What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

First-Line Physical Removal Methods

Physical removal through cryotherapy, curettage, or excision represents the primary treatment approach for molluscum contagiosum, particularly when lesions are symptomatic, numerous, or located near the eyes. 1

Recommended Physical Treatments

• Cryotherapy with liquid nitrogen is a first-line therapy endorsed by the American Academy of Pediatrics and American Academy of Ophthalmology 1, 2

  • May cause postinflammatory hyperpigmentation or, uncommonly, scarring 1
  • More effective than 5% imiquimod in achieving short-term clinical cure 3

• Incision and curettage, simple excision, or excision with cautery are equally effective first-line options 1, 2

  • These methods allow immediate removal of visible lesions 1

• Identify and treat all lesions, including nascent (early) ones, as this reduces recurrence risk by lowering viral load and allowing the host immune response to eliminate residual virus 1, 2

Topical Chemical Treatments

Effective Options

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1

  • Superior to 5% imiquimod for short-term clinical cure 3
  • More effective than 2.5% potassium hydroxide solution 3

• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 4

Ineffective Options to Avoid

• Imiquimod 5% cream is NOT recommended - high-quality evidence from multiple large trials demonstrates no benefit compared to placebo 1, 5, 3
  • Four studies with 850 participants showed no difference in short-term clinical cure (RR 1.33,95% CI 0.92 to 1.93) 3
  • No difference in medium-term cure at 18 weeks (RR 0.88,95% CI 0.67 to 1.14) or long-term cure at 28 weeks (RR 0.97,95% CI 0.79 to 1.17) 3
  • Causes significantly more application site reactions (RR 1.41,95% CI 1.13 to 1.77) and severe reactions (RR 4.33,95% CI 1.16 to 16.19) 3
  • The American Academy of Pediatrics explicitly states imiquimod has not shown benefit in randomized controlled trials 1

Watchful Waiting

• Spontaneous resolution is a reasonable approach for asymptomatic, limited disease in immunocompetent patients 4, 6
  • Lesions typically persist 6-12 months but can last up to 4-5 years without treatment 1, 6
  • Natural resolution remains a strong method given the lack of convincingly effective treatments 3

Special Clinical 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
  • Monitor for resolution of conjunctivitis after treatment 1

Extensive or Recalcitrant Disease

• Multiple large lesions with minimal inflammation suggest immunocompromised state - screen for immunodeficiency 1, 2
  • Consider dermatology referral for extensive disease 1

Pediatric Considerations

• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 4
  • Physical removal methods or 10% potassium hydroxide are preferred in young children 1, 4

Treatment Algorithm

1. Confirm diagnosis by identifying characteristic skin-colored, whitish, or pink papules with central umbilication and shiny surface 1, 2

2. Assess disease extent: number of lesions, location, presence of symptoms, and conjunctivitis 1, 4

3. For symptomatic, numerous, or periocular lesions: proceed with physical removal (cryotherapy, curettage, or excision) 1, 2

4. For limited asymptomatic disease in immunocompetent patients: watchful waiting is acceptable 4, 3

5. Treat all visible lesions including nascent ones to reduce recurrence 1, 2

6. Alternative topical option: 10% potassium hydroxide solution if physical removal is declined 1

Critical Pitfalls to Avoid

• Do not prescribe imiquimod - it lacks efficacy and causes unnecessary side effects 1, 5, 3
• Do not miss nascent lesions during initial treatment, as this is a common cause of recurrence 1
• Do not neglect periocular lesions - they require active treatment to prevent ocular complications 1
• Do not use salicylic acid in children under 2 years 4

Follow-Up

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
• Screen for other sexually transmitted infections in adults with genital molluscum contagiosum 7