What is the management approach for a child or young adult diagnosed with molluscum contagiosum?

Molluscum Contagiosum Management

Primary Treatment Recommendation

For children and young adults with molluscum contagiosum, physical removal methods (curettage, excision, or cryotherapy) are first-line therapy when lesions are symptomatic, multiple, or located near the eyes causing conjunctivitis, while watchful waiting is appropriate for asymptomatic, limited disease. 1, 2

Treatment Algorithm

Step 1: Assess Disease Characteristics

• Asymptomatic, limited lesions, no periocular involvement: Watchful waiting is reasonable, as spontaneous resolution typically occurs in 6-12 months (though can persist up to 4-5 years) 1, 2

• Symptomatic lesions, multiple lesions, or periocular involvement: Active treatment is indicated to prevent autoinoculation, transmission, and complications 1, 2

• Large, multiple lesions with minimal inflammation: Consider screening for immunocompromised state before proceeding with treatment 1, 3

Step 2: Select Treatment Modality

Physical Removal Methods (First-Line):

• Cryotherapy with liquid nitrogen: Achieves complete response in approximately 93% of cases 1, 2

  • Risk of postinflammatory hyperpigmentation (most common cosmetic concern, may persist 6-12 months) or scarring 1, 2
  • Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1
  • No anesthesia typically used, as it has not been shown helpful 1

• Curettage, simple excision, or excision with cautery: Equally effective alternatives to cryotherapy 1, 3

Chemical Treatments (Alternative First-Line):

• 10% potassium hydroxide solution: Similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic results due to lower hyperpigmentation risk 1, 2

  • Contraindicated in children under 2 years when using salicylic acid formulations due to systemic toxicity risk 2

• Cantharidin: Shows effectiveness in observational studies, though randomized controlled trial evidence is limited 1

Step 3: Special Considerations

Periocular Lesions with Conjunctivitis:

• Physical removal is imperative to resolve conjunctivitis 1, 3
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 3
• Monitor for resolution at follow-up 1, 2

Treatment Technique:

• Identify and treat ALL lesions, including nascent ones, to reduce recurrence risk 1, 3
• Reducing viral load allows host immune response to eliminate residual virus 1, 3

Treatments to AVOID

Imiquimod 5%:

• Do NOT use imiquimod for molluscum contagiosum 1, 2, 4
• High-quality evidence from multiple randomized controlled trials shows 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
• Causes significantly more application site reactions (RR 1.41,95% CI 1.13-1.77; NNTH = 11) and severe reactions (RR 4.33,95% CI 1.16-16.19) 1, 5
• FDA label confirms pediatric studies failed to demonstrate efficacy (24% clearance with imiquimod vs 26-28% with vehicle) 4

Other Ineffective Treatments:

• H2 blockers (ranitidine): No evidence supporting efficacy 2

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
• Avoid skin contact with infected individuals and limit exposure to swimming pools associated with known outbreaks 1

Follow-Up

• Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 3
• For extensive or recalcitrant disease, consider dermatology referral 1, 3

Critical Pitfalls to Avoid

• Missing nascent lesions during initial treatment is a common cause of recurrence—examine carefully for early dome-shaped papules without visible umbilication 1
• Neglecting periocular lesions can lead to persistent conjunctivitis requiring active treatment 1
• Using imiquimod wastes time and money while causing unnecessary side effects without benefit 1, 2, 4, 5