What are the treatment options for molluscum contagiosum?

Treatment Options 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, 2

First-Line Treatment Options

• Cryotherapy with liquid nitrogen is an effective first-line treatment for molluscum contagiosum in both children and adults 1, 2
• Incision and curettage is recommended as an effective physical removal method according to the American Academy of Ophthalmology 2
• Simple excision or excision and cautery are equally effective first-line options 1, 2
• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1

Treatment Considerations

• When treating, identify and address all lesions, including nascent ones, to reduce the risk of recurrence 1, 2
• Reducing viral load through treatment often allows the host immune response to eliminate residual virus 2
• For lesions on or near eyelids with associated conjunctivitis, removal of the lesion is indicated, and the conjunctivitis may require weeks to resolve after elimination of the lesion 2
• Watchful waiting is a reasonable approach as molluscum contagiosum typically resolves spontaneously within 6-12 months, though lesions may persist for up to 4-5 years without treatment 1, 3

Special Populations

Children

• For children, cryotherapy and 10% potassium hydroxide are recommended first-line treatments 1
• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 4
• Imiquimod cream has failed to demonstrate efficacy in clinical trials for molluscum contagiosum in children and is not recommended 1, 5

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt consideration of an immunocompromised state 1, 2
• For extensive or recalcitrant disease, consider screening for immunocompromised state and referral to dermatology 1, 2
• Immunocompromised patients may require more aggressive treatment approaches as lesions tend to be more persistent 3

Treatment Pitfalls and Caveats

• Cryotherapy may be associated with postinflammatory hyperpigmentation or, uncommonly, scarring 1
• Destructive therapy may be poorly tolerated in children 6
• Ranitidine is not recommended for molluscum contagiosum as there is no evidence supporting its efficacy 4
• Imiquimod has not shown benefit compared to placebo in randomized controlled trials for molluscum contagiosum 1, 5
• FDA labeling specifically states that imiquimod cream studies failed to demonstrate efficacy in children with molluscum contagiosum 5

Treatment Algorithm

1. Confirm diagnosis based on characteristic appearance of lesions (dome-shaped, smooth-surfaced, pearly papules with central umbilication) 1, 2
2. Assess extent of disease and presence of complications such as associated conjunctivitis 1, 2
3. For limited disease in immunocompetent patients:
   • Consider physical removal methods (cryotherapy, curettage, excision) 1, 2
   • For children, consider 10% potassium hydroxide as an alternative 1
4. For extensive disease or in immunocompromised patients, consider referral to dermatology 1, 2
5. Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2