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, as they prevent transmission and reduce symptoms. 1, 2

First-Line Physical Treatments

The American Academy of Ophthalmology prioritizes physical removal as the primary therapeutic approach 1, 2:

• Incision and curettage is highly effective for removing individual lesions 2
• Simple excision or excision with cautery provides equally effective alternatives 1, 2
• Cryotherapy with liquid nitrogen serves as another first-line option, though it carries risk of postinflammatory hyperpigmentation or scarring 1, 2

When treating, identify and remove ALL lesions including nascent (early) ones to reduce recurrence risk—this is a critical step often overlooked 1, 2. Reducing viral load through comprehensive treatment allows the host immune response to eliminate residual virus 1, 2.

Topical Chemical Treatments (Pediatric Patients)

For children who cannot tolerate physical procedures 1:

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in pediatric patients 1
• Cantharidin shows effectiveness in observational studies, though randomized trial evidence is limited 1
• Salicylic acid is contraindicated in children under 2 years due to systemic toxicity risk 3

Treatments NOT Recommended

• Imiquimod has NOT shown benefit compared to placebo in randomized controlled trials and failed to demonstrate efficacy in two large pediatric studies involving 702 children 1, 4
• Ranitidine has no evidence supporting its use for molluscum contagiosum 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, 2
• Follow-up monitoring is necessary if conjunctivitis persists 1, 2

Immunocompromised Patients

• Multiple large lesions with minimal conjunctival inflammation should prompt screening for immunodeficiency 1, 2
• Consider dermatology referral for extensive or recalcitrant disease 1, 2

Pregnant Patients

• Physical procedures like cryotherapy are safe during pregnancy 5

Treatment Algorithm

1. Confirm diagnosis by identifying characteristic dome-shaped, umbilicated papules that are skin-colored, whitish, or pink 1, 2

2. Assess disease extent: location, number of lesions, presence of symptoms, and periocular involvement 1, 2

3. For limited disease in immunocompetent patients: proceed with physical removal (curettage, excision, or cryotherapy) 1, 2

4. For extensive disease: consider dermatology referral and screen for immunocompromised state 1, 2

5. Treat all visible lesions including nascent ones during the initial visit to minimize recurrence 1, 2

Critical Pitfalls to Avoid

• Do not miss nascent lesions—examine carefully during initial treatment as their omission is a common cause of recurrence 1
• Do not use imiquimod—it lacks efficacy despite being marketed for other dermatologic conditions 1, 4
• Do not neglect periocular lesions—they require active treatment to prevent ocular complications 1, 2
• Do not use salicylic acid in children under 2 years due to systemic toxicity risk 3

Watchful Waiting Consideration

While lesions typically persist 6 months to 5 years and may resolve spontaneously 1, 6, active treatment is generally recommended to prevent transmission, reduce autoinoculation risk, and improve quality of life 6, 7. The European guideline acknowledges waiting for spontaneous resolution as an option in immunocompetent patients 5, but physical removal remains preferred to minimize contagion 1, 2.