What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

Recommended First-Line Approach

Physical removal methods—including curettage, simple excision, excision with cautery, or cryotherapy with liquid nitrogen—are the recommended first-line treatments for molluscum contagiosum in both children and adults. 1, 2

These physical methods should be prioritized because they:

• Prevent ongoing transmission to others 1
• Reduce associated symptoms 1
• Allow the host immune response to eliminate residual virus once viral load is reduced 1, 2

Treatment Algorithm by Clinical Scenario

For Immunocompetent Children and Adults

Step 1: Identify all lesions

• Look for characteristic skin-colored, whitish, or pink papules with shiny surface and central umbilication 1
• Carefully examine for nascent (early) lesions, as treating these simultaneously reduces recurrence risk 1, 2

Step 2: Select physical removal method

• Cryotherapy with liquid nitrogen: First-line option 1, 2
  • Note: May cause postinflammatory hyperpigmentation or rarely scarring 1
• Curettage: Equally effective first-line option 1, 2
• Simple excision or excision with cautery: Alternative first-line options 1, 2

Step 3: Alternative topical treatments (if physical methods declined)

• 10% potassium hydroxide solution: Similar efficacy to cryotherapy in children 1
• Cantharidin: Effective in observational studies, though randomized trial evidence is limited 1

For Periocular Lesions with Conjunctivitis

Physical removal is imperative when lesions are on or near the eyelids with associated conjunctivitis. 1, 2

• Remove the causative lesion promptly 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
• Monitor for conjunctivitis resolution; follow-up is indicated if it persists 1, 2

For Extensive or Recalcitrant Disease

Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state. 1, 2

• Consider referral to dermatology for extensive disease 1, 2
• In immunocompromised patients, lesions may require cidofovir, imiquimod, or interferon 3

Treatments NOT Recommended

Imiquimod for Standard Cases

Imiquimod has not shown benefit compared to placebo in randomized controlled trials and is not recommended for molluscum contagiosum in immunocompetent patients. 1, 4

• Two pediatric studies showed complete clearance rates of 24% with imiquimod versus 26-28% with vehicle 4
• Reserve imiquimod only for immunocompromised patients with severe, recalcitrant lesions 3

Ranitidine

Do not use ranitidine or other H2 blockers for molluscum contagiosum—there is no evidence supporting their efficacy for this condition. 5

Special Populations

Pregnant Women

• Physical procedures such as cryotherapy are safe during pregnancy 3
• Avoid systemic or potentially teratogenic topical agents 3

Children Under 2 Years

• Salicylic acid is contraindicated due to risk of systemic toxicity 5
• Physical removal methods remain appropriate 1

Watchful Waiting Option

• Lesions typically persist 6-12 months but can last up to 4-5 years without treatment 1, 6
• Watchful waiting is reasonable for asymptomatic, non-periocular lesions in immunocompetent patients 5
• However, treatment is generally recommended to reduce transmission risk, prevent autoinoculation, and improve quality of life 6

Critical Pitfalls to Avoid

• Missing nascent lesions during initial treatment is a common cause of recurrence—examine carefully and treat all visible lesions 1, 2
• Do not neglect periocular lesions—these require active treatment to prevent ocular complications 1, 2
• Do not assume limited disease in patients with multiple large lesions and minimal inflammation—this presentation suggests possible immunocompromise requiring further evaluation 1, 2
• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2