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, reduce symptoms, and allow the immune system to clear residual virus. 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—this is critical to prevent recurrence, as reducing viral load enables the host immune response to eliminate residual virus. 1, 2
Topical Chemical Treatments
For patients where physical removal is not preferred or feasible:
- 10% potassium hydroxide solution demonstrates similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1
- Cantharidin shows effectiveness in observational studies, though randomized controlled trial evidence remains limited 1
Treatments That Do NOT Work
Imiquimod has failed to show benefit compared to placebo in randomized controlled trials and is NOT recommended. 1 The FDA label confirms that two large pediatric trials (702 subjects) showed no efficacy—complete clearance rates were actually lower with imiquimod (24%) versus vehicle (26-28%) 3
Special Clinical Situations
Periocular Lesions with Conjunctivitis
- Physical removal is mandatory 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 persistent conjunctivitis requiring follow-up 1
Extensive or Immunocompromised Patients
- Multiple large lesions with minimal conjunctival inflammation suggest immunocompromised state—screen for HIV or other immunodeficiency 1, 2
- Consider dermatology referral for extensive or recalcitrant disease 1, 2
- European guidelines suggest cidofovir, imiquimod, or interferon for severe immunosuppressed cases, though this contradicts pediatric trial data 4
Pregnancy
- Physical procedures like cryotherapy are safe during pregnancy 4
Watchful Waiting Alternative
- Lesions typically persist 6 months to 5 years without treatment 1, 5
- Spontaneous resolution is reasonable in asymptomatic, limited disease 1
- However, treatment is generally recommended to prevent transmission, reduce autoinoculation risk, and improve quality of life 5, 6
Critical Pitfalls to Avoid
- Missing nascent lesions during initial treatment is the most common cause of recurrence—examine carefully and treat all visible lesions simultaneously 1
- Do not use salicylic acid in children under 2 years due to systemic toxicity risk 7
- Do not prescribe imiquimod—it lacks efficacy despite being marketed for this indication 1, 3
- Do not use ranitidine or H2 blockers—no evidence supports their use for molluscum contagiosum 7
- Screen for other sexually transmitted infections in adults with genital lesions 4