What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

The most effective first-line treatment for molluscum contagiosum is 10% potassium hydroxide (KOH), which has comparable efficacy to cryotherapy but with better cosmetic results and fewer side effects. 1, 2

Understanding Molluscum Contagiosum

Molluscum contagiosum is a common viral skin infection affecting 5-11% of children aged 0-16 years. It presents as skin-colored papules with central umbilication and typically resolves spontaneously within 6-12 months, though complete resolution can take up to 4 years 1.

Treatment Algorithm

When to Consider Treatment

• Lesions in cosmetically sensitive areas
• Children with underlying skin conditions (especially eczema)
• Risk of spread to other children
• Symptomatic lesions (itchy, painful, or inflamed)
• Extensive or recurrent lesions

First-Line Treatment Options

1. Observation for spontaneous resolution

   • Appropriate for asymptomatic, limited lesions in immunocompetent patients
   • Monitor every 1-3 months to assess progression

2. 10% Potassium hydroxide (KOH)

   • Apply twice daily until lesions disappear
   • 86.6% complete response rate after 4 weeks
   • Minimal side effects and better cosmetic results than cryotherapy 1, 2
   • Note: 20% KOH is not recommended for children 1

3. Cantharidin application

   • Well-tolerated and effective for bothersome or extensive lesions
   • Applied in-office by healthcare provider 1, 3

Second-Line Treatment Options

1. Cryotherapy with liquid nitrogen

   • 93.3% complete response rate
   • May cause postinflammatory hyperpigmentation or scarring 1, 2
   • Consider local anesthesia for painful lesions

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

   • Apply until white "frosting" develops
   • Can be repeated weekly as needed 1

3. Podophyllin resin 10%-25%

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

4. Surgical options

   • Curettage, excision, tangential scissor excision, or shave excision
   • Immediate removal but potentially painful and frightening for children 1

Important Considerations

Ineffective Treatments

• Imiquimod cream is not recommended as randomized controlled trials have shown it is not more effective than placebo 1, 4, 5
  • High-quality evidence from multiple studies shows no significant difference between 5% imiquimod and vehicle for clinical cure at 12,18, or 28 weeks 5
  • FDA labeling indicates imiquimod failed to demonstrate efficacy in two randomized trials involving 702 pediatric subjects with molluscum contagiosum 4

Special Populations

• Children: Avoid painful treatments when possible; consider the child's ability to cooperate 1
• Adults with extensive lesions: Consider evaluation for immunocompromised state 1
• Lesions near eyes: Prompt treatment recommended to prevent conjunctivitis 1

Prevention of Spread

• Cover visible lesions with clothing or bandages when possible
• Maintain good hand hygiene, especially after touching lesions
• Avoid sharing personal items like towels and clothing 1

Treatment Comparison

Treatment	Efficacy	Side Effects	Ease of Use
10% KOH	86.6% complete response	Minimal	Easy, at-home application
Cryotherapy	93.3% complete response	Hyperpigmentation, scarring	Office procedure
Cantharidin	Effective, well-tolerated	Minimal	Office procedure
Surgical removal	Immediate removal	Pain, potential scarring	Office procedure
Imiquimod	Not more effective than placebo	Application site reactions	Not recommended

Pitfalls to Avoid

• Don't assume all lesions require treatment - spontaneous resolution is common
• Avoid using 20% KOH in children as this concentration has primarily been studied in adults 1
• Be aware that treatment may need to be repeated to address new lesions that appear during the course of treatment
• Remember that imiquimod, despite being commonly prescribed, has been shown to be ineffective in controlled trials 1, 4, 5