What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

The most effective first-line treatment for molluscum contagiosum is cryotherapy with liquid nitrogen, which has a high efficacy rate of 93.3% complete response, though it should be used cautiously in young children due to pain. 1

First-Line Treatment Options

Physical Treatments

• Cryotherapy with liquid nitrogen

  • Apply every 1-2 weeks until lesions resolve
  • High efficacy rate (93.3% complete response)
  • Potential side effects: pain, necrosis, blistering, post-inflammatory hyperpigmentation
  • Consider local anesthesia for painful lesions
  • Not ideal for young children due to pain 1

• Cantharidin application

  • Well-tolerated and effective, especially in pediatric patients
  • Minimal side effects
  • Good option for children who cannot tolerate painful procedures 1, 2

• 10% Potassium hydroxide (KOH)

  • Comparable efficacy to cryotherapy (86.6% complete response rate)
  • Can be applied to lesions with minimal discomfort 1

Surgical Options

• Curettage or excision
  • Immediate removal of visible lesions
  • Options include tangential scissor excision or shave excision
  • Electrosurgery for larger lesions
  • May be painful and frightening for young children 1

Chemical Treatments

• Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90%

  • Apply until white "frosting" develops
  • Can be repeated weekly as needed
  • Neutralize excess acid with talc, sodium bicarbonate, or liquid soap 1

• Podophyllin resin 10%-25%

  • Apply as thin layer and allow to air dry
  • Consider washing off after 1-4 hours to reduce irritation
  • Limitations on application area and volume 1

Ineffective Treatments

• Imiquimod
  • Not recommended as randomized controlled trials show it is not more effective than placebo 1
  • FDA labeling specifically notes that studies in children with molluscum contagiosum failed to demonstrate efficacy 3

Treatment Algorithm Based on Patient Characteristics

For Immunocompetent Patients with Limited Lesions

1. Consider observation for spontaneous resolution for 3-6 months if:
   • Lesions are asymptomatic
   • Limited in number
   • Not in sensitive or cosmetically important areas 1

For Bothersome, Extensive, or Symptomatic Lesions

1. First choice: Cryotherapy (adults/older children) or cantharidin (young children)
2. Alternative: 10% KOH application
3. For resistant cases: Consider surgical options 1

Special Considerations

• Periocular lesions: Prompt treatment recommended to prevent conjunctivitis 1
• Immunocompromised patients: More aggressive approach needed; evaluate for underlying immunocompromised state in adults with large and multiple lesions 1
• Young children: Avoid painful treatments; prefer cantharidin or KOH 1, 2

Prevention of Spread

• Cover visible lesions with clothing or bandages
• Maintain good hand hygiene, especially after touching lesions
• Avoid sharing personal items like towels and clothing
• Avoid scratching or picking at lesions to prevent autoinoculation 1

Monitoring and Follow-up

• Regular monitoring every 1-3 months to assess progression
• Consider active treatment if lesions persist beyond 6-12 months
• For multiple lesions, identify and treat nascent lesions to reduce recurrence risk 1

Common Pitfalls to Avoid

1. Using imiquimod as first-line therapy despite evidence showing lack of efficacy compared to placebo
2. Failing to identify and treat all lesions, which can lead to autoinoculation and spread
3. Using painful treatments in young children without appropriate pain management
4. Not providing adequate prevention guidance to patients and caregivers
5. Overlooking the possibility of an immunocompromised state in adults with extensive disease 1, 3