What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

For bothersome, extensive, or symptomatic molluscum contagiosum lesions, first-line treatments include cryotherapy with liquid nitrogen (93.3% complete response rate), cantharidin application, or 10% potassium hydroxide (86.6% complete response rate). 1

Treatment Algorithm

First-line options:

1. Observation for spontaneous resolution

   • Appropriate for asymptomatic, limited lesions in immunocompetent patients
   • Monitor for 3-6 months
   • Cover visible lesions with clothing or bandages when possible
   • Maintain good hand hygiene

2. Active treatment options (for bothersome, extensive, or symptomatic lesions):

   • Cryotherapy with liquid nitrogen

     • Apply every 1-2 weeks until lesions resolve
     • Efficacy: 93.3% complete response rate
     • Potential side effects: pain, necrosis, blistering, post-inflammatory hyperpigmentation
     • Consider local anesthesia for painful lesions

   • Cantharidin application

     • Well-tolerated and effective
     • Minimal side effects

   • 10% Potassium hydroxide (KOH)

     • Efficacy: 86.6% complete response rate (comparable to cryotherapy)
     • Apply 3 times per week until lesions clear 2

Second-line/alternative options:

1. Chemical treatments

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

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

   • Podophyllin resin 10%-25% in compound tincture of benzoin

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

2. Surgical options

   • Curettage or excision
   • Tangential scissor excision
   • Shave excision
   • Electrosurgery (for larger lesions)

Important Considerations

Efficacy Evidence

• Cryotherapy has the highest documented efficacy (93.3% complete response) 1
• 10% KOH solution shows good efficacy (86.6% complete response) 1
• Imiquimod is not recommended as randomized controlled trials have shown it is not more effective than placebo 1, 3
  • High-quality evidence from multiple large studies shows imiquimod 5% cream lacks efficacy compared to vehicle (placebo) for molluscum contagiosum 3
  • FDA labeling specifically states: "Imiquimod cream was evaluated in two randomized, vehicle-controlled, double-blind trials involving 702 pediatric subjects with molluscum contagiosum... These studies failed to demonstrate efficacy" 4

Special Populations

• Children: Avoid painful treatments in young children when possible 1

  • Consider the child's ability to cooperate
  • Observation for spontaneous resolution is appropriate for most uncomplicated cases

• Periocular lesions: Prompt treatment recommended to prevent conjunctivitis 1

• Immunocompromised patients:

  • Consider evaluation for immunocompromised state in adults with large and multiple lesions 1
  • The safety and efficacy of imiquimod in immunosuppressed patients have not been established 4

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

Follow-up

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

Common Pitfalls

1. Using ineffective treatments: Despite some case reports suggesting benefit 5, 6, high-quality evidence shows imiquimod is not effective for molluscum contagiosum 1, 4, 3

2. Overlooking spontaneous resolution: Many cases resolve without intervention within 6-12 months

3. Causing unnecessary pain: Painful treatments may be traumatic for young children and should be avoided when possible

4. Missing immunocompromised status: Large or widespread lesions in adults may indicate underlying immunosuppression that requires evaluation

5. Inadequate prevention measures: Failing to counsel patients about preventing spread can lead to autoinoculation and new lesions