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

Molluscum Contagiosum Treatment in Children

Primary Treatment Recommendation

For symptomatic, multiple, or periocular molluscum lesions in children, physical removal methods (curettage, cryotherapy, or simple excision) are first-line therapy, while watchful waiting is appropriate for asymptomatic, limited lesions without periocular involvement. 1, 2

Treatment Algorithm

When to Observe vs. Treat

Watchful waiting is reasonable when:

• Lesions are asymptomatic 2
• Limited number of lesions present 2
• No periocular involvement 2
• Lesions typically resolve spontaneously in 6-12 months (though can persist up to 4-5 years) 1, 2

Active treatment is indicated for:

• Symptomatic lesions (pain, itching, redness) 1, 2
• Multiple lesions 1, 2
• Lesions near the eyes causing conjunctivitis 1, 2
• Prevention of autoinoculation and transmission 2
• Cosmetic concerns or social stigma 3

First-Line Treatment Options

Physical Removal Methods

Cryotherapy with liquid nitrogen:

• Achieves complete response in approximately 93% of cases 1, 2
• Major caveat: Risk of postinflammatory hyperpigmentation (most common cosmetic concern, may persist 6-12 months) or scarring 1, 2
• Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1
• No anesthesia typically needed, though treatment success depends heavily on operator skill 1
• Goal is visible freezing extending slightly beyond lesion margin into normal skin 1

Curettage/Simple Excision:

• Recommended by the American Academy of Ophthalmology as first-line for symptomatic or periocular lesions 1, 2
• Particularly important for periocular lesions with conjunctivitis 1, 2

Chemical Treatments

10% Potassium Hydroxide Solution:

• Recommended by the American Academy of Pediatrics as first-line chemical treatment 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

Cantharidin:

• Effective in observational studies with 86% parent satisfaction rate 1
• No serious adverse events found in large retrospective review of 405 children over 1,056 visits 1
• Creates controlled blistering that destroys infected epithelium 1
• Treatment success depends on operator skill and complete application to all lesions including nascent ones 1

Critical Treatment Principles

Treat all lesions including nascent ones:

• Examine carefully 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

Special considerations for periocular lesions:

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

Age-Specific Contraindications

Salicylic acid is contraindicated in children under 2 years due to risk of systemic toxicity 2

Treatments to AVOID

Imiquimod should NOT be used:

• Showed no benefit compared to placebo in randomized controlled trials in children 1, 2, 4
• Two pediatric studies (702 subjects) demonstrated clearance rates of 24% with imiquimod vs. 26-28% with vehicle 4
• The American Academy of Pediatrics explicitly states imiquimod is not effective and should not be used 1, 2

H2 blockers (ranitidine, cimetidine):

• No evidence supporting efficacy 2
• Not included in current American Academy of Pediatrics or American Academy of Dermatology guidelines 2

Prevention and Transmission Control

Hand hygiene is the most important prevention method:

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

Additional prevention measures:

• Avoid sharing towels, clothing, and personal items 1, 2
• Cover all lesions with waterproof bandages if water exposure unavoidable 1, 2
• Limit exposure to swimming pools associated with known outbreaks 1
• Avoid skin-to-skin contact with infected individuals 1

Red Flags Requiring Further Evaluation

Consider immunocompromised state if:

• Multiple large lesions present with minimal inflammation 1
• Extensive or recalcitrant disease 1
• Referral to dermatology may be necessary for examination of other suspicious lesions 1