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 and Prevention

Molluscum contagiosum is a benign viral infection that typically resolves spontaneously within 6-12 months in immunocompetent individuals, though complete resolution can take up to 4 years 1. The American Academy of Pediatrics recommends:

• Observation for asymptomatic, limited lesions in immunocompetent patients
• Monitoring for 3-6 months to assess progression
• Implementing prevention measures to avoid spread

Prevention Measures

• Regular handwashing, especially after touching lesions
• Using separate towels for infected individuals
• Covering lesions before participating in sports or swimming
• Avoiding direct skin-to-skin contact between infected and uninfected individuals
• Cleaning and disinfecting shared surfaces

Treatment Indications

Consider active treatment in the following situations:

• Lesions persist beyond 6-12 months
• Extensive or symptomatic lesions
• Lesions near the eyes (to prevent ocular complications)
• Significant psychosocial distress
• High risk of transmission to others

Treatment Options

1. Physical Treatments

• Cantharidin: Well-tolerated and effective treatment applied by healthcare providers with minimal side effects 1, 2
• Cryotherapy with liquid nitrogen: 93.3% complete response rate, but may cause postinflammatory hyperpigmentation or scarring 1
• Curettage: Effective for immediate removal of visible lesions but painful and potentially frightening for young children 1

2. Chemical Treatments

• 10% Potassium Hydroxide (KOH): Comparable efficacy to cryotherapy (86.6% complete response rate) 1
• Simple excision: Effective for isolated, larger lesions 1
• Excision and cauterization: More definitive but potentially more painful 1

3. Immunomodulators

• Imiquimod: Clinical evidence shows it is not more effective than placebo for molluscum contagiosum 1, 3, 4
  • High-quality evidence from multiple studies demonstrated that 5% imiquimod was no more effective than vehicle in achieving clinical cure 4
  • FDA labeling specifically notes that imiquimod failed to demonstrate efficacy in two randomized controlled trials involving 702 pediatric subjects with molluscum contagiosum 3

Special Considerations

Children

• Avoid painful treatments in young children when possible 1
• Consider local anesthesia before painful procedures like cryotherapy 1
• The British Association of Dermatologists recommends considering the child's ability to cooperate when selecting treatment 1

Lesions Near Eyes

• Require prompt treatment to prevent ocular complications such as conjunctival scarring, epithelial keratitis, and pannus formation 1

Immunocompromised Patients

• May develop severe and recalcitrant lesions requiring more aggressive treatment 5

Treatment Algorithm

1. For asymptomatic, limited lesions in immunocompetent patients:

   • Observation with monitoring every 1-3 months
   • Implementation of prevention measures

2. For lesions requiring intervention (based on location, symptoms, or patient preference):

   • First choice: Cantharidin application by healthcare provider
   • Alternative options: 10% Potassium hydroxide or cryotherapy

3. For lesions near the eyes:

   • Prompt referral for treatment to prevent ocular complications

4. For extensive or recalcitrant lesions:

   • Consider combination therapy or more aggressive physical removal

Common Pitfalls to Avoid

• Overlooking transmission risk: Failing to recognize that molluscum can spread during bathing/showering if towels or washcloths are shared 1
• Inappropriate use of imiquimod: Despite being commonly prescribed, high-quality evidence shows imiquimod is not more effective than placebo 1, 3, 4
• Aggressive treatment in young children: Painful treatments may cause unnecessary trauma when observation is often appropriate 1
• Missing ocular involvement: Lesions near the eyes require prompt treatment to prevent complications 1