What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

Physical removal methods—including curettage, excision, or cryotherapy—are the recommended first-line treatments for molluscum contagiosum, particularly when lesions are symptomatic, numerous, or located near the eyes. 1, 2

First-Line Physical Treatments

Recommended Physical Methods

• Incision and curettage, simple excision, or excision with cautery are equally effective first-line options recommended by the American Academy of Ophthalmology for both children and adults 1, 2
• Cryotherapy with liquid nitrogen is a recommended first-line treatment but may cause postinflammatory hyperpigmentation or, uncommonly, scarring 1, 2
• When treating, identify and address all lesions including nascent (early) ones to reduce recurrence risk, as reducing viral load allows the host immune response to eliminate residual virus 1, 2

Topical Chemical Treatments

Effective Topical Options

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 3

Ineffective Topical Treatments

• Imiquimod has NOT shown benefit compared to placebo in randomized controlled trials and is not recommended by the American Academy of Pediatrics 1
• The FDA label explicitly states that imiquimod cream has been evaluated in children ages 2-12 years with molluscum contagiosum and these studies failed to demonstrate efficacy 4

Treatment Algorithm by Clinical Scenario

For Periocular Lesions

• Physical removal is imperative when lesions are on or near the eyelids with associated conjunctivitis to prevent ocular complications 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
• Follow-up is necessary if conjunctivitis persists 1

For Extensive or Recalcitrant Disease

• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 2
• Consider referral to dermatology for extensive disease or examination of suspicious lesions 1, 2
• In immunosuppressed patients, severe and recalcitrant lesions may require cidofovir, imiquimod, or interferon 5

For Limited Disease in Immunocompetent Patients

• Watchful waiting is reasonable as lesions typically resolve spontaneously within 6-12 months, though they can persist for 6 months to 5 years 1, 3
• Treatment is recommended to prevent transmission, reduce autoinoculation risk, and improve quality of life 6

Critical Pitfalls to Avoid

• Do not miss nascent lesions during initial treatment, as their omission is a frequent cause of recurrence 1
• Do not use salicylic acid in children under 2 years due to risk of systemic toxicity 3
• Do not use ranitidine or other H2 blockers for molluscum contagiosum—there is no evidence supporting their efficacy for this condition 3
• Do not neglect periocular lesions, as they require active treatment to prevent ocular complications 1

Special Populations

Pregnancy

• Physical procedures such as cryotherapy are safe to use during pregnancy 5

Sexually Transmitted Cases

• Patients with genital molluscum contagiosum should be offered screening for other sexually transmitted infections 5
• Treatment is particularly recommended in sexually active individuals to reduce transmission risk 6, 5