Molluscum Contagiosum Treatment
Direct Recommendation
Physical removal methods—including curettage, simple excision, or cryotherapy with liquid nitrogen—are the first-line treatments for molluscum contagiosum when active intervention is warranted, achieving complete response rates of approximately 93% with cryotherapy. 1, 2, 3
Treatment Algorithm
Step 1: Determine Need for Active Treatment
Watchful waiting is appropriate for:
- Asymptomatic lesions 3
- Limited number of lesions 3
- No periocular involvement 3
- Lesions typically resolve spontaneously in 6-12 months, though can persist up to 4-5 years 1, 3
Active treatment is indicated for:
- Symptomatic lesions (pain, itching, inflammation) 1, 3
- Multiple lesions 1, 2, 3
- Lesions near the eyes causing conjunctivitis 1, 2, 3
- Concerns about transmission or autoinoculation 3
- Social or cosmetic concerns 4
Step 2: Choose First-Line Treatment
Physical removal methods (preferred):
- Cryotherapy with liquid nitrogen: 93% complete response rate 3
- Curettage, simple excision, or excision with cautery: equally effective options 1, 2
- Identify and treat ALL lesions, including nascent ones, to reduce recurrence risk 1, 2
Chemical treatments (alternative first-line):
- 10% potassium hydroxide solution: similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic results and lower risk of hyperpigmentation 1, 3
- Cantharidin: effective in observational studies, though randomized trial evidence is limited 1, 5
Step 3: Special Populations and Considerations
Children:
- Physical removal or 10% potassium hydroxide are first-line options 3
- Avoid salicylic acid in children under 2 years due to systemic toxicity risk 3
- Consider watchful waiting for asymptomatic cases 3
Periocular lesions:
- Physical removal is mandatory when conjunctivitis is present 1, 2, 3
- Conjunctivitis may require several weeks to resolve after lesion removal 1, 2
- Avoid cryotherapy on sensitive areas like eyelids 1
Immunocompromised patients:
- Multiple large lesions with minimal inflammation suggest immunodeficiency 1, 2
- Consider screening for immunocompromised state 1
- Referral to dermatology may be necessary 2
Treatments to AVOID
Imiquimod 5%:
- High-quality evidence shows NO benefit compared to placebo for clinical cure at 12,18, or 28 weeks 1, 3, 6
- Causes significantly more application site reactions (NNTH = 11) and severe reactions (NNTH > 40) 1
- Should NOT be used 1, 3
Common Pitfalls and How to Avoid Them
Missing nascent lesions:
- Examine carefully for early, small lesions during initial treatment 1
- Treating nascent lesions simultaneously reduces recurrence by lowering viral load 1, 2
Inadequate treatment of periocular disease:
- Do not neglect lesions near the eyes—they require active treatment to prevent ocular complications 1
- Monitor for conjunctivitis resolution at follow-up 1, 2
Cosmetic complications from cryotherapy:
- Postinflammatory hyperpigmentation is the most common adverse effect, persisting 6-12 months 1
- Consider potassium hydroxide for facial lesions or darker skin tones for better cosmetic outcomes 1, 3
- Avoid treating eyelids, lips, nose, and ears with cryotherapy due to higher complication risk 1
Prevention and Transmission Control
Key prevention measures:
- Hand hygiene with alcohol-based disinfectant or soap and water is most important 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
- Lesions remain infectious throughout their entire course until complete resolution 1
Follow-Up
Follow-up is not usually necessary unless: