What are the treatment options for molluscum contagiosum?

Treatment of Molluscum Contagiosum

First-Line Treatment Recommendation

Physical removal methods—including curettage, simple excision, excision with cautery, or cryotherapy with liquid nitrogen—are the recommended first-line treatments for molluscum contagiosum to prevent transmission and reduce symptoms. 1, 2

Treatment Algorithm

For Immunocompetent Patients

Physical Removal Methods (First-Line):

• Incision and curettage is highly effective for removing individual lesions 1, 2
• Simple excision or excision with cautery are equally effective alternatives 1, 2
• Cryotherapy with liquid nitrogen is another recommended first-line option 1, 2
• Critical: Identify and treat ALL lesions, including nascent (early) ones, to reduce recurrence risk—this is a common pitfall when only treating obvious lesions 1, 2

Topical Chemical Treatments (Alternative First-Line):

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children 1, 3
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 3, 4

For Special Populations

Periocular Lesions with Conjunctivitis:

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

Immunocompromised Patients:

• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 2
• Consider referral to dermatology for extensive or recalcitrant disease 1, 2
• Severe cases may require cidofovir, imiquimod, or interferon 5

Pregnant Patients:

• Physical procedures such as cryotherapy are safe to use 5

Treatments NOT Recommended

Imiquimod:

• FDA labeling explicitly states that imiquimod cream failed to demonstrate efficacy for molluscum contagiosum in two randomized, vehicle-controlled trials involving 702 pediatric subjects 6
• Complete clearance rates were 24% with imiquimod versus 26-28% with vehicle (placebo) 6
• Despite use in immunocompromised patients per European guidelines, it has not shown benefit compared to placebo in randomized controlled trials 1, 5

Ranitidine:

• No evidence supports ranitidine for molluscum contagiosum—it is not included in American Academy of Pediatrics or American Academy of Dermatology guidelines 3

Salicylic Acid in Young Children:

• Contraindicated in children under 2 years due to risk of systemic toxicity 3

Watchful Waiting Option

• Lesions typically resolve spontaneously within 6-12 months but can persist for 6 months to 5 years 1, 7
• Watchful waiting is reasonable in asymptomatic, immunocompetent patients 3
• However, treatment is recommended to prevent transmission, reduce autoinoculation risk, and improve quality of life 7

Key Clinical Considerations

Reducing Viral Load:

• Treating lesions reduces viral load and allows the host immune response to eliminate residual virus 1, 2

Prevention of Transmission:

• Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1
• Avoid skin contact with infected individuals and sharing towels/fomites 1
• Keep lesions covered with waterproof bandages if water exposure is unavoidable 1

Follow-Up:

• Generally not necessary unless conjunctivitis persists or new lesions develop 1, 2

Common Pitfalls to Avoid

• Failing to treat nascent lesions during initial treatment is a frequent cause of recurrence 1
• Underestimating the importance of treating periocular lesions, which require active treatment to prevent ocular complications 1
• Cryotherapy may cause postinflammatory hyperpigmentation or, uncommonly, scarring 1
• In patients with atopic dermatitis, widespread involvement may occur and require more aggressive management 8, 4