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 is recommended by the American Academy of Pediatrics particularly for lesions that are cosmetically bothersome or in patients with underlying skin conditions such as eczema. 1

When to Consider Treatment vs. Observation

Treatment should be considered in the following scenarios:

• Lesions in cosmetically sensitive areas
• Children with underlying skin conditions like eczema
• Cases where there is concern about spread to others
• When lesions are symptomatic (itchy, painful, or inflamed)

For asymptomatic, limited lesions in immunocompetent patients, observation for spontaneous resolution is appropriate, with monitoring for 3-6 months 1. Spontaneous resolution typically occurs within 6-12 months, though complete resolution can take up to 4 years.

Treatment Algorithm

First-line options:

1. 10% Potassium Hydroxide (KOH)

   • Comparable efficacy to cryotherapy (86.6% complete response rate)
   • Well-tolerated in children
   • Clinical pearl: 20% KOH is not recommended for children 1

2. Cantharidin

   • Well-tolerated and effective for bothersome, extensive, or symptomatic lesions
   • Applied by healthcare provider
   • Clinical pearl: VP-102, a standardized preparation of cantharidin, has shown promising results in phase III studies 2

Second-line options:

1. Cryotherapy with liquid nitrogen

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

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

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

3. Surgical options

   • Curettage or excision
   • Tangential scissor excision
   • Shave excision
   • Electrosurgery for larger lesions 1
   • Caution: May be painful and potentially frightening for young children

Not recommended:

• Imiquimod - Randomized controlled trials have shown it is not more effective than placebo 1
  • FDA data confirms lack of efficacy in pediatric studies, with complete clearance rates of 24% for imiquimod versus 26-28% for vehicle 3

Special Considerations

Children

• Avoid painful treatments in young children when possible 1
• Consider the child's ability to cooperate with treatment
• Monitor for potential side effects, especially with topical treatments

Immunocompromised Patients

• May develop severe and recalcitrant lesions
• Consider evaluation for immunocompromised state in adults with large and multiple lesions 1
• May require more aggressive treatment approaches

Pregnant Women

• Physical procedures like cryotherapy are safe during pregnancy 4
• Avoid chemical treatments without established safety profiles

Lesions Near Eyes

• Prompt treatment is recommended to prevent conjunctivitis 1
• Consider consultation with ophthalmology for periocular lesions

Skin of Color

• Exercise caution with treatments that may cause post-inflammatory hyperpigmentation (e.g., cryotherapy) 5

Prevention and Management

To prevent 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

For monitoring:

• Regular follow-up every 1-3 months to assess progression
• Consider active treatment if lesions persist beyond 6-12 months or if complications develop 1

Emerging Treatments

New topical treatments in development include:

• VP-102 (standardized cantharidin preparation)
• SB206 (nitric oxide-releasing product containing berdazimer)

Both have shown promising results in phase III studies and may become the first FDA-approved therapies for molluscum contagiosum 2.