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

Treatment Algorithm

First-line approaches:

• For asymptomatic, limited lesions in immunocompetent patients:

  • Observation for spontaneous resolution (monitor for 3-6 months) 1
  • Spontaneous resolution typically occurs within 6-12 months, though complete resolution can take up to 4 years

• For bothersome, extensive, or symptomatic lesions:

  • Cantharidin application - Well-tolerated and effective with minimal side effects 1
  • 10% Potassium hydroxide (KOH) - 86.6% complete response rate, comparable to cryotherapy but with better cosmetic results 1, 2

Second-line approaches:

• Cryotherapy with liquid nitrogen - 93.3% complete response rate but may cause postinflammatory hyperpigmentation or scarring 1, 2, 3

  • Requires weekly applications for up to 4 weeks
  • Particularly effective for isolated, larger lesions

• 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

Age-specific considerations:

• Children or anxious patients: 10% KOH or cantharidin are preferred due to better tolerability 1
• Children under 12: Imiquimod cream is not FDA-approved and has been shown to be ineffective (24% clearance vs 26-28% with vehicle) 4

Location-specific considerations:

• Eyelid lesions: Require prompt treatment to prevent conjunctivitis 1
  • Hyperfocal cryotherapy can be effective for periorbital lesions 5

Patient-specific considerations:

• Athletes in contact sports: More aggressive treatment approach to prevent transmission 1
• Immunocompromised patients: More aggressive treatment and monitoring due to potentially more extensive disease 1
• Adults with large and multiple lesions: Consider evaluation for immunocompromised state 1

Important Caveats

• Imiquimod is not recommended despite being commonly prescribed, as randomized controlled trials have shown it is not more effective than placebo 1, 4

• Potential complications:

  • Cryotherapy may cause postinflammatory hyperpigmentation or scarring 1, 2
  • Imiquimod in children has been associated with adverse events including erythema (28%), edema (8%), scabbing/crusting (5%), otitis media (5%), and conjunctivitis (3%) 4

• Prevention guidance:

  • Advise patients to avoid touching lesions and intimate contact until lesions resolve
  • Identify and treat nascent lesions to reduce recurrence risk 1

Treatment Efficacy Comparison

Treatment	Efficacy	Advantages	Disadvantages
Observation	Resolution in 6-12 months	No side effects, non-invasive	Takes time, risk of spread
Cantharidin	Effective	Well-tolerated, minimal side effects	Requires professional application
10% KOH	86.6% complete response	Inexpensive, can be applied at home, good cosmetic results	Requires consistent application
Cryotherapy	93.3% complete response	Rapid treatment	Postinflammatory hyperpigmentation, scarring, painful
Mechanical removal	Immediate results	Definitive for treated lesions	Painful, frightening for children