What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

First-Line Treatment Recommendation

Physical removal methods—including cryotherapy with liquid nitrogen, curettage, or simple excision—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 a primary recommended option, though it may cause postinflammatory hyperpigmentation or rarely scarring 1
• Curettage (incision and curettage or simple excision) is equally effective as first-line therapy 1
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 3

Topical Chemical Treatments:

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1, 4
• 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 for up to 4-5 years 1, 4

For Adults

Physical removal remains first-line:

• Incision and curettage, simple excision, excision with cautery, or cryotherapy are all effective options 2
• For genital molluscum contagiosum, treatment is recommended to reduce sexual transmission risk, prevent autoinoculation, and improve quality of life 5, 6

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

Important Treatment Principles

Comprehensive Lesion Treatment:

• Identify and treat ALL lesions, including nascent ones, to reduce recurrence risk 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 is indicated 2
• Conjunctivitis may require weeks to resolve after lesion elimination 2
• Monitor for resolution of conjunctivitis after lesion removal 1

Treatments NOT Recommended

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
• Two pediatric studies (702 subjects) showed complete clearance rates of 24% with imiquimod versus 26-28% with vehicle, demonstrating no efficacy 7
• The exception is immunocompromised patients with severe disease where it may be considered 5

Ranitidine:

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

Follow-Up Recommendations

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

Prevention

• Hand hygiene with alcohol-based disinfectant or soap and water is the most important method to prevent transmission 1
• Patients with genital molluscum should be screened for other sexually transmitted infections 5