What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

First-Line Treatment Approach

Physical removal methods—including cryotherapy with liquid nitrogen, curettage, simple excision, or excision with cautery—are the recommended first-line treatments for molluscum contagiosum to prevent transmission and reduce symptoms. 1, 2

Treatment Algorithm by Patient Population

For Children and Adolescents

Physical Treatments:

• Cryotherapy with liquid nitrogen is the primary recommended first-line therapy 1
• Curettage, simple excision, or excision with cautery are equally effective alternatives 1
• These methods may cause postinflammatory hyperpigmentation or, uncommonly, scarring 1

Topical Chemical Treatments:

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended as first-line 1
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 3
• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 4

Watchful Waiting:

• This is a reasonable approach as lesions typically resolve spontaneously within 6-12 months, though they can persist up to 4-5 years 1, 4

For Adults

Physical removal remains first-line:

• Incision and curettage, simple excision, excision with cautery, or cryotherapy with liquid nitrogen 2
• For genital molluscum contagiosum, physical treatments (cautery, curettage, cryotherapy) or topical chemical treatments like podophyllotoxin are options 5

For Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt consideration of immunocompromised state 1, 2
• Severe and recalcitrant lesions may require cidofovir, imiquimod, or interferon 5
• Referral to dermatology is necessary for extensive or recalcitrant disease 1, 2

Treatments NOT Recommended

Imiquimod:

• Has not shown benefit compared to placebo in randomized controlled trials and is not recommended 1
• Two pediatric studies (702 subjects) showed complete clearance rates of 24% with imiquimod versus 26-28% with vehicle, demonstrating no efficacy 6

Ranitidine:

• Has no evidence supporting efficacy for molluscum contagiosum and should not be used 4

Critical Treatment Principles

Comprehensive Lesion Treatment:

• Identify and treat all lesions, including nascent ones, to reduce risk of recurrence 1, 2
• Reducing viral load allows the host immune response to eliminate residual virus 1, 2

Special Considerations for Periocular Lesions:

• For lesions on or near eyelids with associated conjunctivitis, removal of the lesion is indicated 2
• Conjunctivitis may require weeks to resolve after lesion elimination 2
• Monitor for resolution of conjunctivitis after lesion removal 1

Follow-Up and Monitoring

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
• For extensive disease, consider screening for immunocompromised state 1, 4

Common Pitfalls to Avoid

• Do not use imiquimod for molluscum contagiosum despite its availability—it lacks efficacy 1, 6
• Avoid salicylic acid in children under 2 years 4
• Do not overlook nascent lesions during treatment, as incomplete treatment increases recurrence risk 1, 2
• In adults with extensive genital lesions, screen for other sexually transmitted infections 5