What are the treatment options for molluscum contagiosum?

Treatment for Molluscum Contagiosum

Physical removal methods including incision and curettage, simple excision, excision and cautery, or cryotherapy are recommended as first-line therapy for molluscum contagiosum to prevent transmission and reduce associated symptoms. 1

Overview of Molluscum Contagiosum

• Molluscum contagiosum is a common, benign viral skin infection presenting as skin-colored, whitish, or pink papules with a central umbilication, typically affecting the trunk, face, and extremities in children and adolescents 2, 3
• The condition is caused by a poxvirus and is transmitted through direct skin contact, fomites, or self-inoculation 1
• Lesions typically persist for 6-12 months but can last up to 4-5 years without treatment 2, 4
• The condition is mostly asymptomatic but may present with pain, itching, redness, or occasional bacterial superinfection 2, 3

Treatment Options

First-Line Treatments

• Physical removal methods:

  • Incision and curettage
  • Simple excision
  • Excision and cautery
  • Cryotherapy with liquid nitrogen 2, 1

• Topical chemical treatments:

  • 10% potassium hydroxide solution has similar efficacy to cryotherapy in children 2, 5
  • Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 2

Important Considerations

• Cryotherapy may be associated with postinflammatory hyperpigmentation or, uncommonly, scarring 2
• Imiquimod has not shown benefit compared to placebo in randomized controlled trials for molluscum contagiosum and is not recommended 2, 6
• For lesions near the eyes with associated conjunctivitis, monitor for resolution of conjunctivitis after lesion removal 1
• In immunocompromised patients (especially those with HIV), lesions may be more extensive and persistent, potentially requiring treatment with cidofovir, imiquimod, or interferon 7

Treatment Algorithm

1. For limited disease in immunocompetent patients:

   • Consider observation for spontaneous resolution if lesions are few and not bothersome 2, 4
   • For lesions in cosmetically important areas or in patients with underlying skin conditions like eczema, use physical removal methods or 10% potassium hydroxide 2

2. For extensive disease:

   • Physical removal methods are still first-line but may need to be done in stages 1, 5
   • Identify and treat all lesions, including nascent ones, to reduce risk of recurrence 1

3. For genital lesions:

   • Physical treatments are preferred 7
   • Screen for other sexually transmitted infections 7

4. For pregnant patients:

   • Physical procedures like cryotherapy are considered safe 7

5. For immunocompromised patients:

   • Consider referral to dermatology for management of extensive or recalcitrant disease 1
   • May require more aggressive or specialized treatments 7

Common Pitfalls and Caveats

• Waiting for spontaneous resolution may be appropriate in some cases, but can take months to years and risks spread of lesions through autoinoculation 4
• Treatment should not be more burdensome than the disease itself; consider patient comfort and preferences 8
• Imiquimod, despite being used in clinical practice, failed to demonstrate efficacy in controlled studies and should not be considered a first-line treatment 2, 6
• In children with extensive disease, systemic absorption of topical treatments should be considered 6
• Follow-up is generally not necessary unless conjunctivitis persists or if lesions are extensive/recurrent 1