What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

For most uncomplicated cases of molluscum contagiosum in immunocompetent patients, observation for spontaneous resolution is recommended as first-line management, with active treatment reserved for specific scenarios such as lesions near the eyes, symptomatic lesions, or extensive disease. 1

Initial Approach to Management

The American Academy of Pediatrics recommends:

• Observation for asymptomatic, limited lesions in immunocompetent patients
• Monitoring for 3-6 months to assess progression
• Active treatment if lesions persist beyond 6-12 months or if complications develop

Indications for Active Treatment

Active treatment should be considered in the following scenarios:

• Lesions near the eyes (to prevent conjunctivitis and potential complications)
• Symptomatic lesions (itching, inflammation)
• Extensive or numerous lesions
• Cosmetically concerning lesions
• Presence of "molluscum eczema" (eczematous eruption around lesions)
• Immunocompromised patients
• Adults with large and multiple lesions (consider evaluation for immunocompromised state)
• Genital lesions (to reduce sexual transmission risk)

Treatment Options

First-line Options:

1. Cantharidin

   • Well-tolerated and effective
   • Applied by healthcare provider
   • Minimal side effects
   • Comparable efficacy to cryotherapy 1, 2

2. 10% Potassium Hydroxide (KOH)

   • 86.6% complete response rate
   • Comparable efficacy to cryotherapy 1

3. Cryotherapy with liquid nitrogen

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

Other Treatment Options:

1. Physical removal methods

   • Incision and curettage: Effective for immediate removal but painful
   • Simple excision: Effective for isolated, larger lesions
   • Excision and cauterization: More definitive but potentially more painful 1

2. Topical treatments

   • Salicylic acid
   • Glycolic acid
   • Tretinoin
   • Adapalene (reported success with minimal irritation) 3
   • Podophyllotoxin 4

3. Imiquimod

   • FDA studies show it is not more effective than placebo for molluscum contagiosum in children 5
   • May be considered for immunosuppressed patients with severe and recalcitrant lesions 4

Special Considerations

Pediatric Patients

• Avoid painful treatments in young children when possible
• Consider the child's ability to cooperate
• The British Association of Dermatologists recommends avoiding painful treatments in young children 1
• Systemic absorption of imiquimod was observed in pediatric studies, with potential side effects including decreased WBC and neutrophil counts 5

Lesions Near Eyes

• Require prompt treatment to prevent ocular complications:
  • Conjunctival scarring
  • Epithelial keratitis
  • Pannus formation 1

Immunocompromised Patients

• Develop more severe and recalcitrant lesions
• May require treatment with cidofovir, imiquimod, or interferon 4

Pregnancy

• Physical procedures (e.g., cryotherapy) are safe to use 4

Prevention of Spread and Recurrence

• 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
• Regular monitoring to identify and treat new lesions 1

Special Populations Guidance

• Food Service Workers, Athletes/Contact Sports Professionals, and Childcare Workers:
  • Cover lesions
  • Maintain strict hand hygiene
  • Avoid direct skin contact with others 1

Treatment Algorithm

1. Initial assessment: Determine if lesions are asymptomatic/limited or symptomatic/extensive
2. For asymptomatic, limited lesions: Observation for 3-6 months
3. For lesions requiring treatment:
   • First choice: Cantharidin (well-tolerated, effective, minimal side effects)
   • Alternative options: 10% KOH or cryotherapy
   • For children: Consider less painful options like cantharidin or 10% KOH
   • For lesions near eyes: Prompt treatment with appropriate method
   • For immunocompromised patients: Consider cidofovir, imiquimod, or interferon

Important Caveats

• Spontaneous resolution typically occurs in 6-12 months but can take up to 4 years 1
• No single treatment is uniformly effective for all patients 2
• Imiquimod has not shown efficacy superior to placebo in pediatric studies 5
• Treatment should be considered to prevent spread, reduce discomfort, and improve quality of life 6