What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

First-Line Physical Removal Methods

Physical removal through incision and curettage, simple excision, excision with cautery, or cryotherapy with liquid nitrogen represents the most effective first-line treatment approach for molluscum contagiosum. 1, 2

• Cryotherapy with liquid nitrogen achieves approximately 93% complete response rates and is recommended as first-line therapy by the American Academy of Ophthalmology 2
• Incision and curettage, simple excision, or excision with cautery are equally effective physical removal options 1, 2
• When treating, identify and address ALL lesions including nascent (early) ones to reduce recurrence risk—missing early lesions is a common pitfall 1, 2
• Reducing viral load through treatment allows the host immune response to eliminate residual virus 1, 2

Important Caveat About Cryotherapy

• Cryotherapy carries higher risk of postinflammatory hyperpigmentation and, uncommonly, scarring compared to chemical treatments 2
• This cosmetic concern is particularly relevant for facial lesions or patients with darker skin tones 2

Topical Chemical Treatments

• 10% potassium hydroxide solution has similar efficacy to cryotherapy in children (86.6% vs 93.3% complete response) and confers better cosmetic results due to lower hyperpigmentation risk 2
• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 2
• Imiquimod 5% should NOT be used—high-quality evidence from multiple randomized controlled trials demonstrates no benefit compared to placebo for clinical cure at 12,18, and 28 weeks 2, 3, 4

Critical Evidence on Imiquimod

• Four studies with 850 participants showed no difference in short-term cure (RR 1.33,95% CI 0.92-1.93) 4
• Imiquimod causes significantly more application site reactions (NNTH=11) and severe reactions (RR 4.33) without providing therapeutic benefit 4
• The American Academy of Pediatrics explicitly states imiquimod should not be used for molluscum contagiosum 2

Watchful Waiting as a Valid Option

• Spontaneous resolution typically occurs within 6-12 months but can take up to 4-5 years 2, 5
• Watchful waiting is reasonable for asymptomatic, limited disease in immunocompetent patients 2
• Lesions remain infectious throughout their entire course until complete resolution 2

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 number of lesions, location, presence of symptoms, and associated conjunctivitis if periocular 1, 2
• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 2

Step 2: Determine Treatment Approach

• For symptomatic lesions, multiple lesions, or periocular lesions with conjunctivitis: proceed with physical removal 1, 2
• For limited, asymptomatic disease in immunocompetent patients: watchful waiting is acceptable 2
• For extensive or recalcitrant disease: consider dermatology referral 2

Step 3: Select Specific Treatment Method

• First choice: Cryotherapy with liquid nitrogen OR 10% potassium hydroxide 2
• Choose potassium hydroxide over cryotherapy when cosmetic outcome is priority (facial lesions, darker skin) 2
• Alternative: Physical removal via curettage or excision 1, 2

Special Populations

Periocular Lesions

• Removal of periocular lesions is mandatory when associated conjunctivitis is present 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2

Children Under 2 Years

• Salicylic acid is contraindicated due to risk of systemic toxicity 2, 6

Immunocompromised Patients

• Lesions are typically more extensive, recalcitrant, and persistent 1, 2
• May require referral to dermatology for specialized management 2
• Consider cidofovir, though this is beyond typical primary care management 7

Pregnant Patients

• Physical procedures like cryotherapy are safe 7

Common Pitfalls to Avoid

• Do not use imiquimod—it is ineffective and causes unnecessary side effects 2, 3, 4
• Do not miss nascent lesions during initial treatment—this is the most common cause of recurrence 1, 2
• Do not use ranitidine or other H2 blockers—no evidence supports their use for molluscum contagiosum 6
• Do not neglect periocular lesions—they require active treatment to prevent ocular complications 2

Follow-Up Considerations

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
• Monitor for resolution of conjunctivitis after periocular lesion removal 2
• Screen for other sexually transmitted infections in adults with genital molluscum contagiosum 7, 8