How to manage molluscum contagiosum in children?

Management of Molluscum Contagiosum in Children

Primary Treatment Recommendation

For symptomatic, multiple, or periocular lesions in children, physical removal methods (cryotherapy, curettage, or excision) are first-line therapy, while watchful waiting remains appropriate for asymptomatic, limited disease. 1

Treatment Algorithm

Step 1: Assess Need for Active Treatment

Watchful waiting is reasonable for:

• Asymptomatic lesions 1
• Limited number of lesions 1
• No periocular involvement 1
• Lesions typically resolve spontaneously in 6-12 months, though can persist up to 4-5 years 1

Active treatment is indicated for:

• Symptomatic lesions (pain, itching, redness) 1
• Multiple lesions 1
• Lesions near the eyes causing conjunctivitis 1
• Cosmetic concerns or social stigma 2
• Prevention of autoinoculation and transmission 1

Step 2: Select Treatment Modality

First-Line Physical Treatments

Cryotherapy with liquid nitrogen:

• Achieves complete response in approximately 93% of cases 1
• Major caveat: Risk of postinflammatory hyperpigmentation (particularly in darker skin tones) or scarring 1
• Less cosmetically favorable than chemical treatments for facial lesions 1

Curettage, simple excision, or excision with cautery:

• Recommended as first-line therapy by the American Academy of Ophthalmology 1
• Allows immediate removal of all visible lesions 1

First-Line Chemical Treatment

10% potassium hydroxide solution:

• Similar efficacy to cryotherapy (86.6% complete response vs 93.3% for cryotherapy) 1
• Better cosmetic results with lower risk of hyperpigmentation 1
• Recommended by the American Academy of Pediatrics 1

Cantharidin:

• Shows effectiveness in observational studies 1
• Practical first-line option despite limited randomized controlled trial evidence 2, 3

Step 3: Critical Treatment Principles

Identify and treat ALL lesions, including nascent ones:

• Examine carefully for early lesions that may appear as simple dome-shaped papules without umbilication 1
• Treating nascent lesions simultaneously reduces recurrence risk 1
• Reducing viral load allows host immune response to eliminate residual virus 1

Step 4: Special Considerations

Periocular lesions with conjunctivitis:

• Physical removal is imperative 1
• Conjunctivitis may require several weeks to resolve after lesion removal 1
• Monitor for resolution of conjunctivitis at follow-up 1

Extensive disease with minimal inflammation:

• Consider screening for immunocompromised state 1
• Referral to dermatology may be necessary 1

Age-specific restrictions:

• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 4

Treatments to AVOID

Imiquimod:

• Not effective - showed no benefit compared to placebo in randomized controlled trials 1, 5
• FDA studies in 702 pediatric patients with molluscum contagiosum demonstrated complete clearance rates of 24% with imiquimod versus 26-28% with vehicle 5
• Should not be used 1

Ranitidine or other H2 blockers:

• No evidence supporting efficacy for molluscum contagiosum 4
• Not included in current guidelines from the American Academy of Pediatrics or American Academy of Dermatology 4

Common Pitfalls

Failure to treat nascent lesions:

• Most common cause of recurrence 1
• Early lesions may lack characteristic umbilication 1

Neglecting periocular lesions:

• Require active treatment to prevent ocular complications 1
• Associated conjunctivitis will not resolve without lesion removal 1

Misdiagnosis in atypical presentations:

• In immunocompromised patients, lesions may appear as giant, disseminated, necrotic, or nodular forms without classic umbilication 1
• Cryptococcal infection can present with small, translucent umbilicated papules indistinguishable from molluscum 6

Prevention and Transmission Control

Hand hygiene:

• Most important method to prevent transmission 1
• Use alcohol-based disinfectant or soap and water 1

Avoid sharing:

• Towels, clothing, and personal items 1
• Equipment in communal settings 1

Water exposure:

• Cover all lesions with waterproof bandages if water exposure unavoidable 1
• Limit exposure to swimming pools associated with known outbreaks 1
• Higher transmission risk in hot tubs due to warmer water and closer proximity 1