[Question #2761] Risk due to a kissing exposure

40 months ago

Dear Dr. Handsfield,


About 3.5 months back, I had a brief lip kissing exposure with an acquaintance (married). I was under the influence of a couple of beers and it wasn't deep or open mouth kissing. Was mostly superficial, a couple of times and would have lasted for a few seconds (30-40?). I recall that I felt her tongue once. There were no lesions or blisters visible on her lips (can't say about inside of mouth or tongue but don’t recall feeling anything “bump” like or unusual). I got a few episodes of recurrent cold / upper respiratory infections after that, did comprehensive health check up 91 days post exposure and everything came out clean (STD tests done - HIV and Hepatitis B). On the same day, I got my teeth cleaned up from a dentist and developed a bump at the centre just above my upper lip line the very next day (it had white pus at the centre during the first few days). Note that I do get cold sores on the lips but this wasn't a cold sore flare up. The bump didn't clear up in a week, saw a dermatologist, he diagnosed folliculitis and put me on Fusidic Acid cream for 10 days. Took a second derma opinion a week later, She re-confirmed folliculitis and suggested to continue Fusidic for another week. It's been 20 days now, took a third derma opinion last night, the doc tried to squeeze the bump a couple of times but nothing came out. He suspected Comedone to start with but when I told him about the kissing event and asked if this could be a wart, he responded “unlikely”. Although, on the prescription he ended up writing "Comedone, Molluscum Contagiosum, Wart" but didn't confirm anything and asked to take oral antibiotics (Augmentin 375 mg), apply cleargel and suggested to see him back in a week.


Questions:

  1. What is the risk of acquiring any STD/STI due to the exposure described above? I already have HSV 1 so that's not a concern. I presume Syphilis should also be not a concern. Pls confirm?
  2. What is the risk (%) of acquiring oral HPV (i.e. warts on the lips) due to this exposure? Oral HPV may be less well studied but what’re the chances?  
  3. What are the risk (%) of acquiring Molluscum Contagiosum on the lips due to the exposure above? Note that it’s a single small red bump that’s not easily visible and doesn’t appear to have a dimple or pit at the centre (typical appearance for MC that helps doctors diagnose it easily?). If I stretch my lips wide, it almost becomes flat and I can’t see any pus/fluid inside. Also, not sure if MC happens easily just above the lip line (Mucous membrane)? 
  4. Given the bump has not completely gone in close to 3 weeks, I’m worried about what this might be and how long this could take to go. Can Folliculitis (as diagnosed by first 2 dermatologist) take that long or a month or two to clear up ?
  5. What’s the likelihood of this bump being a result of the event described above (i.e. STI/STD/Skin to skin transfer)?  
  6. Should I refrain from kissing my partner or daughters due to this (understand MC is contagious) ? Don’t want to pass on this infection to anyone


I am really stressed out and need genuine expert advise. Thanks in advance.  


Edward W. Hook M.D.
Edward W. Hook M.D.
40 months ago
Welcome to our Forum. I'll be glad to comment.  Kissing open mouth or otherwise is not a mechanism for transmission of ANY STI except perhapsHSV-1, the cold sore virus which you already have.  Further, the interval between your kissing episode and the appearance of this pesky, persistent "bump" is too long to suggest nearly all STIs except HPV and despite what the 3rd dermatologist said, nothing you describe suggests that this is a wart.  The best single bit of advice I might provide you is to choose the dermatologist you liked best and stick with him/her- going from doctor to doctor makes each one start again and in problems such as yours, having seen the evolution of things over time helps clinicians to provide high quality care.  Doctor shopping only confuses things as each new health care provider will start again.  

In answer to your specific questions:
  1. What is the risk of acquiring any STD/STI due to the exposure described above? I already have HSV 1 so that's not a concern. I presume Syphilis should also be not a concern. Pls confirm?
Correct.  This event is simply not a reason to worry about acquisition of any STI.

2. What is the risk (%) of acquiring oral HPV (i.e. warts on the lips) due to this exposure? Oral HPV may be less well studied but what’re the chances?  
As a rule, when HPV occurs in the oral cavity it occurs inside rather than outside.  Even of the 3 dermatologists you saw, only one mentioned HPV and it was the last thing he/she mentioned.  I would not worry that this is a wart.

3. What are the risk (%) of acquiring Molluscum Contagiosum on the lips due to the exposure above? Note that it’s a single small red bump that’s not easily visible and doesn’t appear to have a dimple or pit at the centre (typical appearance for MC that helps doctors diagnose it easily?). If I stretch my lips wide, it almost becomes flat and I can’t see any pus/fluid inside. Also, not sure if MC happens easily just above the lip line (Mucous membrane)? 
I am not aware of good, precise data on the per exposure probability of MC transmission with direct contact.  I would point out that most MC is NOT transmitted through sexual contact and whether or not you think of kissing as sexual contact, this is not described as a means of MC transmission.  The lesion you describe with the color change, etc. sounds like it is healing.

4. Given the bump has not completely gone in close to 3 weeks, I’m worried about what this might be and how long this could take to go. Can Folliculitis (as diagnosed by first 2 dermatologist) take that long or a month or two to clear up ?
Yes, folliculitis can absolutely take this long to clear, particularly when it is in a regularly touched/abraded place such as the lip or when it is manipulated (squeezed).  Your description in 3 above sounds very much like it is healing to me.

5,  What’s the likelihood of this bump being a result of the event described above (i.e. STI/STD/Skin to skin transfer)?  
Close to zero.  Please see my comments above.

6.  Should I refrain from kissing my partner or daughters due to this (understand MC is contagious) ? Don’t want to pass on this infection to anyone
I see no reason to refrain from kissing your partner related to this lesion.

I hope these comments are helpful.  Please let me know if there are any questions or if any of this is unclear.  EWH
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40 months ago
Thank you Dr. Hook. A few follow up questions based on your response and whatever I could gather from CDC/medhelp articles:

1) The CDC HPV factsheet (https://www.cdc.gov/std/hpv/hpvandmen-fact-sheet-february-2012.pdf) doesn't say anything about HPV transmission in men via kissing. It does mention oral sex and mouth getting affected due to HPV but that's not applicable in my case.  Additionally, CDC only talks about cancer of oropharynx for the oral region - it doesn't mention anything pertaining to oral warts. In your or Dr. HHH's experience, have you ever seen an HPV transmission occurring ONLY via kissing ?  
Also, when you say: "As a rule, when HPV occurs in the oral cavity, it occurs inside rather than outside" - is this backed by any scientific research / evidence or this statement was more driven by your/Dr. HHH's 30+ years of experience and seeing no cases like that ? 

Does all of the above conclusively indicate that my small bump on the upper lip should not be a wart at all ? 

2) At this point, I'm probably more worried about Molluscum Contagiosum. After reading through all the relevant (oral cavity related) medhelp articles on MC I could find and listing a couple below:
http://www.medhelp.org/posts/STDs/Question-about-Mollescum-Contagiosum/show/2118391 : In this thread, you suggest oral MC is very rare and traditionally not thought of as orally transmitted STI. If it happens, would be certainly unusual. 
 - http://www.medhelp.org/posts/STDs/Molluscum-in-my-mouth/show/247397 :  In this thread Dr. HHH says: I have never seen oral MC in an adult or that was sexually acquired; if it happens, it is rare.
 
And considering your response where you said: "would point out that most MC is NOT transmitted through sexual contact and whether or not you think of kissing as sexual contact, this is not described as a means of MC transmission"

Request inputs/clarification on the following: 

i) Do we know how rare is oral MC ? Are there any stats around it ? 1 out of 100 MC cases being oral vs. the rest of the body, 1000, more ? 

ii) If oral MC had to happen, are the chances of its transmission more with oral sex than kissing ? I appreciate there may or may not be enough data points around this, however, would you considering oral sex more riskier (given genital MC could be common) than a kissing event in this rare possibility ? 

iii) In your or Dr. HHH's experience, have you ever come across an MC transmission case that would have happened from kissing alone (no oral sex) ? 

iv) Are there scientific evidences which suggests that kissing contact is not described as a means on MC transmission ? Or this statement is more driven by your/Dr. HHH's 30+ years of experience in which you haven't seen any case of such transmission occurring ? 

All in all, responses that you'd provide for the above questions, and considering my situation: 
 - brief kissing contact, small bump appearing 92 days after exposure (typical incubation for MC - 2 to 3 months)
 - single bump and not in groups or many
 - improving albeit slowly (3 weeks today and not gone) with fusidic acid
 - no clear dimple or pit at the centre of the bump that's evidently visible although bump appears a bit irregular on VERY close examination
 - I don't see any waxy/white substance when I stretch my lips and the bump almost flattens out
 - 2 dermatologist suggesting folliculitis
 - Nothing came out when the 3rd dermatologist tried squeezing it a couple of times 
 
What do you think would be the chances of this being MC ? Extremely low, none, or close to zero ? If you were in my place but still had all the experience and knowledge, would you absolutely NOT worry about MC ? 

3) Sorry for the repeat question but I presume you meant to say that I can kiss both my partner as well as my daughters (9 and 1 year old). If there is a slightest of risk, I wouldn't.

Thank you very much for your time.

Edward W. Hook M.D.
Edward W. Hook M.D.
40 months ago
Your follow-up question is a bit wordy and repetitive and does not in any way change my assessment of advice.  It does suggest a bit of guilt or paranoia however.  Straight to your questions after pointing out that there are few good scientific studies on MC as an STI and when it has been addressed, it is considered a "minor" STI with no serious sequelae.

1. In science and medicine one can never say never.  Strange things happen and clinicians regularly see manifestations of infections they have not seen before.  All of the information you have provided suggests that the lesion you describe is not a wart and is resolving, something that should not happen if it were a wart.

2.  I think your worries are over the top.  What you describe is most compatible with folliculitis as the majority of dermatologists you have seen have already told you. 
i.  There are no good stats.  The CDC does not collect them and what stats are available are based on limited experience.  The infection is far more common in children and a non-STI than as an STI.  Since data are lacking, I prefer not to guess at the prevalence of infection.  I will say however that it is rare and I rarely see it in my own practice.
ii.  Logically and based on observation that friction and minor abrasion make MC acquisition more likely, oral sex would be a far more likely way to acquire MC on your lip than kissing.
iii.  No.

As I have already said, I suspect that your problem is folliculitis, not MC or warts and that you are over reacting.

3.  Sigh....In my opinion there is no reason for you to hesitate to kiss your wife OR your daughter, or other family members. 

I really think you are feeling excessively guilty over having kissed another person.  In many cultures and settings kissing is a non-sexual form of greeting.  Further, even if for some reason you feel that your kissing was in some way an act of infidelity, the likelihood that this event which occurred about three months ago is related to the lesion you noted on your lip is vanishingly low.  EWH
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40 months ago
Thanks for your reply Dr Hook. Over the last 4 days, the only development has been that I have gotten a couple of pimples on my cheek (i usually get them once in a while) which I think might be due to the antibiotic (doxy 1) that I started for my bump above the lip as a normal side effect. The pimples seem to be running “their course” and doesn’t seem or appear like MC (have shrunk slightly from their day 2 size I guess). Not sure if this changes your opinion. Pls suggest.

I know there are no good studies or stats around MC and hence could I please request Dr Handsfield’s perspective based on his experience on this thread ? Hearing from 2 experts might just help me put my mind at ease until bump goes away. Life has been extremely difficult over the past 3+ weeks. I’ll really appreciate your help in this regard.

Edward W. Hook M.D.
Edward W. Hook M.D.
40 months ago
No change in my opinion or suggestions.

Dr. Handsfield and I have not EVER disagreed with each other's advice in working together for nearly 40 years.  He will not be answering this question.

This is my third reply to your questions.  This will conclude the thread and it will be closed later today.  As I move on, and hope that you will, I will also remind you that the Forum does not accept repetitive, anxiety-driven questions and that further questions may be deleted without comment.  I wish you the best.  EWH
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