What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

Primary Treatment Recommendation

Physical removal methods—including curettage, simple excision, excision with cautery, or cryotherapy with liquid nitrogen—are the first-line treatments for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those near the eyes causing conjunctivitis. 1, 2, 3

Treatment Algorithm

For Immunocompetent Patients

Watchful waiting is reasonable for:

• Asymptomatic lesions 3
• Limited number of lesions 3
• No periocular involvement 3
• Lesions typically resolve spontaneously in 6-12 months, though can persist up to 4-5 years 1, 2

Active treatment is indicated for:

• Symptomatic lesions (pain, itching, redness) 1
• Multiple lesions 1, 2, 3
• Lesions near the eyes causing conjunctivitis 1, 2, 3
• Prevention of autoinoculation and transmission 3
• Cosmetic concerns 4

Physical Removal Methods (First-Line)

Cryotherapy with liquid nitrogen:

• Achieves complete response in approximately 93% of cases 1, 3
• Risk of postinflammatory hyperpigmentation or scarring, particularly in darker skin tones 1, 3
• Less cosmetically favorable than chemical treatments 1

Curettage, excision, or excision with cautery:

• Equally effective first-line options 1, 2
• Recommended by the American Academy of Ophthalmology 1, 2, 3

Chemical Treatments (Alternative First-Line)

10% potassium hydroxide solution:

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

Cantharidin:

• Shows effectiveness in observational studies 1
• Practical treatment option, though randomized controlled trial evidence is limited 1, 5

Special Populations

Children:

• Physical removal or 10% potassium hydroxide are first-line options 1, 3
• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 3
• Cryotherapy may be poorly tolerated due to pain 4

Periocular lesions with conjunctivitis:

• Physical removal is imperative 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
• Monitor for resolution at follow-up 1, 2

Immunocompromised patients:

• Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency 1, 2
• May require cidofovir, imiquimod, or interferon for severe, recalcitrant disease 6
• Consider referral to dermatology 1, 2

Pregnant patients:

• Physical procedures such as cryotherapy are safe 6

Critical Treatment Principles

Identify and treat ALL lesions, including nascent ones:

• Reduces risk of recurrence 1, 2
• Reducing viral load allows host immune response to eliminate residual virus 1, 2
• Examine carefully for early lesions during initial treatment 1

Treatments That Should NOT Be Used

Imiquimod:

• Explicitly not recommended—showed no benefit compared to placebo in randomized controlled trials in both adults and children 1, 3, 7
• Failed to demonstrate efficacy in two pediatric studies (24% clearance with imiquimod vs 26-28% with vehicle) 7
• The American Academy of Pediatrics states it should not be used 1, 3

H2 blockers (ranitidine, cimetidine):

• No evidence supporting efficacy 3
• Not included in current guidelines 3

Common Pitfalls to Avoid

• Missing nascent lesions during initial treatment is a frequent cause of recurrence 1
• Do not neglect periocular lesions—they require active treatment to prevent ocular complications 1
• Do not assume minimal conjunctival inflammation with multiple large lesions is benign—consider immunocompromised state 1, 2
• Do not use imiquimod despite its availability—it is ineffective 1, 3, 7

Follow-Up

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
• For periocular lesions with conjunctivitis, monitor for resolution of conjunctivitis after lesion removal 1, 2

Prevention and Transmission Control

• Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1, 3
• Avoid sharing towels, clothing, and personal items 1, 3
• Cover all lesions with waterproof bandages if water exposure is unavoidable 1, 3
• Limit exposure to swimming pools associated with known outbreaks 1