What are the treatment options for Molluscum contagiosum?

Treatment Options for Molluscum Contagiosum

First-Line Physical Removal Methods

Physical removal through cryotherapy, curettage, or excision represents the primary treatment approach for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those causing complications such as conjunctivitis. 1, 2

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
• Requires visible freezing that extends slightly beyond the lesion margin into normal skin for optimal effectiveness 1
• Major caveat: Postinflammatory hyperpigmentation is the most common adverse effect, persisting for 6-12 months, making it less cosmetically favorable than chemical treatments, particularly for facial lesions or patients with darker skin tones 1
• Avoid treating sensitive areas including eyelids, lips, nose, and ears due to higher complication risk 1
• No anesthesia is typically used, as it has not been shown to be helpful 1

Curettage and Excision

• Incision and curettage, simple excision, or excision with cautery are equally effective first-line options 1, 2
• Critical principle: Identify and treat ALL lesions, including nascent ones, during the initial treatment session to reduce recurrence risk 1, 2
• Reducing viral load through treatment allows the host immune response to eliminate residual virus 1, 2

Topical Chemical Treatments

10% Potassium Hydroxide Solution

• Has similar efficacy to cryotherapy in children (86.6% complete response for KOH vs 93.3% for cryotherapy) 1
• Confers better cosmetic results than cryotherapy due to lower risk of hyperpigmentation 1
• Recommended by the American Academy of Pediatrics as first-line topical therapy 1

Cantharidin

• Shows effectiveness in observational studies, though randomized controlled trial evidence is limited 1, 3
• Considered a practical first-line approach by many practitioners for lesions requiring treatment 3, 4
• Applied topically by the physician in office settings 3

Treatments NOT Recommended

Imiquimod

• The FDA label explicitly states that imiquimod failed to demonstrate efficacy for molluscum contagiosum in two randomized, vehicle-controlled trials 5
• In Study 1: 24% clearance with imiquimod vs 26% with vehicle 5
• In Study 2: 24% clearance with imiquimod vs 28% with vehicle 5
• The American Academy of Pediatrics explicitly states that imiquimod should not be used for molluscum contagiosum as it was not shown to be of benefit compared with placebo 1
• Despite lack of efficacy, it may be considered in immunosuppressed patients with severe, recalcitrant lesions where other options have failed 6

Watchful Waiting

• Reasonable approach for asymptomatic, limited disease in immunocompetent patients 1, 7
• Lesions typically resolve spontaneously in 6-12 months but can persist up to 4-5 years 1, 8
• However, active treatment is indicated for: symptomatic lesions, multiple lesions, lesions near eyes causing conjunctivitis, prevention of transmission, or patient preference 1, 2

Special Populations and Considerations

Periocular Lesions

• For lesions on or near eyelids with associated conjunctivitis, physical removal is mandatory 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
• Monitor for persistence of conjunctivitis requiring follow-up 1, 2

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 2
• May develop severe and recalcitrant lesions requiring referral to dermatology 1, 2
• Consider cidofovir, imiquimod, or interferon in severe cases despite limited evidence for imiquimod 6

Pediatric Patients

• Cryotherapy, curettage, and 10% potassium hydroxide are all appropriate first-line options 1, 7
• Avoid salicylic acid in children under 2 years due to risk of systemic toxicity 7
• Destructive therapies may be poorly tolerated in young children 9

Treatment Algorithm

1. Confirm diagnosis by identifying characteristic dome-shaped papules with central umbilication 1, 2
2. Assess disease extent: number of lesions, location, presence of conjunctivitis, symptoms 1, 2
3. For limited disease in immunocompetent patients: proceed with physical removal (cryotherapy, curettage, or excision) or 10% potassium hydroxide 1, 2
4. For periocular lesions with conjunctivitis: physical removal is mandatory 1, 2
5. For extensive disease or immunocompromised patients: refer to dermatology 1, 2
6. Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2

Critical Pitfalls to Avoid

• Failing to treat nascent lesions during initial treatment is a common cause of recurrence 1
• Do not use imiquimod based on FDA trial data showing no benefit over placebo 5
• Do not use ranitidine or other H2 blockers, as there is no evidence supporting efficacy for this condition 7
• Avoid cryotherapy on sensitive areas (eyelids, lips, nose, ears) 1