Is tacrolimus (immunosuppressive medication) ointment 0.03% effective for treating molluscum contagiosum in a 5-year-old male patient with localized papules on the abdomen and pubic area?

Tacrolimus Ointment Will Not Treat Molluscum Contagiosum and May Worsen the Infection

Do not use tacrolimus ointment 0.03% to treat molluscum contagiosum in this 5-year-old patient, as tacrolimus is an immunosuppressive agent that can actually promote viral replication and cause disseminated molluscum contagiosum rather than treating it. 1

Why Tacrolimus is Contraindicated for Molluscum Contagiosum

Mechanism of Harm

• Tacrolimus is a topical immunosuppressant approved only for atopic dermatitis in patients 2 years and older who are unresponsive to conventional therapies 2
• The immunosuppressive properties that make tacrolimus effective for atopic dermatitis create the opposite effect on viral infections—they suppress local immune surveillance and allow poxviruses like molluscum contagiosum to proliferate 1
• A documented case report demonstrates that a 35-year-old patient developed extensive disseminated molluscum contagiosum after 6 months of tacrolimus treatment for atopic dermatitis, with lesions appearing predominantly in areas where tacrolimus had been heavily applied 1

Evidence of Viral Promotion

• Viral skin infections, particularly poxvirus infections (which include molluscum contagiosum), are directly promoted by topical immunosuppressant treatments like tacrolimus, typically in a dose-dependent manner 1
• This represents a known adverse effect of tacrolimus therapy, not a treatment indication 1

Appropriate Management of Molluscum Contagiosum in This Child

Natural Resolution as Primary Strategy

• The strongest evidence supports watchful waiting, as molluscum contagiosum typically resolves spontaneously within months in immunocompetent children 3
• A comprehensive Cochrane review of 22 studies with 1,650 participants found no single intervention convincingly effective for molluscum contagiosum treatment, making natural resolution the most evidence-based approach 3

Active Treatment Options (If Intervention Desired)

If treatment is pursued for social, cosmetic, or infection-spread concerns, consider these evidence-based options:

• 10% potassium hydroxide solution: Shows moderate evidence of efficacy compared to saline and lower concentrations 3
• Cryotherapy: Demonstrated superior efficacy compared to 5% imiquimod in limited studies 3
• Curettage: Commonly used physical removal method, though formal RCT evidence is lacking 4, 3
• Cantharidin: Widely used by dermatologists despite limited controlled trial data 4, 5

Treatments to Avoid

• 5% imiquimod: High-quality evidence shows no benefit over placebo for clinical cure at 12,18, or 28 weeks, with increased application site reactions (NNTH = 11 for any reaction, NNTH > 40 for severe reactions) 3
• Tacrolimus or other immunosuppressants: Contraindicated due to viral promotion risk 1

Critical Clinical Pitfall

The most important caveat is recognizing that this child may have both molluscum contagiosum AND atopic dermatitis occurring simultaneously, which is common 4. If tacrolimus was being considered because of concurrent atopic dermatitis in the affected areas:

• Treat the atopic dermatitis with alternative agents (topical corticosteroids appropriate for the body site) while avoiding the molluscum lesions themselves 4
• Address the molluscum separately using one of the active treatment options above or watchful waiting 3
• Never apply tacrolimus directly to or near molluscum lesions 1