What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

For most uncomplicated cases of molluscum contagiosum, observation for spontaneous resolution is recommended as the first approach, with active treatment reserved for bothersome, extensive, or symptomatic lesions, for which cantharidin application or 10% potassium hydroxide are the preferred first-line treatments. 1

Treatment Algorithm

First-Line Approaches:

1. Observation for spontaneous resolution

   • Appropriate for asymptomatic, limited lesions in immunocompetent patients
   • Monitor for 3-6 months
   • Spontaneous resolution typically occurs within 6-12 months (though complete resolution can take up to 4 years) 1

2. For bothersome, extensive, or symptomatic lesions:

   • Cantharidin application

     • Well-tolerated and effective, especially in children 1, 2
     • 36.2% of patients achieve complete clearance compared to 10.6% with placebo 2
     • Should be applied only by physicians 3
     • Minimal side effects, though discomfort/pain and blistering may occur 4

   • 10% Potassium hydroxide (KOH)

     • Comparable efficacy to cryotherapy (86.6% complete response rate) 1
     • Well-tolerated in children and anxious patients 1

Second-Line Options:

1. Cryotherapy with liquid nitrogen

   • High efficacy (93.3% complete response rate) 1
   • Caution: May cause postinflammatory hyperpigmentation or scarring
   • May require weekly applications for up to 4 weeks
   • Less tolerated in children 1

2. Mechanical removal options

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

Special Considerations

Pediatric Patients

• Cantharidin or 10% KOH are preferred due to better tolerability 1, 5
• Imiquimod is not recommended as randomized controlled trials have shown it is not more effective than placebo 1
• FDA studies confirm imiquimod's lack of efficacy in children with molluscum contagiosum 6

Ocular Involvement

• Lesions on eyelids require prompt treatment to prevent conjunctivitis 1
• Can cause follicular conjunctivitis with punctate epithelial keratitis

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 aggressive treatment

Common Pitfalls and Caveats

• Imiquimod inefficacy: Despite being commonly prescribed, imiquimod has been shown to be no more effective than placebo for molluscum contagiosum in controlled trials 1, 6

• Treatment expectations: No therapy is universally effective, and parents/patients should be informed that multiple treatment sessions may be needed 7, 5

• Side effects of cryotherapy: While effective, cryotherapy may cause postinflammatory hyperpigmentation or scarring, particularly in darker skin types 1

• Prevention of spread: Advise patients to avoid touching lesions and to limit intimate contact until lesions resolve 1

• Monitoring for complications: About 10% of patients develop a pruritic eczematous eruption ("molluscum eczema") that may require additional treatment 7, 5

• Atopic dermatitis: Patients with atopic dermatitis may develop widespread involvement with molluscum and may benefit from more aggressive treatment 7

• Recurrence: Identify and treat nascent lesions to reduce recurrence risk 1