What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

For molluscum contagiosum, 10% potassium hydroxide (KOH) is recommended as a first-line treatment option for bothersome lesions, while observation for spontaneous resolution is appropriate for asymptomatic cases in immunocompetent patients. 1

Treatment Algorithm

First-line Approaches:

1. Observation for spontaneous resolution

   • Appropriate for asymptomatic, limited lesions in immunocompetent patients
   • Complete resolution typically occurs in 6-12 months (can take up to 4 years)
   • Monitor every 1-3 months to assess progression

2. 10% potassium hydroxide (KOH)

   • Recommended by the American Academy of Pediatrics for children
   • Comparable efficacy to cryotherapy (86.6% complete response rate)
   • Particularly useful for cosmetically bothersome lesions or patients with underlying skin conditions like eczema 1

Second-line Options:

1. Cantharidin application

   • Well-tolerated and effective treatment
   • Applied every 21 days until clearance or for up to four treatments
   • Recent studies show 36.2% of patients achieved complete clearance compared to 10.6% with placebo 2, 3

2. Cryotherapy with liquid nitrogen

   • Alternative with similar efficacy to KOH (93.3% complete response rate)
   • Caution: may cause postinflammatory hyperpigmentation or scarring
   • Consider local anesthesia for painful lesions 1

3. Surgical options

   • Curettage, excision, tangential scissor excision, or shave excision
   • Electrosurgery for larger lesions
   • Provides immediate removal but may be painful and frightening for young children 1

4. Chemical treatments

   • Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90%
   • Podophyllin resin 10%-25% in compound tincture of benzoin 1

Important Considerations

When to Treat vs. Observe

Treatment should be considered when:

• Lesions are in cosmetically sensitive areas
• Patient has underlying skin conditions like eczema
• Concern about spread to others exists
• Lesions are symptomatic (itchy, painful, or inflamed)
• Lesions persist beyond 6-12 months 1

Treatments to Avoid

• Imiquimod cream (5%): Not recommended as randomized controlled trials have shown it is not more effective than placebo 1, 4

  • High-quality evidence from multiple studies shows no significant difference between imiquimod and vehicle for clinical cure at 12,18, and 28 weeks 4
  • FDA labeling indicates that imiquimod was evaluated in two randomized trials involving 702 pediatric subjects with molluscum contagiosum, but failed to demonstrate efficacy 5

• 20% KOH: Not recommended in children (primarily studied in adults with sexually transmitted molluscum contagiosum) 1

Special Populations

• Children: Avoid painful treatments if possible, considering the child's ability to cooperate 1
• Lesions near eyes: Prompt treatment recommended to prevent conjunctivitis 1
• Adults with large/multiple lesions: Consider evaluation for immunocompromised state 1

Prevention Strategies

• 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
• For specific occupations (food service workers, athletes, childcare workers): follow strict hygiene protocols 1

Treatment Efficacy Comparison

• 10% KOH vs. 5% imiquimod: KOH demonstrated superior efficacy in comparative studies 6
• Cantharidin vs. placebo: Significantly higher clearance rates (36.2% vs. 10.6%) 2
• 10% Australian lemon myrtle oil vs. olive oil: Lemon myrtle oil showed greater effectiveness 4

Common Pitfalls to Avoid

• Treating all cases aggressively when observation is appropriate for many patients
• Using imiquimod despite evidence showing lack of efficacy compared to placebo
• Failing to identify and treat nascent lesions when treating multiple lesions
• Not considering the psychological impact of painful treatments in young children

Remember that while treatment options exist, the natural resolution of molluscum contagiosum remains a valid approach, especially for asymptomatic cases in immunocompetent patients.