What are the treatment options for molluscum contagiosum?

Treatment of 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, simple excision, or excision and cautery are equally effective physical removal methods recommended by the American Academy of Ophthalmology 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 Approach Based on Patient Population

For Children:

• Cryotherapy or 10% potassium hydroxide solution are recommended first-line treatments 1
• Avoid using salicylic acid in children under 2 years due to risk of systemic toxicity 3
• Physical removal methods may be more difficult to perform in young children due to pain and anxiety 1

For Adults:

• Physical removal methods (incision and curettage, simple excision, excision and cautery, cryotherapy) are recommended first-line treatments 2
• For genital lesions, treatment is recommended to reduce the risk of sexual transmission 4

For Immunocompromised Patients:

• More aggressive treatment may be needed as lesions tend to be more extensive and persistent 2, 4
• Multiple large lesions with minimal inflammation should prompt consideration of an immunocompromised state 2

Important Clinical 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 1, 2
• Molluscum contagiosum typically persists for 6 months to 5 years without treatment 1, 2, 5
• 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

Treatments to Avoid or Use with Caution

• Imiquimod has not shown benefit compared to placebo in randomized controlled trials for molluscum contagiosum and is not recommended by the American Academy of Pediatrics 1
• FDA data shows that imiquimod cream failed to demonstrate efficacy in two randomized, vehicle-controlled trials involving 702 pediatric subjects with molluscum contagiosum 6
• Ranitidine is not recommended for molluscum contagiosum as there is no evidence supporting its efficacy for this condition 3

Treatment Algorithm

1. Confirm diagnosis based on characteristic appearance of lesions (skin-colored, whitish, or pink 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:
   • Choose from 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

Pitfalls and Caveats

• Cryotherapy may be associated with postinflammatory hyperpigmentation or, uncommonly, scarring 1
• Severe local skin reactions with imiquimod in pediatric studies included erythema (28%), edema (8%), scabbing/crusting (5%), flaking/scaling (5%), erosion (2%) and weeping/exudate (2%) 6
• Watchful waiting is a reasonable approach as molluscum contagiosum typically resolves spontaneously, but this may take months to years 1, 3, 5
• For patients with skin of color, be aware that certain treatments like cryotherapy may cause more noticeable post-inflammatory hyperpigmentation 7