What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

The American Academy of Pediatrics recommends 10% potassium hydroxide (KOH) as an effective treatment for molluscum contagiosum, particularly for lesions that are cosmetically bothersome or in patients with underlying skin conditions such as eczema. 1

First-Line Approach: Observation vs. Treatment

Molluscum contagiosum is a benign viral infection that typically resolves spontaneously:

• Spontaneous resolution usually occurs within 6-12 months, though complete clearance may take up to 4 years 1
• For asymptomatic, limited lesions in immunocompetent patients, observation with monitoring for 3-6 months is appropriate 1

Indications for Active Treatment

Consider treatment in the following scenarios:

• Lesions in cosmetically sensitive areas
• Children with underlying skin conditions (especially eczema)
• Risk of spread to other children
• Symptomatic lesions (itchy, painful, or inflamed)
• Lesions persisting beyond 6-12 months 1

Treatment Options

Topical Treatments

1. 10% Potassium hydroxide (KOH)

   • First-line treatment recommended by the American Academy of Pediatrics
   • Comparable efficacy to cryotherapy (86.6% complete response rate)
   • Well-tolerated in children 1
   • Clinical Pearl: 20% KOH is not recommended for children as it has primarily been studied in adults with sexually transmitted molluscum 1

2. Cantharidin

   • Well-tolerated and effective for bothersome, extensive, or symptomatic lesions
   • Applied by healthcare provider and washed off after a specified time
   • Minimal side effects 1, 2

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

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

4. Podophyllin resin 10%-25%

   • Applied as a thin layer and allowed to air dry
   • Should be washed off after 1-4 hours to reduce irritation
   • Limitations on application area and volume 1

Physical Treatments

1. Cryotherapy with liquid nitrogen

   • 93.3% complete response rate
   • Potential complications: postinflammatory hyperpigmentation or scarring
   • Consider local anesthesia for painful lesions 1

2. Surgical options

   • Curettage or excision
   • Tangential scissor excision
   • Shave excision
   • Electrosurgery for larger lesions 1
   • Clinical Pearl: These methods provide immediate removal but may be painful and potentially frightening for young children 1

Treatments to Avoid

Imiquimod is not recommended as randomized controlled trials have shown it is not more effective than placebo 1. FDA labeling confirms that imiquimod failed to demonstrate efficacy in two randomized studies involving 702 pediatric subjects with molluscum contagiosum 3.

Special Considerations

Children

• Avoid painful treatments in young children when possible
• Consider the child's ability to cooperate 1
• For extensive MC involving at least 10% of body surface area, systemic absorption of topical treatments may be a concern 3

Immunocompromised Patients

• Evaluation for immunocompromised state should be considered in adults with large and multiple lesions 1
• These patients may develop severe and recalcitrant lesions requiring more aggressive treatment 4

Lesions Near Eyes

• Prompt treatment is recommended to prevent conjunctivitis 1

Prevention Strategies

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
• Regular monitoring every 1-3 months to assess progression 1

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis (dome-shaped papules with central umbilication)
   • Assess extent, location, and patient symptoms

2. Decision Point:

   • For limited, asymptomatic lesions in immunocompetent patients → Observation
   • For extensive, symptomatic, or cosmetically concerning lesions → Active treatment

3. Treatment Selection:

   • First-line: 10% KOH for most pediatric patients
   • Alternative: Cantharidin for extensive or multiple lesions
   • For isolated or larger lesions: Consider cryotherapy or curettage

4. Follow-up:

   • Monitor every 1-3 months
   • Consider alternative treatment if no response after 2-3 months
   • Identify and treat nascent lesions to reduce recurrence risk 1