Molluscum Contagiosum Treatment
Primary Treatment Recommendation
Physical removal methods—including curettage, simple excision, cryotherapy with liquid nitrogen, or excision with cautery—are the first-line treatments for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those near the eyes causing conjunctivitis. 1, 2, 3
Treatment Algorithm
For Children
Watchful waiting is appropriate for asymptomatic lesions, limited disease, and no periocular involvement, as spontaneous resolution typically occurs in 6-12 months (though can persist up to 4-5 years) 1, 3
Active treatment is indicated when lesions are symptomatic (painful, itchy), multiple, or located near the eyes with associated conjunctivitis 1, 3
First-line options for children:
- Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases, though carries risk of postinflammatory hyperpigmentation or scarring 1, 3
- 10% potassium hydroxide solution has similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic results due to lower hyperpigmentation risk 1, 3
- Cantharidin shows effectiveness in observational studies, though randomized controlled trial evidence is limited 1
Critical caveat: Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 3
For Adults
Physical removal remains first-line: incision and curettage, simple excision, excision with cautery, or cryotherapy 2
For limited disease in immunocompetent adults: proceed directly with physical removal methods 2
For extensive disease or immunocompromised patients: consider referral to dermatology 2
Special Considerations for Periocular Lesions
Lesions on or near eyelids with associated conjunctivitis require physical removal to prevent ongoing ocular inflammation 1, 2, 3
The conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
Avoid cryotherapy on sensitive areas including eyelids, lips, nose, and ears due to higher complication risk 1
Critical Treatment Principles
Identify and treat ALL lesions, including nascent ones, during the initial treatment session to reduce recurrence risk 1, 2
Reducing viral load through treatment allows the host immune response to eliminate residual virus 1, 2
Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2
Treatments to AVOID
Imiquimod should NOT be used for molluscum contagiosum. Multiple high-quality randomized controlled trials demonstrate 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), while causing significantly more application site reactions (RR 1.41,95% CI 1.13-1.77) and severe reactions (RR 4.33,95% CI 1.16-16.19). 1, 3, 4, 5, 6
Red Flags Requiring Further Evaluation
Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state, as this presentation may indicate underlying immune deficiency 1, 2
Extensive or recalcitrant disease warrants referral to dermatology for evaluation of other suspicious lesions 1
Prevention and Transmission Control
Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 3
Avoid sharing towels, clothing, and personal items 3
Cover all lesions with waterproof bandages if water exposure is unavoidable 1
Limit exposure to swimming pools and hot tubs associated with known outbreaks 1