What are the treatment options for molluscum contagiosum?

Treatment of Molluscum Contagiosum

Recommended First-Line Approach

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, 3

Treatment Algorithm by Clinical Context

For Immunocompetent Children and Adolescents

Physical Removal Methods:

• Cryotherapy with liquid nitrogen is the primary recommended option, though it may cause postinflammatory hyperpigmentation or rarely scarring 2
• Curettage (incision and curettage or simple excision with or without cautery) provides effective removal 1, 3
• Treat all visible lesions, including nascent ones, to reduce recurrence risk, as reducing viral load allows the host immune response to eliminate residual virus 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 2
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 2, 4
• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 2

Watchful Waiting:

• Spontaneous resolution typically occurs within 6-12 months but can take up to 4-5 years 2, 5
• This is a reasonable approach for asymptomatic cases, though treatment is often preferred to prevent transmission and autoinoculation 5

For Adults (Including Sexually Transmitted Cases)

Physical Removal Methods (First-Line):

• Incision and curettage, simple excision, excision with cautery, or cryotherapy are equally effective first-line options per the American Academy of Ophthalmology 3, 6
• Identify and treat all lesions including nascent ones to reduce recurrence 3

For Genital Molluscum:

• Physical procedures (cautery, curettage, cryotherapy) are recommended 6
• Topical podophyllotoxin or imiquimod may be considered, though evidence is limited 6
• Screen for other sexually transmitted infections in patients with genital molluscum 6

For Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 3
• Severe and recalcitrant lesions may require cidofovir, imiquimod, or interferon 6
• Referral to dermatology is necessary for extensive or recalcitrant disease 1, 3

Special Considerations

Periocular Lesions

• Remove lesions on or near eyelids to prevent associated conjunctivitis 1, 3
• Conjunctivitis may require weeks to resolve after lesion elimination 3
• Monitor for persistent conjunctivitis requiring follow-up 1

Pregnancy

• Physical procedures such as cryotherapy are safe during pregnancy 6

Atopic Dermatitis

• Patients with atopic dermatitis may develop widespread involvement requiring more aggressive treatment 7, 4

Treatments NOT Recommended

Imiquimod for Molluscum in Children:

• Imiquimod has not shown benefit compared to placebo in randomized controlled trials and is not recommended by the American Academy of Pediatrics 1
• FDA labeling specifically states that studies in children ages 2-12 years with molluscum contagiosum failed to demonstrate efficacy, with complete clearance rates of 24% for imiquimod versus 26-28% for vehicle 8

Ranitidine:

• No evidence supports ranitidine for molluscum contagiosum; current guidelines from the American Academy of Pediatrics and American Academy of Dermatology do not include it among recommended treatments 2

Clinical Pitfalls to Avoid

• Do not use salicylic acid in children under 2 years due to systemic toxicity risk 2
• Do not assume limited disease in patients with multiple large lesions and minimal inflammation—this may indicate immunocompromised state requiring further evaluation 1, 3
• Do not neglect nascent lesions during treatment, as incomplete treatment increases recurrence risk 1, 3
• Follow-up is generally not necessary unless conjunctivitis persists or new lesions develop 1, 3