What are the treatment options for molluscum contagiosum in children?

Treatment for Molluscum Contagiosum in Children

Primary Treatment Recommendation

Physical removal methods (curettage, simple excision, or cryotherapy) are the first-line treatment for molluscum contagiosum in children, particularly for symptomatic lesions, multiple lesions, or those near the eyes. 1, 2

Treatment Algorithm

When to Treat vs. Observe

Watchful waiting is appropriate for:

• Asymptomatic lesions 2
• Limited number of lesions 2
• No periocular involvement 2
• 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, inflammation) 1, 2
• Multiple lesions 1, 2
• Periocular lesions causing conjunctivitis 1, 2
• Prevention of autoinoculation and transmission 2
• Cosmetic concerns or social stigma 3

First-Line Treatment Options

Physical Removal Methods:

• Curettage is the most efficacious treatment with the lowest rate of side effects (4.7%), requiring only one visit in 80.6% of cases 4
• Must be performed with adequate anesthesia and is time-consuming 4
• Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases 1, 2
• Risk of postinflammatory hyperpigmentation or scarring, particularly in darker skin tones 1, 2

Chemical Treatments:

• 10% potassium hydroxide solution has similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic results 1, 2
• Can be applied at home by parents 5
• Lower risk of hyperpigmentation compared to cryotherapy 1

Cantharidin:

• Effective bloodless alternative particularly in office settings 4, 6
• Required one visit in 36.7% of cases, two visits in 43.3%, and three visits in 20.0% 4
• Moderate complication rate (18.6%) due to blister formation 4
• Avoid on facial lesions, eyelids, and diaper area 7

Special Considerations by Location

Periocular Lesions:

• Physical removal is imperative to resolve associated follicular conjunctivitis 1, 5
• Conjunctivitis may require several weeks to resolve after lesion removal 1
• Monitor for resolution at follow-up 1, 2
• Avoid cryotherapy on eyelids due to higher risk of complications 1

Facial Lesions:

• Trichloroacetic acid is a safe alternative for facial molluscum when cantharidin is contraindicated 7
• Consider cosmetic outcomes carefully, as cryotherapy may cause persistent hyperpigmentation 1

Critical Treatment Principles

Treat ALL lesions simultaneously:

• Identify and treat nascent (early) lesions during initial treatment 1, 5
• Reducing viral load allows host immune response to eliminate residual virus 1, 5
• Failure to treat new lesions is a common cause of recurrence 1, 5

Associated Itching Management:

• Regular application of emollients to treat xerosis and reduce itching 5
• Treating all lesions reduces local irritation 5

Age-Specific Restrictions

• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 2, 5
• May be considered at 3 years with caution 5

Treatments to AVOID

Imiquimod:

• Not effective and should NOT be used 2, 5
• Showed no benefit compared to placebo in randomized controlled trials in 702 pediatric subjects 8
• Complete clearance rates were 24% with imiquimod vs. 26-28% with vehicle 8
• High rate of side effects including severe erythema (28%), edema (8%), and application site reactions 8

H2 Antagonists (Ranitidine, Cimetidine):

• No evidence of efficacy 2, 5
• Not recommended by current guidelines 2, 5

Common Pitfalls to Avoid

• Do not miss nascent lesions during initial treatment—this is the most common cause of recurrence 1, 5
• Do not neglect periocular lesions—they require active treatment to prevent ocular complications 1, 5
• Do not use cantharidin on face, eyelids, or diaper area—risk of excessive blistering 7
• Do not use cryotherapy on sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1

Red Flags Requiring Further Evaluation

• Multiple large lesions with minimal inflammation may indicate immunocompromised state 1, 5
• Consider screening for immunodeficiency in extensive or recalcitrant disease 1
• Referral to dermatology may be necessary for atypical presentations 1

Prevention and Transmission Control

• Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 2
• Avoid sharing towels, clothing, and personal items 2
• Cover all lesions with waterproof bandages if water exposure is unavoidable 1
• Limit exposure to swimming pools and hot tubs associated with known outbreaks 1