What are the treatment options for molluscum contagiosum?

Treatment of Molluscum Contagiosum

The most effective first-line treatments for molluscum contagiosum are physical removal methods including cryotherapy, curettage, and excision, which should be used to prevent transmission and reduce associated symptoms. 1, 2

Clinical Presentation and Diagnosis

• 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 1
• The condition is caused by a poxvirus and is transmitted through direct skin contact, fomites, or self-inoculation 1
• Lesions typically persist for 6 months to 5 years without treatment 2
• Multiple large lesions with minimal inflammation may indicate an immunocompromised state 2

First-Line Treatment Options

Physical Removal Methods

• Incision and curettage is recommended as an effective first-line treatment 1, 2
• Simple excision or excision and cautery are equally effective first-line options 2
• Cryotherapy with liquid nitrogen is another recommended first-line treatment 1, 3
• When treating, identify and address all lesions, including nascent ones, to reduce the risk of recurrence 1

Topical Chemical Treatments

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children 1
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1

Special Populations and Considerations

Children

• Physical methods and 10% potassium hydroxide are effective in children 1, 3
• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 3
• Watchful waiting is reasonable as lesions typically resolve spontaneously within 6-12 months 3

Pregnancy

• Physical procedures such as cryotherapy are safe during pregnancy 4

Immunocompromised Patients

• Immunosuppressed patients develop more severe and recalcitrant lesions 4
• These patients may require treatment with cidofovir, imiquimod, or interferon 4
• Consider screening for immunocompromised state in patients with extensive or recalcitrant disease 1

Ocular Involvement

• For lesions on or near eyelids with associated conjunctivitis, removal of the lesion is indicated 2
• Monitor for resolution of conjunctivitis after lesion removal, which may take weeks 2

Treatment Algorithm

1. Confirm diagnosis based on characteristic appearance of lesions 2
2. Assess extent of disease and presence of complications such as associated conjunctivitis 2
3. For limited disease in immunocompetent patients, proceed with physical removal methods 2
4. For extensive disease or in immunocompromised patients, consider referral to dermatology 2
5. Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 2

Important Caveats and Pitfalls

• Imiquimod has not shown benefit compared to placebo in randomized controlled trials for molluscum contagiosum and is not recommended 1, 5
• FDA studies showed that imiquimod was not effective for molluscum contagiosum in children, with clearance rates of 24% compared to 26-28% with vehicle 5
• Ranitidine is not recommended for molluscum contagiosum as there is no evidence supporting its efficacy 3
• Cryotherapy may be associated with postinflammatory hyperpigmentation or, uncommonly, scarring 1
• Patients with molluscum contagiosum should be screened for other sexually transmitted infections, especially in cases of genital lesions 4