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 the first-line approach, with active treatment reserved for bothersome, extensive, or symptomatic lesions. 1

First-Line Management Approach

• Observation for spontaneous resolution

  • Appropriate for asymptomatic, limited lesions in immunocompetent patients
  • Spontaneous resolution typically occurs within 6-12 months (may take up to 4 years)
  • Regular monitoring every 1-3 months to assess progression 1

• Prevention measures during observation period

  • Cover lesions when possible
  • Maintain good hand hygiene, especially after touching lesions
  • Avoid sharing personal items like towels and clothing
  • Wear flip-flops in communal showers
  • Clean shared surfaces that may contact lesions 1

Treatment Indications

Consider active treatment when:

• Lesions are bothersome, extensive, or symptomatic
• Lesions persist beyond 6-12 months
• Lesions are near the eyes (to prevent ocular complications)
• Patient/parent preference due to social or cosmetic concerns
• Risk of spread to others is high (e.g., athletes, childcare workers) 1

Treatment Options

Physical Treatments

1. Cantharidin

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

2. Cryotherapy with liquid nitrogen

   • 93.3% complete response rate
   • Potential complications: postinflammatory hyperpigmentation or scarring
   • Consider local anesthesia for painful lesions
   • May not be suitable for young children due to pain 1, 2, 3

3. Incision and curettage

   • Effective for immediate removal of visible lesions
   • Painful and potentially frightening for young children 1

Topical Treatments

1. 10% Potassium hydroxide (KOH)

   • 86.6% complete response rate, comparable to cryotherapy
   • Inexpensive and provides better cosmetic results than cryotherapy
   • Applied twice daily until lesions resolve 1, 2

2. Imiquimod

   • Not more effective than placebo for molluscum contagiosum
   • FDA studies in children showed no efficacy advantage over vehicle
   • Can cause application site reactions 1, 4, 5

Special Considerations

Periocular Lesions

• Require prompt treatment to prevent ocular complications
• Potential complications include conjunctival scarring, epithelial keratitis, and pannus formation
• Hyperfocal cryotherapy may be effective for periocular lesions 1, 6

Pediatric Patients

• FDA studies show imiquimod is not effective for molluscum in children aged 2-12 years 4
• Avoid painful treatments in young children when possible
• Consider the child's ability to cooperate with treatment 1

Secondary Infection

• For molluscum with secondary cellulitis, treat with antibiotics targeting Gram-positive bacteria (especially streptococci and Staphylococcus aureus)
• Oral beta-lactams for mild cellulitis (where CA-MRSA is not prevalent)
• Parenteral antibiotics for more severe infections 1

Treatment Algorithm

1. Initial assessment: Determine if lesions are symptomatic, extensive, near eyes, or causing distress
2. For limited, asymptomatic lesions: Observation with prevention measures
3. For lesions requiring treatment:
   • First choice: Cantharidin (well-tolerated, effective, minimal side effects)
   • Alternative: 10% KOH (comparable efficacy, better cosmetics than cryotherapy)
   • For older children/adults: Cryotherapy (high efficacy but potentially painful)
   • For isolated larger lesions: Simple excision or curettage

Common Pitfalls and Caveats

• Imiquimod, despite being commonly prescribed, has not shown efficacy superior to placebo in clinical trials 1, 4, 5
• Painful treatments may cause significant distress in young children and should be avoided when possible
• Treatment near eyes requires special care to avoid ocular complications
• Even with treatment, recurrence is common, and patients should be informed about this possibility
• Immunocompromised patients may require more aggressive and repeated treatments (not covered in this evidence)