Figure 1. Flowchart of participants’ pro

Analysis, Version 21). Both a descriptive statistics likemean and SD (Standard Deviation) together with analyticstatistics like Chi-square (v2) test and t-test have been donewhen appropriate. P-Values less than 0.05 were consideredsignificant. The results were presented in the form of fre-quency table and graphs.

3. Results

A total of 52 patients have been enrolled in this thera-peutic trial. Patients were divided into two equal groups;each consists of 26 patients. Out of a total of 52 patientswith MC, 25 patients in group A and 20 patients in groupB completed the study. In group A, one patient discontin-ued the treatment due to noncompliance, and in group B,six patients did not complete the study, one of them didn’ttolerate the local irritation caused by therapeutic agent heused while others due to noncompliance (Fig. 1).

The age of patients ranged from 2 to 34 years, with amean ± SD of 10.84 ± 9.02 years, the youngest patientwas 2 years old and the oldest one was 34 years old. Themales outnumbered females (28 vs. 17) with a male tofemale ratio 1.6:1. The two groups were well-matched in

ibility (n=60)

Excluded (n=8) Not meeting inclusion criteria (n=5) Declined to participate (n=3)

(n=52)

Allocated to intervention B (n=26) Received allocated intervention (n=26) Did not received allocated intervention (n=0)

tion

Lost to follow up due to non-compliance (n=5) Discontinued intervention due to severe local irritation caused by therapeutic agent used (n=1)

-up

Analyzed (n=21) -1 excluded from analysis due to missing data

sis

gress through the phases of the trial.

110 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery 20 (2016) 107–114

terms of pre-treatment clinical parameters and there wasno significant variation between them in terms of age andgender (Table 1).

The duration of the disease among all patients rangedfrom 2 weeks to 6 months and a family history of MCwas positive in 18 out of the 45 patients (40%).

The number of lesions per patient ranged from 1 to 75lesions with a mean ± SD of 8.95 ± 9.32 lesions and thetotal number of lesions was 403 lesions. Thirty-nine(86.6%) patients had 1–15 lesions, 4 (8.9%) patients had16–30 patients and 2 patients had more than 30 lesions.

At the end of the study, 16 (64%) out of 25 patients ingroup A showed complete clearance of lesions [181(82.3%) lesions out of 220], while cases in group B showedtotal clearance of lesions in 14 (70%) out of 20 patients with143 (78.1%) lesions out of 183 (Table 2). The results of bothgroups were comparable and there was no significant differ-ence between them (P-value > 0.67). The time needed forcomplete clearance of MC lesions in both groups rangedfrom 1 to 4 weeks (Table 3). Therapeutic response for both10% KOH solution and 25% podophyllin solution is shownin (Figs. 2–5).

During the study period no systemic side effect in bothgroups was encountered whereas local side effects werereported in 72% and 75% in group A and group B respec-tively (Table 4).

At follow up visit (one month after stopping thetreatment), 5 (25%) out of 20 patients used podophyllin

Table 1The frequency distribution of patients with molluscum contagiosum according

Age (Year) Group A

Male No. (%) Female No. (%) Total No. (%)

2–10 11 (44) 7 (28) 18 (72)11–20 3 (12) 0 (0) 3 (12)21–30 3 (12) 0 (0) 3 (12)P31 0 (0) 1 (4) 1 (4)Total* 17 (68) 8 (32) 25 (100)

Site Group A Group B

No. of Patients Lesions No. and (%) No. of Patients

Genitalia 5 99 (45) 5Trunk 17 90 (41) 10Extremities 11 31 (14) 9Total** 220 (100)

* Group A (mean ± SD = 9.56 ± 9.22) years. Group B (mean ± SD = 12.45** Group A (mean ± SD of 8.8 ± 11.33) lesions. Group B (mean + SD of 9.1

Table 2Scores of therapeutic response in the patients with MC in both groups (A) an

Scores of response Group A

No. and (%) of patients No. and (%) of

Complete clearance 16 (64) 181 (82.3)Partial clearance 4 (16) 23 (10.4)No response 5 (20) 16 (7.3)Total 25 (100) 220 (100)

According to the number of patients P-value > 0.671, Chi Square = 0.18According to the number of lesions P-value > 0.298, Chi Square = 1.08

treatment developed new lesions whereas new lesions wereseen in 2 (10%) out of 25 patients who were treated withKOH solution at new sites other than those previouslyinvolved. No recurrence of any treated lesions in patientsof both groups could be detected.

All side effects were transient and lasted just few weeksand had totally disappeared.

4. Discussion

In last few years, MC seems to be so common amongIraqi patients especially children and a large proportionof those patients or their guardians seek a suitable therapywhich is asked to be non-painful, non-disfiguring and withan acceptable cost. Many topical therapeutic agents hadbeen tried in the treatment of MC with variable successrates, these included: phenol solution with a success rate(clearance of lesions) of (41%) Chen et al., 2013, TCA solu-tion (60%) Goyal et al., 2014, salicylic and lactic acids(100%) Kӧse et al., 2013, cantharidin (23%) Chen et al.,2013, benzoyl peroxide (Chen et al., 2013), tretinoin(45%) Goyal et al., 2014, diphencyprone (64%) Kanget al., 2005, cidofovir (93%) Hanson and Diven, 2003;Chen et al., 2013, podophyllotoxin (92%) Markos, 2001,and imiquimod (75–82%) Seo et al., 2010.

Since 1999, KOH solution in different concentrations(2.5–20%) is tried in the treatment of MC (Romiti et al.,1999; Kӧse et al., 2013; Mahajan et al., 2003; Ucmak

to the age, gender and sites of lesions.

Group B

Male No. (%) Female No. (%) Total No. (%)

7 (35) 6 (30) 13 (65)0 (0) 1 (5) 1 (5)4 (20) 2 (10) 6 (30)0 (0) 0 (0) 0 (0)11 (55) 9 (45) 20 (100)

Total

Lesions No. and (%) No. of Patients Lesions No. and (%)

60 (32.8) 10 159 (39.5)65 (35.4) 27 155 (38.5)58 (31.8) 20 89 (22)183 (100) 403 (100)

± 8.73) years. P-Value > 0.284. Total (mean ± SD of 10.84 ± 9.02) years.5 ± 5.90) lesions. Total (mean ± SD of 8.95 ± 9.32) lesions.

d (B) at the end of 4th week of treatment.

Group B

lesions No. and (%) of patients No. and (%) of lesions

14 (70) 143 (78.1)4 (20) 31 (16.9)2 (10) 9 (4.9)20 (100) 183 (100)

Table 3Time needed for complete clearance of MC lesions in both groups.

Duration of treatment Group A Group B

No. and (%) of patients No. and (%) of lesions No. and (%) of patients No. and (%) of lesions

1 week 1 (6.25) 1 (0.5) 3 (21.4) 20 (14)2 weeks* 9 (56.25) 106 (58.6) 5 (35.7) 41 (28.7)3 weeks 3 (18.75) 24 (13.3) 4 (28.6) 67 (46.8)4 weeks 3 (18.75) 50 (27.6) 2(14.3) 15 (10.5)Total 16 (100) 181 (100) 14 (100) 143 (100)

* Within two weeks of treatment: P-value < 0.00, Chi Square = 8.67

B A

Figure 2. A photograph showing disappearance of MC lesions in a patient treated with 25% podophyllin solution. (A) Before treatment, (B) After 2 weeksof treatment.

BA

Figure 3. A photograph showing complete clearance of huge number of MC lesions in a patient treated with 25% podophyllin solution. (A) Beforetreatment, (B) after 4 weeks of treatment.

N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery 20 (2016) 107–114 111

et al., 2014; Can et al., 2014; Short et al., 2006). Romitiet al. (1999) reported a full remission in 32 out of the 35(91.4%) patients treated with 10% KOH solution in anaverage of 30 days. The same researchers carried out inthe year 2000 another study trying 5% KOH solution andclaimed a (100%) remission rate in an average of six weeks

(Romiti et al., 2000). Short et al in 2006 treated 10 patientswith 10% KOH solution in a placebo-controlled study andthey found 70% clearance rate for KOH versus 20% for theplacebo (Short et al., 2006). Also Can et al. (2014) treated40 children with MC with 10% KOH solution but withtwice daily application and they reported (92.5%) clearance

BA

Figure 4. Disappearance of MC lesions in a patient treated with 10% KOH solution, (A) before treatment, (B) after 4 weeks of treatment.

BA

Figure 5. Disappearance of MC lesions in a patient treated with 10% KOH solution, (A) before treatment, (B) after 4 weeks of treatment.

112 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery 20 (2016) 107–114

rate within a mean period of 4 weeks. Ucmak et al. (2014)treated 25 patients with MC comparing (2.5% and 5%)KOH solution for 2 months, they found significant differ-ence between the success rates (23.1% and 66.7% respec-tively). Mahajan et al. (2003) treated 27 patients with20% KOH solution. All treated children were cleared oftheir lesions within 17 days of treatment. However, stingingsensation and postinflammatory pigmentation were fre-quent side effects.

Our result regarding 10% KOH solution in the treat-ment of MC seems to be comparable with previous

mentioned studies that used same concentration of KOHand similar duration of treatment (Kang et al., 2005;Mahajan et al., 2003; Short et al., 2006).

Regarding podophyllin trials in MC, for our best knowl-edge and search, only came across only one study dating to1949 done by Barefoot at al. They reported only 3 patientstreated with topical application of 20% podophyllin and allof them were cured. They considered it as a safe home ther-apy but requires reliable patients (Barefoot, 1951). We havefound a success rate of 70% of patients treated with 25%podophyllin solution.

Table 4Comparison of local side effects noticed in both group (A) and (B).

Side effects Group (A) No. and (%) of patients Group (B) No. and (%) of patients

Burning 18 (72) 12 (60)Erythema 11 (44) 13 (65)Erosion 12 (48) 7 (35)Hyperpigmentation 16 (64) 11 (55)Hypopigmentation 3 (12) 2 (10)Itching 7 (28) 3 (15)Total patients with adverse effects 18 (72) 15 (75)

P-Value > 0.684

N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery 20 (2016) 107–114 113

The present therapeutic trial has found both 10% KOHand 25% podophyllin solutions to be effective in the treat-ment of MC with comparable results. In terms of the num-ber of patients cured podophyllin was slightly better thanKOH solution (70% versus 64%) with non-significant sta-tistical difference (P > 0.67); while in terms of the numberof lesions cleared off the reverse was true (KOH 82% versuspodophyllin 78%) and also with non-significant differencestatistically (P > 0.29).

Many local side effects especially erythema, burning sen-sation and dyspigmentation were seen in both groups ofpatients enrolled in this study. Although the frequency ofthese local side effects was slightly higher among patientstreated with podophyllin (75% versus 72%), however thedifference was statistically insignificant (P > 0.68). Allreported local adverse effects were mild and transient anddisappeared spontaneously shortly after the end of treat-ment except one patient who suffered severe local irritationcaused by podophyllin that prevented him from continuingthe treatment due to intolerability. Most of these local sideeffects are similarly reported in many other studies(Barefoot, 1951; Romiti et al., 2000, 1999; Kӧse et al.,2013; Mahajan et al., 2003; Ucmak et al., 2014; Canet al., 2014; Short et al., 2006). Fortunately, neither sys-temic side effects nor local scarring were encountered dur-ing this study.

5. Conclusion

Both 10% KOH solution and 25% podophyllin solutionare effective local therapies for the treatment of MC withcomparable success rates (64% and 70% respectively).

Conflict of interest

There is no conflict of interest associated this study.

References

Barefoot, S.W., 1951. Resin of podophyllum in treatment of molluscumcontagiosum. AMA Arch. Derm. Syphilol. 63 (2), 256–259.

Bikowski Jr., J.B., 2004. Molluscum contagiosum: the need for physicianintervention and new treatment options. Cutis 73 (3), 202–206.

Binder, B., Weger, W., Komericki, P., Kopera, D., 2008. Treatment ofmolluscum contagiosum with a pulsed dye laser: pilot study with 19children. J. Dtsch. Dermatol. Ges. 6, 121–125.

Can, B., Topaloglu, F., Kavala, M., Turkoglu, Z., Zindanc±, I., Sudogan,S., 2014. Treatment of pediatric molluscum contagiosum with 10%potassium hydroxide solution. J. Dermatol. Treat. 25 (3), 246–248.

Centers for Disease Control and Prevention. (2015, May). Molluscumcontagiosum: Prevention. CDC. Retrieved 11/9/2015 from <http://www.cdc.gov/poxvirus/molluscum-contagiosum/prevention.html>.

Chen, X., Anstey, A.V., Bugert, J.J., 2013. Molluscum contagiosum virusinfection Review. Lancet Infect. Dis. 13 (10), 877–888.

Dohil, M., Prendiville, J.S., 1996. Treatment of molluscum contagiosumwith oral cimetidine: clinical experience on 13 patients. Pediatr.Dermatol. 13 (4), 310–312.

Dohil, M.A., Lin, P., Lee, J., Lucky, A.W., Paller, A.S., Eichenfi eld, L.F.,2006. The epidemiology of molluscum contagiosum in children. J. Am.Acad. Dermatol. 54, 47–54.

Goyal, V., Maheshwari, A.K., Goyal, S., Gill, M., 2014. A, comparativestudy of efficacy of 10% KOH, tricholoracetic acid (TCA) and 0.05%tretinoin for the treatment of molluscum contagiosum. Sch. J. Appl.Med. Sci. 2 (4A), 1196–1198.

Hanson, D., Diven, D.G., 2003. Molluscum contagiosum. Dermatol.Online J. 9 (2), 2.

Jones, C.E., Muram, D., 1993. Use of CO2 laser in treatment ofmolluscum contagiosum: Reports of four cases. J. Pediatr. Adolesc.Gynecol. 6 (1), 39–41.

Kang, S.H., Lee, D., Park, J.H., Cho, S.H., Lee, S.S., Park, S.W., 2005.Treatment of molluscum contagiosum with topical diphencypronetherapy. Acta Derm. Venereol. 85, 529–530.

Kӧse, O., Ozmen, I., Arca, E., 2013. An open, comparative study of 10%potassium hydroxide solution versus salicylic and lactic acid combi-nation in the treatment of molluscum contagiosum in children. J.Dermatol. Treat. 24, 300–304.

Leslie, K.S., Dootson, G., Sterling, J.C., 2005. Topical salicylic acid gel asa treatment for molluscum contagiosum in children. J. Dermatol.Treat. 16, 336–340.

Mahajan, B.B., Pall, A., Gupta, R.R., 2003. Topical 20% KOH-aneffective therapeutic modality for molluscum contagiosum in children.Indian J. Dermatol. Venereol. Leprol. 69, 175–177.

Markos, A.R., 2001. The successful treatment of molluscum contagiosumwith podophyllotoxin (0.5%) self-application. Int. J. STD AIDS 12(12), 833.

Piggott, C., Friedlander, S.F., Tom, W., 2012. Poxvirus infections. In:Wolff, K., Goldsmith, L.A., Katz, S.I., Gilchrest, B.A., Paller, A.S.,Leffell, D.J. (Eds.), . In: Fitzpatrick’s Dermatology in GeneralMedicine, 195. McGraw-Hill-Company, New York, pp. 1899–1913,8th ed.

Rajouria, E.A., Amatya, A., Karn, D., 2011. Comparative study of 5%potassium hydroxide solution versus 0.05% tretinoin cream formolluscum contagiosum in children. Kathmandu Univ. Med. J.(KUMJ) 9 (36), 291–294.

Romiti, R., Ribiero, A.P., Grinblat, B.M., 1999. Treatment of molluscumcontagiosum with potassium hydroxide. A clinical approach in 35children. Pediatr. Dermatol. 16, 228–231.

Romiti, R., Ribeiro, A.P., Romiti, N., 2000. Evaluation of the effective-ness of 5% potassium hydroxide for the treatment of molluscumcontagiosum. Pediatr. Dermatol. 17, 495.

114 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery 20 (2016) 107–114

Seo, S.-H., Chin, H.-W., Jeong, D.-W., Sung, H.-W., 2010. An open,randomized, comparative clinical and histological study of imiquimod5% cream versus 10% potassium hydroxide solution in the treatment ofmolluscum contagiosum. Ann. Dermatol. 22 (2), 156–162.

Sharquie, K.E., Hameed, A.F., Abdulwahhab, W.S., 2015. Pathogenesisof molluscum contagiosum: a new concept for the spontaneousinvolution of the disease. Our Dermatol. Online 6 (3), 265–269.

Short, K.A., Fuller, L.C., Higgins, E.M., 2006. Double-blind, random-ized, placebo-controlled trial of the use of topical 10% potassiumhydroxide solution in the treatment of molluscum contagiosum.Pediatr. Dermatol. 23 (3), 279–281.

Silverberg, N.B., 2007. A practical approach to molluscum contagiosum.Contemp. Pediatr. 24 (9), 63–72.

Sterling, J.C., 2010. Virus infections. In: Burns, T., Breathnach, S., Cox, N.,Griffiths, C. (Eds.), . In: Rook’s Textbook of Dermatology, 33. Wiley-Blackwell Publishing Company, Singapore, pp. 1489–1566, 8th ed.

Ucmak, D., Akkurt, M.Z., Kacar, S.D., Sula, B., Arica, M., 2014.Comparative study of 5% and 2.5% potassium hydroxide solution formolluscum contagiosum in children. Cutaneous Ocul. Toxicol. 33 (1),54–59.

Valentine, C.L., Diven, D., 2000. Treatment modalities for molluscumcontagiosum. Dermatol. Ther. 13, 285–289.

Vos, T., Flaxman, A.D., Naghavi, M., et al., 2012. Years lived withdisability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study2010. Lancet 380 (9859), 2163–2196.