Steroids Worsen Molluscum Contagiosum
Topical corticosteroids should be avoided in molluscum contagiosum as they can worsen the infection by suppressing the local immune response and potentially lead to more extensive disease. 1, 2
Mechanism of Steroid Effects on Molluscum Contagiosum
- Molluscum contagiosum virus (MCV) naturally evades immune surveillance through viral proteins that inhibit or dampen several immune pathways, contributing to its prolonged survival in the epidermis 3
- Topical corticosteroids further suppress the local inflammatory response that is necessary for the body to clear the infection 2
- Corticosteroids may potentiate the spread of the primary MCV infection by inhibiting the natural immune response 2
- The "beginning of the end" (BOTE) inflammatory response, which is a sign of the body's immune system fighting the infection, may be suppressed by steroids 3
Clinical Implications
- Patients with cellular immune deficiency, including those on corticosteroids, are predisposed to more extensive and persistent molluscum contagiosum infections 4
- Eczematous id reactions around molluscum papules represent an immunologically mediated host response to MCV and often signal the beginning of regression 2
- Suppressing these reactions with topical steroids may prolong the infection, which typically lasts 6-12 months but can persist for up to 4-5 years 1, 5
- In immunocompromised patients, molluscum contagiosum can present with multiple large lesions and atypical presentations 6
Management Recommendations
- First-line treatments should focus on physical removal methods such as cryotherapy, curettage, or excision rather than immunosuppressive treatments 1
- 10% potassium hydroxide solution is recommended as an effective topical chemical treatment with similar efficacy to cryotherapy 1
- For eczematous id reactions that are symptomatic and require treatment, use only short-course treatments of topical corticosteroids and avoid prolonged use 2
- Cantharidin (0.7%) is an FDA-approved treatment option that may affect the immune avoidance mechanisms of MCV 3, 7
- Imiquimod has not shown benefit compared to placebo in randomized controlled trials and is not recommended by the American Academy of Pediatrics 1, 8
Special Considerations
- In patients already on systemic corticosteroids for other conditions, more aggressive treatment of molluscum contagiosum may be necessary due to their compromised immune response 4
- Patients with atopic dermatitis are more susceptible to molluscum contagiosum and may require special attention to prevent spread and superinfection 7
- For extensive or recalcitrant disease, consider screening for an immunocompromised state 1
- Molluscum contagiosum near the eyes may cause conjunctivitis that requires monitoring after lesion removal 1