What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

First-Line Treatment Recommendations

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

Physical Removal Methods

• Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases and is highly effective for both children and adults 1, 3

  • Risk of postinflammatory hyperpigmentation or, uncommonly, scarring—particularly relevant for facial lesions or patients with darker skin tones 1, 3
  • Despite cosmetic concerns, remains a primary recommended option by the American Academy of Ophthalmology 1

• Curettage, excision, or excision with cautery are equally effective first-line physical removal options 1, 2

  • Particularly useful for isolated or limited lesions 2
  • Allow for immediate removal and reduced viral load 1

Chemical Treatments

• 10% potassium hydroxide solution is recommended by the American Academy of Pediatrics as a first-line chemical treatment 1, 3

  • Similar efficacy to cryotherapy (86.6% complete response for KOH vs 93.3% for cryotherapy) 1
  • Better cosmetic results with lower risk of hyperpigmentation compared to cryotherapy 1
  • More effective than 2.5% potassium hydroxide solution 1

• Cantharidin has shown effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 4

Watchful Waiting as an Alternative

• Spontaneous resolution is reasonable for asymptomatic, limited disease in immunocompetent patients 1, 3
  • Lesions typically resolve in 6-12 months but can persist for 6 months to 5 years 1, 2
  • Natural resolution remains a valid approach when treatment risks outweigh benefits 5

Treatment Algorithm

Step 1: Assess Disease Characteristics

• Number of lesions: Single/few vs. multiple/extensive 1, 2
• Location: Periocular lesions require active treatment due to conjunctivitis risk 1, 2, 3
• Symptoms: Asymptomatic vs. symptomatic (pain, itching, inflammation) 1
• Immune status: Multiple large lesions with minimal inflammation suggest immunocompromised state 1, 2

Step 2: Choose Treatment Based on Assessment

For symptomatic, multiple, or periocular lesions:

• Proceed with physical removal (cryotherapy, curettage, or excision) 1, 2, 3
• Alternative: 10% potassium hydroxide for better cosmetic outcome 1, 3

For asymptomatic, limited disease:

• Watchful waiting is acceptable 1, 3
• Consider treatment if patient/family prefers active intervention to prevent transmission 1

For extensive or recalcitrant disease:

• Screen for immunocompromised state 1, 2
• Consider dermatology referral 1, 2

Step 3: Treatment Execution Principles

• Identify and treat ALL lesions, including nascent ones, to reduce recurrence risk 1, 2
• Reducing viral load allows host immune response to eliminate residual virus 1, 2
• For periocular lesions with conjunctivitis, removal is imperative—conjunctivitis may require weeks to resolve after lesion elimination 1, 2

Treatments to AVOID

Imiquimod 5% cream should NOT be used for molluscum contagiosum. 1, 3, 6, 5

• High-quality evidence from multiple randomized controlled trials shows no benefit compared to placebo for clinical cure at 12,18, or 28 weeks 1
• Causes significantly more application site reactions (NNTH = 11) and severe application site reactions (NNTH > 40) compared to vehicle 1
• The American Academy of Pediatrics explicitly states imiquimod should not be used 1, 3
• FDA labeling confirms two large pediatric studies failed to demonstrate efficacy 6

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 systemic toxicity risk 3
• Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1, 3

Adults

• Same treatment principles as children apply 2
• In sexually active adults, genital lesions warrant screening for other sexually transmitted infections 7

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt immunodeficiency screening 1, 2
• May require referral to dermatology for extensive or recalcitrant disease 1, 2

Common Pitfalls and How to Avoid Them

• Failing to treat nascent lesions during initial treatment is a frequent cause of recurrence—examine carefully for early dome-shaped papules without obvious umbilication 1
• Neglecting periocular lesions can lead to persistent conjunctivitis—these require active treatment, not watchful waiting 1, 2
• Using imiquimod based on outdated information—this has been definitively shown ineffective and causes unnecessary side effects 1, 3, 6, 5
• Underestimating disease in immunocompromised patients—extensive lesions with minimal inflammation warrant further evaluation 1, 2

Follow-Up Considerations

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
• For periocular lesions, monitor for resolution of conjunctivitis at follow-up 1, 3
• If lesions recur, re-examine for missed nascent lesions 1