What is the best approach to treating molluscum contagiosum?

Treatment of Molluscum Contagiosum

Primary Treatment Recommendation

Physical removal methods—including cryotherapy with liquid nitrogen, curettage, or excision—are the first-line treatment for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or periocular involvement. 1

Treatment Algorithm

When to Treat Actively vs. Observe

• Treat actively if any of the following are present: 1, 2

  • Symptomatic lesions (pain, itching, redness)
  • Multiple lesions
  • Lesions near the eyes causing conjunctivitis
  • Concerns about transmission to others
  • Patient/parent preference for active intervention

• Watchful waiting is reasonable only for: 2

  • Asymptomatic lesions
  • Limited number of lesions
  • No periocular involvement
  • Note: Lesions typically resolve spontaneously in 6-12 months but can persist up to 4-5 years 1, 3

First-Line Physical Treatment Options

Cryotherapy with liquid nitrogen 1, 2

• Achieves complete response in approximately 93% of cases 2
• Apply until visible freezing extends slightly beyond the lesion margin into normal skin 1
• Common pitfall: Risk of postinflammatory hyperpigmentation (most common adverse effect, may persist 6-12 months) or scarring 1, 2
• Avoid treating sensitive areas including eyelids, lips, nose, and ears due to higher complication risk 1
• No anesthesia is typically needed 1

Curettage or excision 1, 2

• Recommended by the American Academy of Ophthalmology as first-line for periocular lesions 1
• Particularly important for lesions causing conjunctivitis 1

First-Line Chemical Treatment Options

10% potassium hydroxide solution 1, 2

• Similar efficacy to cryotherapy (86.6% complete response vs. 93.3% for cryotherapy) 1
• Better cosmetic results than cryotherapy due to lower risk of hyperpigmentation 1
• Preferred for facial lesions or patients with darker skin tones 1

Cantharidin 1

• Shows effectiveness in observational studies 1
• Limited randomized controlled trial evidence 1

Critical Treatment Principles

Treat ALL lesions, including nascent ones 1

• Carefully examine for early lesions during initial treatment 1
• Common pitfall: Missing nascent lesions is a frequent cause of recurrence 1
• Reducing viral load allows the host immune response to eliminate residual virus 1

Special Populations

Periocular Lesions with Conjunctivitis

• Physical removal is mandatory to resolve conjunctivitis 1
• Conjunctivitis may take several weeks to resolve after lesion removal 1
• Follow-up monitoring required until conjunctivitis resolves 1

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency 1
• Consider referral to dermatology for extensive or recalcitrant disease 1
• Atypical presentations may occur (giant, disseminated, necrotic forms) 1

Children Under 2 Years

• Salicylic acid is contraindicated due to risk of systemic toxicity 2

Treatments That DO NOT WORK

Imiquimod should NOT be used 1, 2, 4

• Showed no benefit compared to placebo in randomized controlled trials in both adults and children 1, 4
• Two pediatric studies (702 subjects) demonstrated 24% clearance with imiquimod vs. 26-28% with vehicle 4
• Explicitly not recommended by the American Academy of Pediatrics 1
• FDA labeling specifically states imiquimod "failed to demonstrate efficacy" for molluscum contagiosum 4

H2 blockers (ranitidine, cimetidine) 2

• No evidence supporting efficacy 2
• Not included in current guidelines 2

Prevention and Transmission Control

Hand hygiene is the most critical prevention method 1, 2

• Use alcohol-based disinfectant or soap and water 1, 2

Avoid transmission through: 1, 2

• Direct skin-to-skin contact
• Sharing towels, clothing, or personal items
• Cover all lesions with waterproof bandages if water exposure unavoidable 2
• Limit exposure to swimming pools associated with known outbreaks 1