What are the treatment options for molluscum contagiosum?

Treatment for Molluscum Contagiosum

Recommended First-Line Treatment

Physical removal methods—including cryotherapy with liquid nitrogen, curettage, or simple excision—are the recommended first-line treatments for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those near the eyes. 1, 2

Treatment Algorithm by Clinical Scenario

For Immunocompetent Children and Adolescents

Physical Treatments (Preferred):

• Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases and is recommended as first-line therapy 1
• Curettage, simple excision, or excision with cautery are equally effective first-line options 1, 2
• These methods prevent transmission, reduce symptoms, and allow faster resolution than spontaneous clearance 1

Topical Chemical Treatments (Alternative):

• 10% potassium hydroxide solution shows similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic outcomes and lower risk of postinflammatory hyperpigmentation 1
• Cantharidin has demonstrated effectiveness in observational studies, though randomized controlled trial evidence is limited 1

Important Caveat: Cryotherapy carries higher risk of postinflammatory hyperpigmentation or scarring, making it less favorable for facial lesions or patients with darker skin tones 1

For Immunocompetent Adults

• Incision and curettage, simple excision, or cryotherapy are recommended first-line treatments 2
• Treatment approach mirrors pediatric management with physical removal methods as primary therapy 2

For Periocular Lesions with Conjunctivitis

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

• The conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
• Monitor for resolution of conjunctivitis after treatment; follow-up is necessary if conjunctivitis persists 1, 2

For 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 and recalcitrant lesions may require cidofovir, imiquimod, or interferon 3

Watchful Waiting Option

Observation without treatment is reasonable for asymptomatic, limited disease in immunocompetent patients, as spontaneous resolution typically occurs in 6-12 months (though can take up to 4-5 years) 1, 4

Critical Treatment Principles

Identify and treat ALL lesions, including nascent ones, to reduce recurrence risk 1, 2

• Reducing viral load allows the host immune response to eliminate residual virus 1, 2
• Failure to treat early lesions is a common cause of recurrence 1

Treatments NOT Recommended

Imiquimod should NOT be used for molluscum contagiosum—randomized controlled trials showed no benefit compared to placebo in both adults and children 1, 5

• Two pediatric studies (702 subjects) showed complete clearance rates of 24% with imiquimod versus 26-28% with vehicle 5
• This contradicts older literature suggesting imiquimod as an option 3, 6

Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 7

Special Populations

Pregnancy

Physical procedures (cryotherapy, curettage) are safe and should be used preferentially 3

Genital Molluscum

• Treatment is recommended to reduce sexual transmission risk and prevent autoinoculation 3, 4
• Screen for other sexually transmitted infections in patients with genital molluscum 3

Common Pitfalls to Avoid

• Do not overlook nascent lesions during initial treatment—examine carefully and treat simultaneously to prevent recurrence 1
• Do not neglect periocular lesions—they require active treatment to prevent ocular complications 1
• Do not assume limited disease in patients with multiple large lesions and minimal inflammation—consider immunodeficiency screening 1, 2
• Do not use imiquimod despite its mention in older literature—current evidence does not support its efficacy 1, 5