Treatment of Molluscum Contagiosum
Physical removal methods including curettage, excision, or cryotherapy are the recommended first-line treatments for molluscum contagiosum to prevent transmission and reduce symptoms. 1, 2
Treatment Algorithm
Initial Assessment
- Confirm diagnosis by identifying characteristic dome-shaped, skin-colored to pink papules (2-5 mm) with central umbilication, typically on trunk, face, and extremities 1, 3
- Check for lesions near the eyelids, as these may cause associated conjunctivitis requiring prompt treatment 1, 2
- If multiple large lesions are present with minimal inflammation, screen for immunocompromised state 1, 2
First-Line Physical Treatments
For immunocompetent patients:
- Incision and curettage is highly effective as first-line therapy 1, 2
- Simple excision or excision with cautery are equally effective alternatives 1, 2
- Cryotherapy with liquid nitrogen is another recommended first-line option 1, 2
Critical treatment principle: Identify and treat ALL lesions, including nascent (early) ones, during the initial treatment session to reduce recurrence risk 1, 2
First-Line Topical Chemical Treatments
For children:
- 10% potassium hydroxide solution has similar efficacy to cryotherapy and is recommended by the American Academy of Pediatrics 1
- Cantharidin has shown effectiveness in observational studies, though randomized trial evidence is limited 1, 4
Important caveat: Salicyric acid is contraindicated in children under 2 years due to systemic toxicity risk 5
Treatments NOT Recommended
- Imiquimod has NOT shown benefit compared to placebo in randomized controlled trials for molluscum contagiosum and should not be used 1, 6
- Ranitidine has no evidence supporting efficacy for molluscum contagiosum 5
Special Populations
Pregnant women:
- Physical procedures such as cryotherapy are safe to use 3
- Avoid systemic or potentially teratogenic topical agents 3
Immunocompromised patients:
- Develop severe and recalcitrant lesions requiring more aggressive treatment 3
- May require cidofovir, imiquimod (despite lack of efficacy in immunocompetent patients), or interferon 3
- Consider dermatology referral for extensive disease 1, 2
Periocular lesions:
- 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
Watchful Waiting Option
- Spontaneous resolution typically occurs within 6-12 months but can take up to 5 years 1, 7
- Reasonable approach in asymptomatic, immunocompetent patients who prefer to avoid treatment 5, 3
- However, treatment is generally recommended to prevent transmission, reduce autoinoculation risk, and improve quality of life 7
Common Pitfalls to Avoid
- Missing nascent lesions during initial treatment is the most common cause of recurrence—examine carefully and treat all visible lesions 1, 2
- Neglecting periocular lesions can lead to persistent conjunctivitis and ocular complications 1, 2
- Using imiquimod based on its approval for other conditions—it has failed to demonstrate efficacy in controlled trials for molluscum 1, 6
- Overlooking immunodeficiency in patients with extensive, large, or minimally inflamed lesions 1, 2
Follow-Up
- Routine follow-up is not necessary unless conjunctivitis persists or new lesions develop 1, 2
- Reducing viral load through treatment allows the host immune response to eliminate residual virus 1, 2
- Screen for other sexually transmitted infections in adults with genital molluscum 3
Treatment Considerations by Age
Children:
- Cryotherapy may cause postinflammatory hyperpigmentation or scarring 1
- Physical treatments are often poorly tolerated due to pain 8
- Topical potassium hydroxide offers a less traumatic alternative 1
Adults with genital lesions: