What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

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

Disease Overview

• Molluscum contagiosum presents as characteristic skin-colored, whitish, or pink papules with a shiny surface and central umbilication, typically affecting the trunk, face, and extremities in children and adolescents 1, 2
• 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 1
• The condition is mostly asymptomatic but may present with pain, itching, redness, or occasional bacterial superinfection 1

First-Line Treatment Options

• Physical removal methods:
  • Cryotherapy with liquid nitrogen 1
  • Incision and curettage 1
  • Simple excision 1
  • Excision and cautery 1
• Chemical treatments:
  • 10% potassium hydroxide solution (similar efficacy to cryotherapy in children) 1
  • Cantharidin (shown effectiveness in observational studies) 1

Important Treatment Considerations

• Identify and treat all lesions, including nascent ones, to reduce risk of recurrence 1
• Reducing viral load often allows the host immune response to eliminate residual virus 1
• Cryotherapy may be associated with postinflammatory hyperpigmentation or, uncommonly, scarring 1
• If lesions are near the eyes with associated conjunctivitis, monitor for resolution of conjunctivitis after lesion removal 1
• In immunocompromised patients, lesions may be more extensive and require more aggressive treatment 2

Treatment Cautions

• Imiquimod has not shown benefit compared to placebo in randomized controlled trials and is not recommended 1
• FDA labeling specifically states that imiquimod cream "has been evaluated in children ages 2 to 12 years with molluscum contagiosum and these studies failed to demonstrate efficacy" 3
• Multiple large studies provide moderate-quality evidence for a lack of effect of 5% imiquimod compared to vehicle (placebo) 4

Special Populations

• If extensive or recalcitrant disease is present, consider screening for immunocompromised state 1
• Referral to dermatology may be necessary for examination of other suspicious lesions or treatment of extensive disease 1
• In pregnancy, physical procedures like cryotherapy are considered safe 5
• Immunosuppressed patients may develop severe and recalcitrant molluscum lesions that may require treatment with cidofovir, imiquimod or interferon 5

Emerging Treatments

• Two experimental topical drugs show promise in recent phase III studies:
  • VP-102 (standardized preparation of topical cantharidin) 6
  • SB206 (topical nitric oxide-releasing product containing berdazimer) 6
  • These treatments have potential to become the first FDA-approved therapies for molluscum contagiosum 6

Treatment Algorithm

1. Initial approach: Consider physical removal methods (cryotherapy, curettage) or 10% potassium hydroxide as first-line therapy 1
2. For widespread lesions: Consider topical treatments like potassium hydroxide or cantharidin 1, 5
3. For periocular lesions: Monitor for associated conjunctivitis and treat lesions to resolve both conditions 1
4. For recalcitrant cases: Consider referral to dermatology and evaluation for immunocompromised state 1