What are the treatment options for molluscum contagiosum?

Molluscum Contagiosum Treatment

Primary Recommendation

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

Treatment Algorithm

Step 1: Confirm Diagnosis and Assess Disease Extent

• Look for characteristic dome-shaped, skin-colored to pink papules (2-5 mm) with central umbilication, typically on trunk, face, and extremities 1, 3
• Check for associated conjunctivitis if lesions are on or near eyelids 1, 2
• If multiple large lesions are present with minimal inflammation, screen for immunocompromised state 1, 2

Step 2: Select Treatment Based on Clinical Scenario

For Immunocompetent Patients with Limited Disease:

• Curettage, simple excision, or cryotherapy are equally effective first-line options 1, 2
• Treat ALL visible lesions, including nascent ones, during the initial session to reduce recurrence risk 1, 2
• Reducing viral load allows the host immune response to eliminate residual virus 1, 2

For Children (Pediatric-Specific Options):

• 10% potassium hydroxide solution has similar efficacy to cryotherapy and is recommended by the American Academy of Pediatrics 1
• Cantharidin shows effectiveness in observational studies, though randomized trial evidence is limited 1
• Watchful waiting is reasonable as lesions typically resolve spontaneously within 6-12 months 4
• Cryotherapy may cause postinflammatory hyperpigmentation or scarring 1

For Periocular Lesions with Conjunctivitis:

• Physical removal is mandatory to resolve conjunctivitis 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 2

For Extensive or Recalcitrant Disease:

• Refer to dermatology for comprehensive evaluation 1, 2
• Consider immunocompromised screening if disease is unusually extensive 1, 2

Step 3: Follow-Up

• Follow-up is generally unnecessary unless conjunctivitis persists or new lesions develop 2

What NOT to Use

Imiquimod: Not Effective

• Imiquimod has NOT shown benefit compared to placebo in randomized controlled trials and is not recommended by the American Academy of Pediatrics 1
• FDA labeling explicitly states that imiquimod cream "failed to demonstrate efficacy" in two randomized trials involving 702 pediatric subjects with molluscum contagiosum 5
• In Study 1: 24% clearance with imiquimod vs. 26% with vehicle 5
• In Study 2: 24% clearance with imiquimod vs. 28% with vehicle 5

Ranitidine: No Evidence

• Current guidelines from the American Academy of Pediatrics and American Academy of Dermatology do not include ranitidine among recommended treatments 4
• The British Association of Dermatologists mentions ranitidine only for warts, not molluscum contagiosum 4

Important Caveats

Common Pitfalls:

• Failing to treat nascent lesions during initial treatment is a frequent cause of recurrence 1, 2
• Do not use salicylic acid in children under 2 years due to systemic toxicity risk 4
• Do not neglect periocular lesions, as they require active treatment to prevent ocular complications 1

Special Populations:

• Immunosuppressed patients develop severe, recalcitrant lesions that may require cidofovir, imiquimod (despite lack of evidence in immunocompetent patients), or interferon 3
• Pregnant patients can safely receive physical procedures like cryotherapy 3
• Lesions typically persist 6 months to 5 years without treatment 1, 6

Alternative Considerations:

• While oral cimetidine has been reported in small case series (13 patients) with some success 7, it is not included in current major guideline recommendations 1, 4
• Podophyllotoxin and other topical chemical treatments are mentioned in European guidelines for genital molluscum 3