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

Active Treatment Indications:

• Symptomatic lesions (pain, itching, inflammation) 1, 3
• Multiple lesions (to prevent autoinoculation and transmission) 1, 2
• Periocular lesions with associated conjunctivitis 1, 2, 3
• Patient desire to prevent spread or reduce social stigma 1

Watchful Waiting is Appropriate 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, 3

Physical Removal Methods (First-Line)

Cryotherapy with Liquid Nitrogen:

• Achieves complete response in approximately 93% of cases 1, 3
• Apply until visible freezing extends slightly beyond the lesion margin into normal skin 1
• Major caveat: Risk of postinflammatory hyperpigmentation (most common adverse effect, may persist 6-12 months) or scarring 1, 3
• Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1
• No anesthesia is typically needed 1

Curettage/Excision:

• Equally effective as cryotherapy 1, 2
• Options include incision and curettage, simple excision, or excision with cautery 1, 2

Chemical Treatments (Alternative First-Line)

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 compared to cryotherapy 1
• Particularly advantageous for facial lesions or patients with darker skin tones 1

Cantharidin:

• Effective in observational studies, though randomized controlled trial evidence is limited 1, 4
• Applied topically by physician 4

Treatments That DO NOT WORK

Imiquimod:

• Explicitly NOT recommended—showed no benefit compared to placebo in randomized controlled trials in both adults and children 1, 3, 5
• Two pediatric studies (702 subjects) showed clearance rates of 24% with imiquimod vs 26-28% with vehicle 5
• Should not be used despite being an immunomodulator 1, 3

Critical Treatment Principles

Treat ALL Lesions Including Nascent Ones:

• Identify and treat early lesions that may appear as simple dome-shaped papules without umbilication 1, 2
• Treating nascent lesions simultaneously reduces recurrence risk 1
• Reducing viral load allows the host immune response to eliminate residual virus 1, 2

Special Considerations for Periocular Lesions:

• Physical removal is imperative for lesions on or near eyelids with associated conjunctivitis 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
• Monitor for resolution of conjunctivitis at follow-up 1, 2

Age-Specific Considerations

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
• Cryotherapy may be poorly tolerated due to pain 1

Adults:

• Same physical removal methods as children 2
• In sexually active adults, treatment is recommended to reduce sexual transmission risk 6, 7

Immunocompromised Patients

Red Flags:

• Multiple large lesions with minimal inflammation suggest immunocompromised state 1, 2
• Lesions may be extensive, recalcitrant, giant, disseminated, or atypical 1

Management:

• Consider screening for immunodeficiency 1
• Referral to dermatology for extensive or recalcitrant disease 1, 2
• May require specialized treatments (cidofovir, interferon) 7

Follow-Up

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

Prevention and Transmission Control

Hand Hygiene:

• Most important prevention method—use alcohol-based disinfectant or soap and water 1, 3

Avoid Sharing:

• Do not share towels, clothing, personal items, or equipment 1, 3
• Cover all lesions with waterproof bandages if water exposure is unavoidable 1, 3

Water Exposure:

• Limit exposure to swimming pools associated with known outbreaks 1
• Hot tubs present higher transmission risk than standard pools 1
• Return to shared water facilities only when all lesions have completely resolved 1