What are the treatment options for molluscum contagiosum?

Treatment of Molluscum Contagiosum

Direct Answer

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

Treatment Algorithm

Step 1: Confirm Diagnosis and Assess Disease Extent

• Identify characteristic skin-colored, whitish, or pink papules with shiny surface and central umbilication 1, 2
• Assess number of lesions, location (especially proximity to eyes), and presence of associated conjunctivitis 1, 2
• In adults with multiple large lesions and minimal inflammation, screen for immunocompromised state 1

Step 2: Select First-Line Physical Treatment

For immunocompetent patients with limited disease:

• Incision and curettage is highly effective for physical removal 1
• Simple excision or excision with cautery are equally effective alternatives 1
• Cryotherapy with liquid nitrogen is another recommended first-line option 1, 2
• Identify and treat ALL lesions, including nascent (early) ones, to reduce recurrence risk 1, 2

Step 3: Consider Topical Chemical Treatments (Alternative Options)

For children (when physical methods are not tolerated):

• 10% potassium hydroxide solution has similar efficacy to cryotherapy 2
• Cantharidin has shown effectiveness in observational studies, though randomized trial evidence is limited 2

Important contraindication: Salicylic acid is contraindicated in children under 2 years due to systemic toxicity risk 3

Step 4: What NOT to Use

Imiquimod is NOT recommended:

• FDA-labeled studies in 702 pediatric patients with molluscum contagiosum failed to demonstrate efficacy 4
• Complete clearance rates were no better than vehicle (24% imiquimod vs. 26-28% vehicle) 4
• Despite European guidelines mentioning it as an option for genital molluscum 5, the highest quality evidence from FDA trials shows no benefit 4

Special Considerations

Periocular Lesions with Conjunctivitis

• Physical removal is mandatory when lesions are on or near eyelids with associated conjunctivitis 1, 2
• Conjunctivitis may require weeks to resolve even after lesion elimination 1, 2

Extensive or Recalcitrant Disease

• Consider screening for immunocompromised state 2, 3
• Refer to dermatology for extensive disease or examination of suspicious lesions 2

Immunocompromised Patients

• May develop severe, recalcitrant lesions requiring specialized treatments 5
• Atypical presentations may occur without classic umbilication 2

Follow-Up

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
• Monitor for complete resolution before declaring treatment success 2

Critical Pitfalls to Avoid

• Missing nascent lesions during initial treatment is a common cause of recurrence—examine carefully and treat all visible lesions simultaneously 1, 2
• Do not use imiquimod—despite its availability and historical use, high-quality FDA trials definitively show no benefit over placebo 4
• Do not use salicylic acid in children under 2 years due to systemic toxicity risk 3
• Do not delay treatment of periocular lesions with conjunctivitis—active removal is required to prevent ocular complications 1, 2

Watchful Waiting Option

• Lesions typically persist 6 months to 5 years but resolve spontaneously in immunocompetent patients 1, 2, 6
• Watchful waiting is reasonable for asymptomatic, non-genital lesions in immunocompetent patients who prefer to avoid treatment 2, 3
• However, treatment is recommended to prevent transmission, reduce autoinoculation risk, and improve quality of life 6, 7