Treatment Options for Molluscum Contagiosum
First-Line Treatment Recommendation
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
Treatment Algorithm
For Immunocompetent Children and Adults
Active Treatment Indications:
- Symptomatic lesions (pain, itching, inflammation) 1, 3
- Multiple lesions (to prevent autoinoculation and transmission) 1, 3
- 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 lesion margin into normal skin 1
- Common pitfall: Risk of postinflammatory hyperpigmentation (most common cosmetic concern, may persist 6-12 months) or scarring, particularly in darker skin tones 1, 3
- Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1
- No anesthesia 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, 3
- Better cosmetic results than cryotherapy due to lower risk of hyperpigmentation 1, 3
- Particularly appropriate for facial lesions or patients with darker skin 1
Cantharidin:
- Shows effectiveness in observational studies, though randomized controlled trial evidence is limited 1
- Can be considered as an alternative option 1
Critical Treatment Principle
Identify and treat ALL lesions, including nascent (early) ones, during the initial treatment session to reduce recurrence risk. 1, 2 Reducing viral load allows the host immune response to eliminate residual virus 1, 2
Treatments That Should NOT Be Used
Imiquimod:
- FDA-labeled indication explicitly states that studies in children ages 2-12 with molluscum contagiosum failed to demonstrate efficacy 4
- Showed no benefit compared to placebo in randomized controlled trials 1, 3
- Should not be used for molluscum contagiosum 1, 3
Special Populations
Periocular Lesions
- Physical removal is imperative when lesions are 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
Immunocompromised Patients
- Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state 1, 2
- Consider referral to dermatology for extensive or recalcitrant disease 1, 2
- May present with atypical manifestations (giant, disseminated, necrotic forms) without classic umbilication 1
Pediatric Considerations
- Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 3
- Physical removal methods and 10% potassium hydroxide are appropriate first-line options 1, 3
- Safety and efficacy not established for children under 12 years for genital/perianal warts 4
Prevention and Transmission Control
Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1, 3
Additional measures:
- Avoid skin-to-skin contact with infected individuals 1
- Do not share towels, clothing, or personal items 1, 3
- Cover all lesions with waterproof bandages if water exposure unavoidable 1, 3
- Limit exposure to swimming pools and hot tubs associated with known outbreaks 1
- Avoid scratching lesions to prevent autoinoculation 1