What is the recommended treatment approach for a child with molluscum contagiosum?

Treatment of Molluscum Contagiosum in Children

Primary Recommendation

For symptomatic lesions, multiple lesions, or periocular lesions in children, physical removal methods (curettage, excision, or cryotherapy) are the first-line treatment, while watchful waiting is appropriate for asymptomatic, limited disease. 1, 2

Treatment Algorithm

When to Treat vs. Observe

Active treatment is indicated for:

• Symptomatic lesions (painful, itchy, or inflamed) 2
• Multiple lesions (to prevent autoinoculation and transmission) 1, 2
• Periocular lesions causing conjunctivitis 1, 2
• Lesions causing cosmetic concerns or social stigma 3
• Children with atopic dermatitis (at higher risk for widespread involvement) 3

Watchful waiting is reasonable 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

First-Line Treatment Options

Physical removal methods (recommended by American Academy of Ophthalmology): 1, 2

• Curettage, simple excision, or excision with cautery 2
• Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases 2
• Risk: postinflammatory hyperpigmentation or scarring, particularly in darker skin tones 1, 2

Chemical treatment alternative:

• 10% potassium hydroxide solution (recommended by American Academy of Pediatrics) has similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic results 1, 4
• Can be applied at home by parents 4
• Lower risk of hyperpigmentation compared to cryotherapy 1

Critical Treatment Principles

Identify and treat ALL lesions, including nascent ones, during the initial treatment session to reduce recurrence risk—this is the most common pitfall when lesions recur. 1, 4 Reducing viral load allows the host immune response to eliminate residual virus. 1, 4

Adjunctive Management

For associated itching and xerosis:

• Regular application of emollients to control itching and treat associated xerosis 4
• This is particularly important in children with atopic dermatitis 4

Special Considerations

Periocular lesions with conjunctivitis:

• Physical removal is imperative 1
• Conjunctivitis may take several weeks to resolve after lesion removal 1
• Monitor for resolution at follow-up 1

Age-specific precautions:

• Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 2, 4

Red flags for immunodeficiency:

• Multiple large lesions with minimal inflammation warrant screening for immunocompromised state 1, 4

Treatments to AVOID

Imiquimod should NOT be used—the American Academy of Pediatrics explicitly states it showed no benefit compared to placebo in randomized controlled trials. 1, 2

Ranitidine or other H2 blockers have no evidence of efficacy and are not recommended by current guidelines. 2, 4

Prevention and Transmission Control

Hand hygiene is the most important prevention method:

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

Common Pitfalls to Avoid

• Missing nascent lesions during initial treatment is the most frequent cause of recurrence 1, 4
• Neglecting periocular lesions can lead to persistent conjunctivitis 4
• Using cryotherapy on sensitive areas (eyelids, lips, nose, ears) increases complication risk 1
• Expecting immediate resolution of conjunctivitis—it may take several weeks after lesion removal 1