Treatment Options for Molluscum Contagiosum
First-Line Treatment Recommendation
Physical removal methods—including curettage, simple excision, or cryotherapy with liquid nitrogen—are the recommended first-line treatments for molluscum contagiosum in both children and adults. 1, 2
Treatment Algorithm by Clinical Scenario
For Immunocompetent Children and Adults
Physical Destruction Methods (First-Line):
- Curettage (incision and curettage) is highly effective and recommended as primary therapy 1, 2
- Cryotherapy with liquid nitrogen is equally effective as first-line treatment 1, 3
- Simple excision or excision with cautery are alternative physical removal options 1, 2
- These methods prevent transmission, reduce symptoms, and allow the host immune response to eliminate residual virus 1
Topical Chemical Treatments (Alternative Options):
- 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1, 3
- Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 3, 4
- Podophyllotoxin is an option for genital molluscum in adults 5
Critical Treatment Principles
Identify and treat ALL lesions, including nascent (early) ones, during the initial treatment session to reduce recurrence risk. 1, 2 Missing early lesions is a common pitfall that leads to treatment failure 1.
Reducing viral load through comprehensive treatment allows the host immune response to clear residual virus 1, 2.
Special Populations and Situations
Periocular Lesions with Conjunctivitis:
- Physical removal is imperative when lesions are on or near eyelids with associated conjunctivitis 1, 2
- Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
- Monitor for resolution of conjunctivitis after treatment 1
Immunocompromised Patients:
- Multiple large lesions with minimal conjunctival inflammation should prompt screening for immunodeficiency 1, 2
- Consider referral to dermatology for extensive or recalcitrant disease 1, 2
- Severe cases may require cidofovir, imiquimod, or interferon 5
Pregnant Patients:
- Physical procedures such as cryotherapy are safe during pregnancy 5
Children Under 2 Years:
- Salicylic acid is contraindicated due to risk of systemic toxicity 3
Treatments NOT Recommended
Imiquimod:
- Has NOT shown benefit compared to placebo in randomized controlled trials and is not recommended by the American Academy of Pediatrics 1
- FDA-approved studies in 702 pediatric patients with molluscum contagiosum (ages 2-12) showed complete clearance rates of 24% with imiquimod versus 26-28% with vehicle—demonstrating no efficacy 6
- The FDA label explicitly states: "Imiquimod cream has been evaluated in children ages 2 to 12 years with molluscum contagiosum and these studies failed to demonstrate efficacy" 6
Ranitidine:
- No evidence supports ranitidine for molluscum contagiosum; it is not included in any current guidelines 3
Watchful Waiting as an Option
Observation without treatment is reasonable in asymptomatic, immunocompetent patients, as lesions typically resolve spontaneously within 6-12 months, though can persist up to 4-5 years 1, 3, 7, 4.
Active treatment is indicated when:
- Lesions are symptomatic (painful, itchy, inflamed) 1
- Multiple or numerous lesions are present 1, 2
- Lesions cause associated conjunctivitis 1, 2
- Prevention of transmission is desired 7, 8
- Patient has atopic dermatitis (increased risk of widespread involvement) 4, 9
Important Caveats and Pitfalls
Cryotherapy may cause postinflammatory hyperpigmentation or, uncommonly, scarring, particularly in darker skin types 1.
Do not overlook nascent lesions during initial treatment—examine carefully for early lesions as treating them simultaneously reduces recurrence 1, 2.
Screen for sexually transmitted infections in adults with genital molluscum contagiosum 5.
Follow-up is generally not necessary unless conjunctivitis persists or new lesions develop 1, 2.