What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

Physical removal methods—including cryotherapy, curettage, or excision—are the recommended first-line treatments for molluscum contagiosum in both children and adults, with the goal of preventing transmission and reducing symptoms. 1, 2

First-Line Physical Treatments

Cryotherapy with Liquid Nitrogen

• Cryotherapy is a recommended first-line therapy for molluscum contagiosum across all age groups 1, 2
• Be aware that cryotherapy may cause postinflammatory hyperpigmentation or, less commonly, scarring 1

Surgical Removal Methods

• Incision and curettage is an effective physical removal method 2
• Simple excision or excision with cautery are equally effective first-line options 1, 2
• These physical methods are particularly important when lesions are on or near the eyelids with associated conjunctivitis, as removal is necessary to resolve the conjunctivitis 1, 2

Topical Chemical Treatments

For Children

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is a recommended first-line topical treatment 1
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1
• Do not use salicylic acid in children under 2 years due to risk of systemic toxicity 3

Imiquimod: Not Recommended

• Imiquimod has not shown benefit compared to placebo in randomized controlled trials for molluscum contagiosum and is not recommended 1
• In pediatric studies, imiquimod cream failed to demonstrate efficacy, with complete clearance rates of 24% in the imiquimod group versus 26-28% in the vehicle group 4
• Despite being mentioned in some older literature as a novel option 5, 6, current high-quality evidence does not support its use 1, 4

Treatment Algorithm

Step 1: Confirm Diagnosis and Assess Disease Extent

• Look for characteristic skin-colored, whitish, or pink papules with shiny surface and central umbilication 1, 2
• Assess the number of lesions, location (especially proximity to eyes), and presence of complications such as conjunctivitis 1, 2
• If lesions are multiple and large with minimal inflammation, consider screening for immunocompromised state 1, 2

Step 2: Identify All Lesions Including Nascent Ones

• Carefully examine for nascent (early) lesions during initial treatment, as treating them simultaneously reduces risk of recurrence 1
• Early lesions may appear as simple dome-shaped papules without central umbilication 1
• Reducing viral load through comprehensive treatment allows the host immune response to eliminate residual virus 1, 2

Step 3: Select Treatment Based on Clinical Context

For Limited Disease in Immunocompetent Patients:

• Proceed with physical removal methods (cryotherapy, curettage, or excision) 1, 2
• In children, 10% potassium hydroxide solution is an alternative to cryotherapy 1

For Periocular Lesions with Conjunctivitis:

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

For Extensive or Recalcitrant Disease:

• Consider referral to dermatology 1, 2
• Screen for immunocompromised state 1, 2

For Immunocompromised Patients:

• Lesions may be severe and recalcitrant, potentially requiring cidofovir, imiquimod, or interferon (though evidence for imiquimod is weak) 5
• Referral to dermatology is recommended 1

Step 4: Follow-Up

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
• Monitor for resolution of conjunctivitis if lesions were periocular 1

Watchful Waiting as an Alternative

• Molluscum contagiosum typically resolves spontaneously within 6-12 months, though lesions can persist for 6 months to 5 years 1, 3
• However, treatment is recommended to reduce risk of sexual transmission (in adults), prevent autoinoculation, and improve quality of life 7, 5, 8
• The European guideline notes that waiting for spontaneous resolution is an option in immunocompetent patients 5

Critical Pitfalls to Avoid

• Do not miss nascent lesions during initial treatment—this is a common cause of recurrence 1
• Do not use imiquimod for molluscum contagiosum, as it lacks efficacy despite being mentioned in older literature 1, 4
• Do not neglect periocular lesions, as they require active treatment to prevent ocular complications 1
• Do not use salicylic acid in children under 2 years 3
• Do not use ranitidine or other H2 blockers for molluscum contagiosum—there is no evidence supporting their efficacy 3

Special Populations

Pregnancy

• Physical procedures such as cryotherapy are safe to use during pregnancy 5

Sexually Active Adults

• Patients with genital molluscum contagiosum should be offered screening for other sexually transmitted infections 5, 8
• Treatment is particularly recommended to reduce sexual transmission risk 7, 8