Molluscum Contagiosum Treatment
First-Line Treatment Recommendation
Physical removal methods—including cryotherapy with liquid nitrogen, curettage, or simple excision—are the recommended first-line treatments for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those near the eyes causing conjunctivitis. 1, 2
Treatment Algorithm
For Immunocompetent Patients
Physical Removal Methods:
- Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases and is highly effective 1
- Curettage, simple excision, or excision with cautery are equally effective alternatives 1, 2
- Treat ALL lesions simultaneously, including nascent (early) ones, as this reduces viral load and allows the host immune response to eliminate residual virus 1, 3
Topical Chemical Treatments:
- 10% potassium hydroxide solution is as effective as cryotherapy (86.6% vs 93.3% complete response) and offers better cosmetic results with lower risk of postinflammatory hyperpigmentation 1
- Can be applied at home by parents for children, providing convenience 3
Watchful Waiting:
- Reasonable for asymptomatic, limited disease in immunocompetent patients 1
- Lesions typically resolve spontaneously in 6-12 months but can persist up to 4-5 years 1, 4
For Pregnant Patients
Physical procedures such as cryotherapy are safe to use during pregnancy 4
For Immunocompromised Patients
- Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency 1, 2
- Severe and recalcitrant lesions may require cidofovir, imiquimod, or interferon 4
- Referral to dermatology is recommended for extensive or recalcitrant disease 1
Critical Treatment Principle
Identifying and treating nascent lesions during the initial treatment session is crucial—failure to do so is the most common cause of recurrence 1, 3
What NOT to Use
Imiquimod 5% cream is NOT recommended for molluscum contagiosum. High-quality evidence from multiple randomized controlled trials demonstrates no benefit compared to placebo for clinical cure at 12 weeks (RR 1.33,95% CI 0.92-1.93), 18 weeks (RR 0.88,95% CI 0.67-1.14), or 28 weeks (RR 0.97,95% CI 0.79-1.17) 1, 5, 6. The FDA label confirms that two pediatric studies failed to demonstrate efficacy, with complete clearance rates of 24% for imiquimod versus 26-28% for vehicle 5. The American Academy of Pediatrics explicitly states imiquimod should not be used 1.
Additionally:
- Ranitidine and other H2 antagonists have no evidence of efficacy and should not be used 3
- Salicylic acid is contraindicated in children under 2 years due to systemic toxicity risk 3
Special Considerations for Periocular Lesions
Lesions on or near the eyelids with associated conjunctivitis require active treatment to prevent complications 1, 2, 3:
- Physical removal is imperative for resolution of conjunctivitis 1
- Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
- Careful examination of periocular areas is essential 3
Adverse Effects and Cosmetic Considerations
Cryotherapy risks:
- Postinflammatory hyperpigmentation is the most common adverse effect, potentially persisting 6-12 months 1
- Uncommon scarring may occur 1
- Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1
Potassium hydroxide:
- Better cosmetic outcomes than cryotherapy due to lower hyperpigmentation risk 1
Imiquimod (if used off-label despite lack of efficacy):
- Application site reactions occur more frequently than vehicle (RR 1.41,95% CI 1.13-1.77, NNTH = 11) 6
- Severe application site reactions are significantly more common (RR 4.33,95% CI 1.16-16.19) 5, 6
Follow-Up
Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2