What is the recommended treatment for molluscum contagiosum?

Recommended Treatment for Molluscum Contagiosum

Primary Recommendation

Physical removal methods—including curettage, simple excision, or cryotherapy with liquid nitrogen—are the recommended first-line treatments for molluscum contagiosum to prevent transmission and reduce symptoms. 1

Treatment Algorithm

For Immunocompetent Children and Adults

Active Treatment Indications:

• Treat lesions that are symptomatic (painful, itchy), numerous, causing associated conjunctivitis, or located near the eyes 1
• Consider treatment to prevent autoinoculation, limit spread to others, and reduce social stigma 2
• Lesions associated with eczematous eruptions ("molluscum eczema") warrant treatment to alleviate discomfort 3

First-Line Physical Methods:

• Cryotherapy with liquid nitrogen is highly effective and recommended by the American Academy of Pediatrics 1
• Curettage (incision and curettage or simple excision) provides immediate removal and is equally effective 1, 4
• Cantharidin shows effectiveness in observational studies, though randomized trial evidence is limited 1, 3

First-Line Topical Chemical Treatment:

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children and is recommended by the American Academy of Pediatrics 1

Alternative Approach:

• Watchful waiting is reasonable for asymptomatic, limited disease, as lesions typically resolve spontaneously within 6-12 months (though can persist up to 5 years) 1, 5

For Periocular Lesions

Mandatory treatment approach:

• Physical removal is imperative for lesions on or near eyelids with associated conjunctivitis 1, 4
• Conjunctivitis may require several weeks to resolve after lesion elimination 4
• Monitor for persistent conjunctivitis requiring follow-up 1

For Immunocompromised Patients

Special considerations:

• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 4
• Severe and recalcitrant lesions may require cidofovir, imiquimod, or interferon 6
• Consider dermatology referral for extensive or recalcitrant disease 1

For Sexually Transmitted Molluscum

• Physical procedures (cryotherapy, cautery, curettage) are recommended 6
• Screen for other sexually transmitted infections 6
• In pregnancy, physical procedures like cryotherapy are safe 6

Critical Treatment Principles

Comprehensive lesion identification:

• Identify and treat ALL lesions, including nascent (early) ones, during the initial treatment session 1, 4
• Failure to treat nascent lesions is a common cause of recurrence 1
• Reducing viral load allows the host immune response to eliminate residual virus 1, 4

Lesion characteristics to recognize:

• Skin-colored, whitish, or pink papules with shiny surface and central umbilication 1
• Early lesions may appear as dome-shaped papules without visible umbilication 1

Treatments NOT Recommended

Imiquimod:

• Has NOT shown benefit compared to placebo in randomized controlled trials and is not recommended by the American Academy of Pediatrics 1
• Failed to demonstrate efficacy in two pediatric trials (24% clearance vs. 26-28% with vehicle) 7

Ranitidine:

• No evidence supports efficacy for molluscum contagiosum 5
• Not included in current American Academy of Pediatrics or American Academy of Dermatology guidelines 5

Important Caveats and Pitfalls

Age-specific contraindications:

• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 5

Adverse effects to anticipate:

• Cryotherapy may cause postinflammatory hyperpigmentation or, uncommonly, scarring 1
• Local skin reactions with physical treatments include erythema, edema, scabbing, and flaking 7

Follow-up considerations:

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 4
• Examine carefully for nascent lesions during initial treatment to reduce recurrence risk 1