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 indicated for bothersome, extensive, or symptomatic lesions. 1

First-Line Approach: Observation vs. Treatment

When to Observe

• Asymptomatic, limited lesions in immunocompetent patients
• Monitor for 3-6 months
• Spontaneous resolution typically occurs within 6-12 months (though complete resolution may take up to 4 years) 1

When to Consider Active Treatment

• Bothersome, extensive, or symptomatic lesions
• Lesions near the eyes (to prevent ocular complications)
• Lesions causing psychological distress
• Cases where spread prevention is critical (e.g., in childcare settings)
• When lesions persist beyond 6-12 months 1

Treatment Options

Physical/Procedural Treatments

1. Cantharidin

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

   Clinical Pearl: Ideal for children as it's painless during application

2. Cryotherapy with liquid nitrogen

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

   Clinical Pearl: Better for older children and adults who can tolerate the procedure

3. Curettage/Excision

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

Topical Treatments

1. 10% Potassium Hydroxide (KOH)

   • Comparable efficacy to cryotherapy (86.6% complete response rate)
   • More effective than 5% imiquimod 1, 2

   Clinical Pearl: Can be applied at home by caregivers

2. Imiquimod

   • Not more effective than placebo for molluscum contagiosum
   • High-quality evidence shows lack of effect compared to vehicle 1, 2
   • FDA label notes clinical trials failed to demonstrate efficacy in children 3
   • May cause application site reactions 3, 2

Special Considerations

Pediatric Patients

• Avoid painful treatments in young children when possible 1
• Consider the child's ability to cooperate with treatment
• FDA label indicates imiquimod was not effective in pediatric clinical trials 3

Lesions Near Eyes

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

Immunocompromised Patients

• May develop severe and recalcitrant lesions
• May require more aggressive treatment approaches 4

Prevention of Spread and Recurrence

Key Prevention Strategies

1. Personal hygiene

   • Regular handwashing, especially after touching lesions
   • Using separate towels for infected individuals
   • Not sharing personal items 1

2. Lesion management

   • Cover lesions with clothing or bandages when possible
   • Avoid direct skin-to-skin contact between infected and uninfected individuals 1

3. Environmental measures

   • Clean and disinfect shared surfaces
   • Wear flip-flops in communal showers
   • Shower thoroughly before and after swimming 1

Follow-up Recommendations

• Regular monitoring every 1-3 months to assess progression
• Consider active treatment if lesions persist beyond 6-12 months or if complications develop 1
• For treated lesions, follow-up to assess response and need for additional treatment

Common Pitfalls to Avoid

1. Failing to recognize that molluscum can spread during bathing/showering if towels or washcloths are shared
2. Overlooking the need for prompt treatment of periocular lesions
3. Using painful treatments in young children unnecessarily when observation is appropriate
4. Continuing with ineffective treatments (like imiquimod) despite evidence showing lack of efficacy 1, 3, 2