What are the treatment options for pediatric patients with molluscum contagiosum?

Treatment of Molluscum Contagiosum in Pediatrics

Primary Recommendation

For pediatric patients with molluscum contagiosum, physical removal methods (curettage, cryotherapy, or excision) are first-line therapy for symptomatic lesions, multiple lesions, or periocular involvement, while watchful waiting is appropriate for asymptomatic, limited disease. 1, 2

Treatment Algorithm

When to Treat Actively

Active treatment is indicated for:

• Symptomatic lesions causing pain, itching, or discomfort 1
• Multiple or widespread lesions 1, 2
• Periocular lesions, especially those causing conjunctivitis 1, 2
• Lesions causing social stigma or impacting quality of life 1
• Prevention of autoinoculation and transmission to others 2

When Watchful Waiting is Appropriate

Observation without treatment 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, 2

First-Line Treatment Options

Physical Removal Methods (Preferred)

Curettage:

• Most effective option with 70% cure after one treatment and 96% cure after two treatments 3
• High patient and parent satisfaction (97%) 3
• Recommended by the American Academy of Ophthalmology as first-line therapy 1, 2

Cryotherapy with liquid nitrogen:

• Achieves complete response in approximately 93% of cases 1, 2
• Similar efficacy to potassium hydroxide (93.3% vs 86.6%) 1
• Important caveat: Risk of postinflammatory hyperpigmentation or scarring, particularly in darker skin tones 1, 2
• Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1

Chemical Treatments

10% Potassium Hydroxide Solution:

• Recommended by the American Academy of Pediatrics as first-line chemical treatment 1
• Similar efficacy to cryotherapy (86.6% complete response) 1
• Better cosmetic results with lower risk of hyperpigmentation compared to cryotherapy 1

Cantharidin:

• Effective in observational studies, though randomized controlled trial evidence is limited 1
• Practical first-line option for many practitioners 4

Special Considerations for Periocular Lesions

For lesions on or near the eyelids with conjunctivitis:

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

Critical Treatment Principles

Treat all lesions, including nascent ones:

• Carefully examine for early lesions during initial treatment 1
• Treating nascent lesions simultaneously reduces recurrence risk 1
• Reducing viral load allows host immune response to eliminate residual virus 1

Treatments to AVOID

Imiquimod is NOT recommended:

• The American Academy of Pediatrics explicitly states imiquimod showed no benefit compared to placebo in randomized controlled trials 1, 2
• FDA drug label confirms two pediatric studies (702 subjects) failed to demonstrate efficacy: complete clearance was 24% with imiquimod versus 26-28% with vehicle 5
• This directly contradicts one small observational study 6, but guideline-level evidence and FDA data take precedence

Salicylic acid:

• Contraindicated in children under 2 years due to risk of systemic toxicity 2

Age-Specific Considerations

Children under 2 years:

• Avoid salicylic acid 2
• Physical removal methods remain safe and effective 1, 2

Children 2-12 years:

• All treatment modalities can be considered 1, 2
• Curettage shows excellent effectiveness and acceptance in this age group 3

Red Flags Requiring Further Evaluation

Multiple large lesions with minimal inflammation:

• May indicate immunocompromised state 1, 7
• Consider screening for immunodeficiency 1
• Referral to dermatology may be necessary 1

Prevention and Transmission Control

Hand hygiene is the most important preventive measure:

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

Follow-Up

Follow-up is not usually necessary unless:

• Conjunctivitis persists after lesion removal 1
• New lesions develop 7
• Extensive or recalcitrant disease suggests immunocompromised state 1