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. 1

First-Line Treatment Approaches

Observation

• Appropriate for asymptomatic, limited lesions in immunocompetent patients
• Spontaneous resolution typically occurs within 6-12 months, though complete resolution can take up to 4 years 1
• Monitoring for 3-6 months is recommended by the American Academy of Pediatrics 1

Active Treatment Options (for bothersome/extensive lesions)

1. Cantharidin Application

   • Well-tolerated and effective first-line treatment 1, 2
   • Particularly suitable for children due to better tolerability 1
   • Applied in-office by healthcare provider

2. 10% Potassium Hydroxide (KOH)

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

3. Cryotherapy with Liquid Nitrogen

   • Highly effective with 93.3% complete response rate 1
   • 94% clearance rate demonstrated in a prospective cohort study 3
   • Caution: May cause postinflammatory hyperpigmentation or scarring 1
   • May require weekly applications for up to 4 weeks 1

4. 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

Anatomical Location

• Eyelid lesions: Require prompt treatment to prevent conjunctivitis 1
• Genital lesions: May require more aggressive management

Patient Population

• Athletes in contact sports: More aggressive treatment approach recommended to prevent transmission 1
• Immunocompromised patients: More extensive disease requiring aggressive treatment 1
• Children: Prefer 10% KOH or cantharidin due to better tolerability 1

Ineffective Treatments

• Imiquimod: Not recommended as randomized controlled trials have shown it is not more effective than placebo 1
• FDA labeling specifically states that imiquimod cream "has been evaluated in children ages 2 to 12 years with molluscum contagiosum and these studies failed to demonstrate efficacy" 4

Treatment Algorithm

1. Assess the patient:

   • Extent of lesions (few vs. many)
   • Location (face, eyelids, genital area, etc.)
   • Symptoms (asymptomatic vs. symptomatic)
   • Immune status (immunocompetent vs. immunocompromised)
   • Age and ability to tolerate procedures

2. Decision pathway:

   • If few, asymptomatic lesions in immunocompetent patient: Observation for 3-6 months
   • If lesions are bothersome, extensive, or symptomatic:
     • For children: Cantharidin or 10% KOH
     • For adults: Cryotherapy or curettage
   • If eyelid involvement: Prompt treatment required
   • If immunocompromised: More aggressive approach with combination therapy

Prevention and Management Tips

• Advise patients to avoid touching lesions to prevent autoinoculation
• Recommend avoiding sharing personal items (towels, clothing)
• For athletes, follow specific return-to-play guidelines from athletic organizations 1
• Identify and treat nascent lesions to reduce recurrence risk 1

Pitfalls and Caveats

• Cryotherapy may cause hypopigmentation, especially in patients with darker skin tones 3
• Multiple treatments may be necessary regardless of the method chosen
• In adults with large and multiple lesions, evaluation for immunocompromised state should be considered 1
• Lesions may recur even after successful treatment if all lesions are not identified and treated