What are the management options for a patient with Molluscum contagiosum, considering the condition's self-limiting nature and potential need for treatment due to discomfort, numerous lesions, or a weakened immune system?

Molluscum Contagiosum Management

Direct Recommendation

Physical removal methods (cryotherapy, curettage, or excision) are first-line therapy for symptomatic lesions, multiple lesions, or those causing complications like conjunctivitis, while watchful waiting remains appropriate for asymptomatic, limited disease in immunocompetent patients. 1

Treatment Algorithm

Step 1: Assess Disease Severity and Patient Factors

• Identify lesion characteristics: Look for skin-colored, whitish, or pink papules with shiny surface and central umbilication on trunk, face, and extremities 1
• Count lesions and assess distribution: Multiple lesions warrant more aggressive treatment to reduce viral load and prevent autoinoculation 1
• Check for complications: Examine for associated conjunctivitis if lesions are on or near eyelids, perilesional eczema, or signs of bacterial superinfection 1
• Screen for immunocompromise: Multiple large lesions with minimal inflammation should raise suspicion for HIV or other immunodeficiency 1, 2

Step 2: Select Treatment Based on Clinical Scenario

For Symptomatic, Multiple, or Periocular Lesions (Active Treatment Indicated)

First-line physical removal options (choose based on availability and patient tolerance):

• Cryotherapy with liquid nitrogen: Achieves 93% complete response rate, but carries higher risk of postinflammatory hyperpigmentation (especially in darker skin) and uncommon scarring 1
• Curettage, simple excision, or excision with cautery: Equally effective alternatives recommended by the American Academy of Ophthalmology 1, 2
• 10% potassium hydroxide solution: Similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic outcomes due to lower hyperpigmentation risk 1
• Cantharidin: Effective in observational studies, now FDA-approved as drug-device product, though randomized trial evidence remains limited 1, 3

For Asymptomatic, Limited Disease in Immunocompetent Patients

• Watchful waiting is reasonable: Spontaneous resolution typically occurs in 6-12 months, though can extend to 4-5 years 1, 4
• Consider treatment anyway to prevent transmission to others, reduce autoinoculation risk, and improve quality of life 5, 3

Step 3: Execute Treatment with Key Technical Points

When performing physical removal:

• Treat ALL lesions including nascent ones: Carefully examine for early dome-shaped papules without visible umbilication, as missing these is the most common cause of recurrence 1
• Reducing viral load allows host immune response to clear residual virus 1, 2
• Avoid sensitive areas with cryotherapy: Do not treat eyelids, lips, nose, or ears due to higher complication risk 1
• No anesthesia needed for cryotherapy: Has not been shown helpful, and success depends on operator skill and complete application 1

For periocular lesions with conjunctivitis:

• Physical removal is imperative: Conjunctivitis will not resolve without lesion removal 1
• Expect delayed resolution: Conjunctivitis may require several weeks to resolve after lesion elimination 1

Step 4: Follow-Up Strategy

• No routine follow-up needed unless conjunctivitis persists or new lesions develop 1, 2
• For extensive or recalcitrant disease: Screen for immunocompromised state and consider dermatology referral 1

Critical Pitfalls to Avoid

• Do NOT use imiquimod: Explicitly shown to have no benefit compared to placebo in randomized trials 1
• Do NOT use ranitidine or H2 blockers: No evidence supports efficacy for molluscum contagiosum 6
• Do NOT use salicylic acid in children under 2 years: Risk of systemic toxicity 6
• Do NOT dismiss "benign neglect" concerns: While self-limiting, untreated lesions increase transmission risk, prolong infection duration, and cause psychosocial distress 3
• Do NOT overlook nascent lesions: Treating only visible umbilicated papules while missing early lesions leads to treatment failure 1

Special Populations

Immunocompromised patients:

• Expect atypical presentations including giant, disseminated, necrotic, or nodular forms without classic umbilication 1
• Consider cryptococcal infection in differential diagnosis 1
• Lesions persist longer and require more aggressive treatment 5

Sexually active adults:

• Genital lesions warrant treatment to reduce sexual transmission risk 5
• Large multiple lesions with minimal inflammation should prompt HIV screening 2

Prevention Counseling

• Hand hygiene is most important: Alcohol-based disinfectant or soap and water 1
• Avoid direct skin contact with infected individuals and sharing towels, clothing, or personal items 1
• Cover lesions with waterproof bandages if water exposure unavoidable 1
• Limit pool/hot tub exposure: Particularly avoid facilities with known outbreaks; hot tubs pose higher risk than pools 1