Different Dermoscopic Aspects of Molluscum Contagiosum in the Same Patient: Case Report

Molluscum contagiosum (MC) presents by skin lesions secondary to a viral skin infection at the expense of epidermal keratinocytes having appearances with specific intracytoplasmic inclusions caused by the smallpox virus. It is a frequent pathology that affects the skin and mucous membranes. The diagnosis of CD is easy, but when clinical features lack atypical lesions, it can hinder the diagnosis of CD. It is then that there is a need for early and easy diagnosis of CD by the ticket of the dermoscopy which is a non-invasive diagnostic tool that allows visualizing the different dermoscopic aspects that we describe through the same observation.


Introduction
Molluscum contagiosum (MC) is a viral infection of epidermal keratinocytes which results in skin lesion with characteristic intracytoplasmic inclusions. Clinically, the lesions are often multiple umbilicated papules of normal skin color or slightly erythematous, 2 to 4 mm in diameter, with a translucent and shiny appearance, located on the body [1]. The diagnosis is clinical, except that in the literature, in cases where the lesions are atypical, various mentioned methods of diagnosis can facilitate the latter, including dermoscopy [2].
Dermoscopy is a non-invasive technique used initially for the early diagnosis of skin tumors such as melanoma and to detect melanocytic lesions, subsequently to describe the characteristics of other dermatoses, notably inflammatory, but also infectious, such as MC [3].
We report an observation where we could visualize the difference. dermoscopic aspects of MC and this in the same patient.

Case Presentation
It is about a patient, 46 years old, having a personal history, a retroviral infection under triple therapy, followed by internal medicine, and who consults for non-painful bleeding lesions at the level of the body evolving for a month. On clinical examination, we had multiple papules and nodules of firm consistency resting on normal skin in places and erythematous and inflamed in others. The largest was a nodule of 1cm temporal right and the youngest of 5mm, of multiple numbers and extended on all the body, these lesions were with the umbilicated surface for the most part, and all are on the base not infiltrated (Fig-1 and  Fig-2). Multiple pigmented scar macules are also been noted.
The dermoscopic examination found similar aspects in the lesions first evoking molluscum contagiosum. We had a peripheral ring vascularization, a radial appearance, and pointed vessels. We also observed holes of rounded shape sometimes filled with a yellowish substance which is keratin and sometimes empty, and around these holes bright whiteish structures in the shape of a cloverleaf reminiscent of rosettes (Fig-3).
The histology, as well as the bacteriological and mycological culture, made it possible to eliminate cutaneous cryptococcosis and cutaneous histoplasmosis and to confirm our diagnosis of Molluscum contagiosum.

Discussion
Dermoscopy of molluscum contagiosum was first reported by Vásquez-López et al. and this in 2004 [5]. Since then, few publications have been interested in the use of dermoscopy in this infection. In the literature, ring vascularization is the only vascular aspect described in lesions of the molluscum contagiosum, in a recent study, different aspects were classified by the study published by Vásquez-López et al [4]. And in addition to the vascular crown pattern, two other models, which are; the radial and punctiform models have been reported [2].
On the other hand, the presence of inflammation and perilesional eczema is associated with the punctate vascular pattern. Vásquez-López et al., [4] also reported that his dermoscopic presentations could be either isolated or associated. Zaballos et al., [5] and Morales et al., [6] had associated aspect such as mixed vascular was the crown and radial motif.
The clinical aspect of the umbilication of the papules is manifested on the dermoscopic plane by amorphous zones in the form of orifices, in previous publications carried out these orifices presented two types of morphology; either with a yellow-white substance in its center which is keratin, or the type with a homogeneous orifice and without any visible central and rounded structure of uniform color. In many cases, this orifice is clinically undetectable, but visible on dermoscopy. Dermoscopy mainly identifies the presence of vessels which is the main advantage of this diagnostic technique, as well as to visualize the orifices when they are clinically not perceptible. Lesions of the molluscum contagiosum with inflammation and/or excoriation and personal eczema are associated with dermoscopy with vascularization in point.
We report through our publication another dermoscopic sign, never seen in the previous publication which is that of rosettes, which we could detect in the form of bright whitish structures, observed only in polarized dermoscopy, can refer to intrafollicular keratin or fibrosis.

Conclusion
In conclusion, the different dermoscopic aspects found in our analysis of cutaneous lesions of the MC are the vascular patterns in crown, punctiform, and radial. As well as the central orifices filled or not by a yellowish structure. Perilesional skin which can be inflamed or eczematized was also noted. The particularity of our publication is the visualization of rosettes, hitherto never reported as a visualized dermoscopic sign in lesions of CM.