What are the treatment options for molluscum contagiosum?

Molluscum Contagiosum Treatment Options

For most uncomplicated cases of molluscum contagiosum in immunocompetent patients with limited, asymptomatic lesions, observation for spontaneous resolution with monitoring for 3-6 months is the recommended first-line approach. 1

Treatment Decision Algorithm

First-line approaches:

1. Observation for spontaneous resolution

   • Appropriate for most uncomplicated cases in immunocompetent patients
   • Monitor for 3-6 months
   • Complete resolution typically occurs within 6-12 months but can take up to 4 years

2. For bothersome, extensive, or symptomatic lesions:

   • Cantharidin application - Well-tolerated and effective, especially in children 1, 2
   • 10% Potassium hydroxide (KOH) - Comparable efficacy to cryotherapy (86.6% complete response rate) 1

Second-line approaches:

1. Cryotherapy with liquid nitrogen

   • Effective treatment (93.3% complete response rate)
   • Caution: May cause postinflammatory hyperpigmentation or scarring
   • May require weekly applications for up to 4 weeks 1

2. Mechanical removal options

   • Curettage
   • Simple excision
   • Excision and cauterization
   • Note: These may be painful and potentially frightening for young children 1

Special Considerations

Children and Anxious Patients

• Prefer 10% KOH or cantharidin due to better tolerability 1
• Cantharidin application is quick, simple, and painless, making it ideal for children 3, 2
• 92% of pediatric dermatologists report satisfaction with cantharidin's efficacy, though 79% report side effects like discomfort/pain and blistering 4

Ocular Involvement

• Lesions on eyelids require prompt treatment to prevent conjunctivitis 5, 1
• Eyelid lesions can cause follicular conjunctivitis with punctate epithelial keratitis 5

Athletes in Contact Sports

• More aggressive treatment approach recommended to prevent transmission 1
• Follow specific return-to-play guidelines from athletic organizations

Immunocompromised Patients

• More aggressive treatment and monitoring recommended 1
• May have more extensive disease requiring combination approaches
• In adults with large and multiple lesions, evaluation for immunocompromised state should be considered

Atopic Dermatitis

• Patients with atopic dermatitis may develop widespread involvement 6
• May require more aggressive or combination therapy

Treatment Efficacy and Considerations

• Imiquimod is not recommended as randomized controlled trials have shown it is not more effective than placebo 1
• FDA studies in children showed imiquimod was not more effective than vehicle (24% vs 26-28% clearance rates) 7
• Common side effects of treatments include:
  • Cryotherapy: Postinflammatory hyperpigmentation, scarring
  • Cantharidin: Discomfort/pain, blistering (though generally well-tolerated)
  • Imiquimod: Erythema (28%), edema (8%), scabbing/crusting (5%) 7

Prevention of Spread

• Advise patients to avoid touching lesions
• Avoid sharing personal items (towels, clothing)
• Avoid intimate contact until lesions resolve
• Cover lesions during contact sports or swimming

Clinical Pearls

• Molluscum contagiosum affects 5-11% of children aged 0-16 years 1
• About 10% of patients develop a pruritic eczematous eruption around lesions 6
• Approximately 4% of children develop numerous and recurrent lesions without immunological problems 6
• Distinctive clinical sign: shiny, dome-shaped umbilicated lesions of the eyelid skin or margin 5
• As of 2021, there were no FDA-approved treatments specifically for molluscum contagiosum 8