Treatment Options for Molluscum Contagiosum
Physical removal methods—including curettage, simple excision, or cryotherapy with liquid nitrogen—are the recommended first-line treatments for molluscum contagiosum in both children and adults. 1, 2
First-Line Physical Treatments
The American Academy of Ophthalmology prioritizes physical removal as the primary therapeutic approach:
- Incision and curettage is highly effective for removing individual lesions 1, 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
First-Line Topical Chemical Treatments (Pediatric Patients)
For children who cannot tolerate physical procedures:
- 10% potassium hydroxide solution demonstrates similar efficacy to cryotherapy in pediatric populations 1
- Cantharidin shows effectiveness in observational studies, though randomized controlled trial evidence remains limited 1
Treatments NOT Recommended
- Imiquimod has failed to show benefit compared to placebo in randomized controlled trials for molluscum contagiosum and should not be used 1, 3
- The FDA label confirms that two pediatric studies (702 subjects) showed no efficacy: complete clearance rates were 24% with imiquimod versus 26-28% with vehicle 3
- Ranitidine has no evidence supporting its use for molluscum contagiosum and should be avoided 4
Watchful Waiting as an Alternative
- Spontaneous resolution typically occurs within 6-12 months but can take up to 4-5 years 1
- This approach is reasonable for asymptomatic, limited disease in immunocompetent patients 1, 5
- However, treatment is preferred to prevent transmission, reduce autoinoculation risk, and improve quality of life 5
Special Clinical Scenarios
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 2
Immunocompromised Patients
- Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency 1, 2
- These patients develop severe, recalcitrant lesions requiring dermatology referral 1, 6
- Consider cidofovir, imiquimod, or interferon for extensive disease in this population 6
Pregnancy
- Physical procedures like cryotherapy are safe during pregnancy 6
Pediatric Considerations
- Salicylic acid is contraindicated in children under 2 years due to systemic toxicity risk 4
- Physical treatments may be poorly tolerated in young children 7
Treatment Algorithm
- Confirm diagnosis by identifying characteristic dome-shaped, umbilicated papules 1, 2
- Assess disease extent: count lesions, identify nascent ones, check for periocular involvement 1, 2
- For limited disease in immunocompetent patients: proceed with physical removal (curettage, excision, or cryotherapy) 1, 2
- For pediatric patients unable to tolerate physical methods: use 10% potassium hydroxide solution 1
- For extensive or recalcitrant disease: screen for immunodeficiency and refer to dermatology 1, 2
- For periocular lesions with conjunctivitis: physical removal is non-negotiable 1, 2
Critical Pitfalls to Avoid
- Failing to treat nascent lesions is the most common cause of recurrence—examine carefully for early dome-shaped papules without obvious umbilication 1
- Neglecting periocular lesions can lead to persistent conjunctivitis requiring weeks to resolve 1, 2
- Using imiquimod based on older literature—recent high-quality pediatric trials definitively show no benefit 1, 3
- Underestimating immunocompromised states when seeing multiple large lesions with minimal inflammation 1, 2