Molluscum contagiosum (MC) is a virus-related contagion caused by the Poxvirus characterized by multiple umbilicated papules. Severe molluscum is common in immunocompromised patients. In this case we are discussing case of 32-year-old HIV-positive individual with widespread MC, recalcitrant to topical therapy, under antiretroviral therapy, who was treated with oral isotretinoin and had a dramatic outcome. Although studies are needed to confirm the effectiveness of oral isotretinoin therapy in MC, its easy availability, cost, and excellent safety profile appear to offer a promising therapeutic option.

A 32-year-old male patient presented to the outpatient clinic with an eruption of widespread skin-colored, dome-shaped lesions over his face and neck for one year. The lesions were asymptomatic but gradually increasing in size and number. 

On examination, several lesions were widespread over the eyelids, forehead, cheeks, nose, and neck, sparing the trunk and extremities. They were pearly in color, umbilicated, dome-shaped papules which were discrete to coalescing, with a size ranging from a few millimeters to one centimeter. We made our clinical diagnosis as MC in an immunocompromised patient and confirmed it after extirpation with a needle to find molluscae bodies in some of the skin lesions. Skin biopsy was not considered an option for diagnosis as a clinical diagnosis was sufficient in such cases. Dermoscopy might have assisted us with the confirmative diagnosis but was not performed due to its unavailability. Isotretinoin was used as an option because of its property of being a systemic retinoid with intracellular conversion into tretinoin and its effects on cellular proliferation and differentiation. 

After one month of follow-up, there was subjective (both the patient and physician) and objective improvement in the appearance and count of the lesions with almost no lesions in the right half of the face and few lesions in the left half of the face. The patient had no adverse effects of oral isotretinoin use except dry lips which were managed using petrolatum jelly. The remission was maintained even after two months of follow-up.

Although topical retinoic acids have been used in the treatment of molluscum, oral isotretinoin could be promising in widespread and recalcitrant MC. Indeed, randomized controlled studies are needed to confirm the effectiveness of this treatment, but its excellent safety profile appears to offer an attractive therapeutic option.