What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

For molluscum contagiosum, observation for spontaneous resolution is recommended as first-line management for asymptomatic, limited lesions in immunocompetent patients, with active treatment reserved for bothersome, extensive, or symptomatic lesions. 1

First-Line Approach: Observation

• Spontaneous resolution typically occurs within 6-12 months, though complete resolution may take up to 4 years 1
• Observation is appropriate for most uncomplicated cases, especially in immunocompetent patients with limited lesions
• Regular monitoring every 1-3 months is recommended to assess progression 1

When to Consider Active Treatment

Active treatment should be considered in the following situations:

• Lesions persist beyond 6-12 months
• Lesions are bothersome, extensive, or symptomatic
• Lesions are near the eyes (to prevent ocular complications)
• Patient has atopic dermatitis (increased risk of spread)
• For social or cosmetic reasons
• To prevent transmission to others

Treatment Options

Physical Treatments (First-line for those requiring intervention)

1. Cantharidin

   • Well-tolerated and effective for bothersome lesions 1
   • Applied by healthcare provider
   • Minimal side effects
   • Clinical pearl: Particularly useful in children as it's painless during application 2

2. Cryotherapy with liquid nitrogen

   • 93.3% complete response rate 1
   • Potential complications: postinflammatory hyperpigmentation or scarring
   • Consider local anesthesia before treatment for painful lesions 1
   • Not recommended as first-line in young children due to pain 1

3. Curettage/Excision

   • Effective for immediate removal of visible lesions 1
   • Drawbacks: Painful, potentially frightening for young children
   • Best for isolated, larger lesions

Topical Chemical Treatments

1. 10% Potassium Hydroxide (KOH)

   • Comparable efficacy to cryotherapy (86.6% complete response rate) 1
   • More effective than 5% imiquimod based on available evidence 3
   • Low-cost option with reasonable efficacy

2. Imiquimod

   • Not more effective than placebo according to high-quality evidence 1, 3
   • FDA studies show no significant difference between imiquimod and vehicle in pediatric patients 4
   • More application site reactions compared to vehicle 3

Special Considerations

Pediatric Patients

• Avoid painful treatments in young children 1
• Consider the child's ability to cooperate with treatment
• Cantharidin is often well-tolerated in children 2
• Imiquimod has not demonstrated efficacy in children with molluscum contagiosum 4

Lesions Near Eyes

• Require prompt treatment to prevent ocular complications 1
• Complications can include conjunctival scarring, epithelial keratitis, and pannus formation
• Consultation with ophthalmology may be appropriate

Immunocompromised Patients

• May develop severe and recalcitrant lesions 5
• May require more aggressive treatment approaches

Prevention of Spread and Recurrence

• Cover visible lesions with clothing or bandages when possible 1
• Maintain good hand hygiene, especially after touching lesions
• Avoid sharing personal items like towels and clothing
• Use separate towels for infected individuals
• Avoid direct skin-to-skin contact between infected and uninfected individuals
• Clean and disinfect shared surfaces that may come in contact with lesions
• Wear flip-flops or sandals in communal showers 1

Treatment Algorithm

1. For asymptomatic, limited lesions in immunocompetent patients:

   • Observation with monitoring every 1-3 months

2. For lesions requiring treatment (symptomatic, extensive, near eyes, or persistent):

   • First-line: Cantharidin application by healthcare provider
   • Alternative: 10% Potassium hydroxide solution
   • For older children/adults: Consider cryotherapy

3. For isolated, larger lesions:

   • Consider curettage or simple excision

4. For lesions near eyes:

   • Prompt treatment to prevent ocular complications
   • Consider ophthalmology consultation

Common Pitfalls to Avoid

• Failing to recognize that molluscum can spread during bathing/showering if towels or washcloths are shared 1
• Using imiquimod as first-line therapy despite evidence showing it's not more effective than placebo 1, 3
• Using painful treatments in young children unnecessarily 1
• Neglecting to monitor for new lesions during the treatment period
• Overlooking the need for specific precautions in special populations (athletes, childcare workers, food service workers) 1