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, cryotherapy with liquid nitrogen, or excision with cautery represents the primary treatment approach for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those causing complications. 1, 2

Physical Treatment Efficacy

• Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases and is recommended as first-line therapy by the American Academy of Ophthalmology 1
• Incision and curettage, simple excision, or excision with cautery are equally effective first-line options 2
• Physical removal is especially critical when lesions are on or near the eyelids with associated conjunctivitis, as removal resolves the conjunctivitis (though resolution may take several weeks) 1, 2

Key Treatment Principle

• Identify and treat ALL lesions, including nascent (early) ones, during the initial treatment session to reduce recurrence risk 1, 2
• Reducing viral load through comprehensive treatment allows the host immune response to eliminate residual virus 1, 2

Topical Chemical Treatments

Potassium Hydroxide (KOH)

• 10% potassium hydroxide solution shows similar efficacy to cryotherapy in children (86.6% complete response vs 93.3% for cryotherapy) 1
• KOH confers better cosmetic results with lower risk of postinflammatory hyperpigmentation compared to cryotherapy, making it preferable for facial lesions or darker skin tones 1

Cantharidin

• Cantharidin demonstrates effectiveness in observational studies, though randomized controlled trial evidence remains limited 1

Treatments That Should NOT Be Used

• Imiquimod has NOT shown benefit compared to placebo in randomized controlled trials and is explicitly not recommended by the American Academy of Pediatrics 1, 3
• The FDA label confirms that imiquimod cream failed to demonstrate efficacy in two pediatric studies (complete clearance rates: 24% imiquimod vs 26-28% vehicle) 3
• Ranitidine has no evidence supporting efficacy for molluscum contagiosum and should be avoided 4

Watchful Waiting as an Alternative

• Watchful waiting is reasonable for asymptomatic, limited disease in immunocompetent patients 1
• Lesions typically persist 6-12 months but can last up to 4-5 years without treatment, eventually resolving spontaneously 1, 5
• However, treatment is often recommended to prevent transmission, reduce autoinoculation risk, and improve quality of life 5, 6

Special Populations and Considerations

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 2
• Extensive or recalcitrant disease warrants referral to dermatology 1, 2
• European guidelines suggest cidofovir, imiquimod, or interferon for severe cases in immunosuppressed patients, though evidence is limited 7

Pediatric Considerations

• Salicylic acid is contraindicated in children under 2 years due to systemic toxicity risk 4
• Physical treatments may be poorly tolerated in young children 8

Pregnancy

• Physical procedures like cryotherapy are safe during pregnancy 7

Treatment Algorithm

1. Confirm diagnosis by identifying characteristic dome-shaped papules with central umbilication, shiny surface, and typical distribution 1, 2

2. Assess disease extent and complications:

   • Check for periocular lesions with associated conjunctivitis 1, 2
   • Evaluate for signs of immunocompromise (multiple large lesions with minimal inflammation) 1, 2
   • Look for nascent lesions that require simultaneous treatment 1

3. Select treatment based on presentation:

   • For symptomatic, multiple, or periocular lesions: Physical removal (cryotherapy, curettage, or excision) 1, 2
   • For cosmetically sensitive areas or darker skin: Consider 10% KOH over cryotherapy 1
   • For limited, asymptomatic disease in immunocompetent patients: Watchful waiting is acceptable 1
   • For extensive disease or immunocompromise: Refer to dermatology 1, 2

4. Follow-up: Generally unnecessary unless conjunctivitis persists or new lesions develop 1, 2

Critical Pitfalls to Avoid

• Do not miss nascent lesions during initial treatment—this is the most common cause of recurrence 1
• Do not use imiquimod, as it lacks efficacy despite being FDA-approved for other indications 1, 3
• Do not neglect periocular lesions, as they require active treatment to prevent ocular complications 1
• Be aware that cryotherapy carries higher risk of postinflammatory hyperpigmentation and scarring compared to chemical treatments 1