What is the treatment for molluscum contagiosum (a viral skin infection) of the eyelid?

Treatment of Molluscum Contagiosum of the Eyelid

Physical removal of the eyelid lesion is the definitive treatment for molluscum contagiosum affecting the eyelid, with incision and curettage, simple excision, excision with cautery, or cryotherapy all being equally effective first-line options. 1, 2

Clinical Recognition and Pathophysiology

Molluscum contagiosum of the eyelid presents as single or multiple shiny, dome-shaped umbilicated lesions on the eyelid skin or margin, typically causing unilateral follicular conjunctivitis with punctate epithelial keratitis. 1 The conjunctivitis results from viral shedding from the eyelid lesion onto the ocular surface. 1 Long-standing lesions may develop corneal pannus. 1

Treatment Algorithm

Step 1: Confirm Diagnosis and Assess Disease Extent

• Identify the characteristic umbilicated lesions on slit-lamp examination 3
• Look for associated follicular conjunctivitis or punctate keratitis 1
• Critical pitfall: In adults with multiple large lesions and minimal conjunctival inflammation, consider immunocompromised state (particularly HIV) and order appropriate screening 1, 2

Step 2: Physical Removal (First-Line Treatment)

All of the following methods are equally effective: 1, 2

• Incision and curettage (aggressive enough to cause bleeding) 1
• Simple excision 1
• Excision with cautery 1
• Cryotherapy with liquid nitrogen 2, 4
• Novel approach: Curettage using fine forceps under an operating microscope has been reported as beneficial and safe, with complete resolution without scarring 3

Step 3: Identify All Lesions

Examine carefully for nascent (early) lesions and treat them simultaneously to reduce recurrence risk. 1, 2 Reducing the viral load through treatment allows the host immune response to eliminate residual virus. 2, 4

Step 4: Post-Treatment Expectations

• The associated conjunctivitis may require weeks to resolve after lesion elimination 1, 2
• Follow-up is not usually necessary unless conjunctivitis persists 1, 2

What NOT to Use

Imiquimod cream is NOT recommended for molluscum contagiosum. 5 Two randomized, vehicle-controlled trials in 702 pediatric patients demonstrated complete clearance rates of 24% with imiquimod versus 26-28% with vehicle—these studies failed to demonstrate efficacy. 5 The FDA label explicitly states imiquimod "has been evaluated in children ages 2 to 12 years with molluscum contagiosum and these studies failed to demonstrate efficacy." 5

Special Considerations

Immunocompromised Patients

• Multiple and/or large molluscum lesions with relatively little conjunctival inflammation should prompt HIV testing 1, 2
• These patients may require referral to dermatology for extensive disease management 2, 4
• Severe recalcitrant cases in immunocompromised patients may require systemic therapies (cidofovir, interferon) managed by specialists 6

Natural History Without Treatment

• Lesions can spontaneously resolve but may persist for 6 months to 5 years 2, 4, 7
• Treatment is indicated in symptomatic patients to prevent transmission, reduce autoinoculation risk, and resolve associated conjunctivitis 1, 2

Key Clinical Pitfalls

• Do not wait for spontaneous resolution when eyelid lesions are causing conjunctivitis—the conjunctivitis will persist until the lesion is removed 1
• Do not miss nascent lesions during treatment, as this increases recurrence risk 1, 2
• Do not use topical antivirals alone—they are not effective for molluscum contagiosum 1
• Do not overlook immunocompromised status in adults with extensive disease 1, 2