What are the treatment options for molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

First-Line Treatment Recommendation

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

Treatment Algorithm by Clinical Scenario

For Immunocompetent Children and Adults

Physical Removal Methods (First-Line):

• Cryotherapy with liquid nitrogen is effective and recommended by the American Academy of Pediatrics as first-line therapy 1, 2
• Curettage (incision and curettage or simple excision) provides immediate removal and is recommended by the American Academy of Ophthalmology 1, 3
• Excision with cautery is equally effective as other physical methods 3
• When treating, identify and remove ALL lesions including nascent (early) ones to reduce recurrence risk, as reducing viral load allows the host immune response to eliminate residual virus 1, 3

Topical Chemical Treatments (Alternative First-Line):

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1, 2
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 2, 4

Important Caveat: Cryotherapy may cause postinflammatory hyperpigmentation or, uncommonly, scarring 1

For Periocular Lesions with Conjunctivitis

Physical removal is imperative when lesions are on or near the eyelids with associated conjunctivitis, as the conjunctivitis will not resolve without lesion removal 1, 3

• The conjunctivitis may require several weeks to resolve even after complete lesion elimination 1, 3
• Monitor for resolution of conjunctivitis after treatment 1

Watchful Waiting Option

Observation without treatment is reasonable for asymptomatic, limited disease in immunocompetent patients, as lesions typically resolve spontaneously within 6-12 months (though can persist up to 4-5 years) 1, 2

Treatments NOT Recommended

Imiquimod 5% cream has NOT shown benefit compared to placebo in randomized controlled trials for molluscum contagiosum and is not recommended by the American Academy of Pediatrics 1

• FDA labeling confirms that studies in children ages 2-12 years with molluscum contagiosum failed to demonstrate efficacy 5
• Despite this, imiquimod is mentioned in some European guidelines as an option, though the highest quality evidence does not support its use 6

Ranitidine has no role in molluscum contagiosum treatment—current guidelines from the American Academy of Pediatrics and American Academy of Dermatology do not include it among recommended treatments 2

Special Populations and Considerations

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 3
• Extensive or recalcitrant disease warrants referral to dermatology 1, 2

Pediatric Patients

• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 2
• Safety and efficacy have not been established for patients under 12 years with genital/perianal warts 5

Pregnant Patients

• Physical procedures such as cryotherapy are safe to use during pregnancy 6

Common Pitfalls to Avoid

Failure to treat nascent lesions is a frequent cause of recurrence—examine carefully for early lesions during initial treatment and treat them simultaneously 1

Underestimating periocular lesions—these require active treatment to prevent ocular complications, not observation 1

Using imiquimod based on older literature—despite its mention in some guidelines, high-quality randomized controlled trials and FDA evaluation have shown it does not work for molluscum contagiosum 1, 5

Follow-Up

Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 3