What is the treatment for genital molluscum contagiosum?

Treatment for Genital Molluscum Contagiosum

For genital molluscum contagiosum, physical removal methods (cryotherapy, curettage, or excision) are the recommended first-line treatments to prevent sexual transmission and reduce autoinoculation risk, though watchful waiting for spontaneous resolution is an acceptable alternative in immunocompetent patients. 1, 2, 3

Treatment Approach

First-Line Physical Treatments

Physical removal methods are most effective and should be prioritized:

• Cryotherapy with liquid nitrogen applied every 1-2 weeks until lesions clear 1, 2, 3
• Curettage (incision and curettage or simple excision) provides immediate removal 1, 2
• Excision and cautery is equally effective as other physical methods 2

These methods directly reduce viral load and allow the host immune response to eliminate residual virus 1, 2.

Topical Chemical Treatments

If physical methods are not feasible or preferred:

• Podophyllotoxin 0.5% solution or gel can be used, though evidence is primarily from genital wart studies rather than molluscum-specific trials 3
• Imiquimod 5% cream is mentioned in European guidelines for genital molluscum, but failed to demonstrate efficacy in pediatric molluscum trials and showed no benefit compared to placebo 4, 3

Important caveat: The FDA label explicitly states that imiquimod failed to demonstrate efficacy for molluscum contagiosum in two randomized controlled trials (complete clearance rates of 24% with imiquimod vs. 26-28% with vehicle) 4.

Watchful Waiting

• Spontaneous resolution is acceptable in immunocompetent patients who prefer to avoid treatment, as lesions typically resolve within 6 months to 5 years 1, 3, 5
• However, treatment is generally recommended for genital lesions to reduce sexual transmission risk and prevent autoinoculation 3, 5, 6

Treatment Algorithm

1. Confirm diagnosis by identifying characteristic dome-shaped, smooth-surfaced papules (2-5 mm) with central umbilication in the genital area 3

2. Assess disease extent and immune status:

   • Multiple large lesions with minimal inflammation suggest immunocompromised state and warrant HIV/immunodeficiency screening 1, 2
   • Check for associated conjunctivitis if lesions are near eyes 1, 2

3. Select treatment based on patient factors:

   • For limited disease in immunocompetent adults: Proceed with cryotherapy or curettage 1, 2
   • For extensive or recalcitrant disease: Consider dermatology referral 1, 2
   • For immunocompromised patients: May require cidofovir, imiquimod, or interferon for severe cases 3

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

5. Screen for other sexually transmitted infections, as genital molluscum is a marker for sexual transmission 3, 6

Special Considerations

• Pregnancy: Physical procedures like cryotherapy are safe during pregnancy 3
• Periocular lesions: Require active treatment to prevent or resolve associated conjunctivitis, which may take weeks to clear after lesion removal 1, 2
• Follow-up: Generally not necessary unless conjunctivitis persists or new lesions develop 1, 2

Critical Pitfalls to Avoid

• Do not rely on imiquimod as first-line therapy for molluscum contagiosum—it has failed to demonstrate efficacy in controlled trials despite being mentioned in some guidelines 4
• Do not miss nascent lesions during initial treatment, as this is a common cause of recurrence 1
• Do not overlook immunocompromised states when patients present with extensive, large, or recalcitrant lesions 1, 2
• Do not assume treatment is mandatory—spontaneous resolution is acceptable if the patient understands transmission risks and prefers observation 3, 5