What is the first-line treatment for molluscum contagiosum in a healthy 30-year-old man?

Treatment of Molluscum Contagiosum in a 30-Year-Old Male

Physical removal methods—specifically cryotherapy with liquid nitrogen, curettage, or simple excision—are the recommended first-line treatments for molluscum contagiosum in a healthy 30-year-old man. 1

First-Line Treatment Options

Physical Removal Methods (Preferred)

• Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases and is recommended as first-line therapy 2, 1
• Incision and curettage is equally effective as a physical removal method 1
• Simple excision or excision with cautery are also recommended first-line options 1
• Physical removal methods are particularly important for preventing transmission and reducing associated symptoms 2

Topical Chemical Treatments (Alternative)

• 10% potassium hydroxide solution has similar efficacy to cryotherapy (86.6% complete response vs 93.3% for cryotherapy) and confers better cosmetic results due to lower risk of hyperpigmentation 2
• Cantharidin has shown effectiveness in observational studies, with 86% patient satisfaction in a large retrospective review of 405 patients, though randomized controlled trial evidence is limited 2, 3

Treatment Algorithm

1. Confirm diagnosis by identifying characteristic skin-colored, whitish, or pink dome-shaped papules with central umbilication and shiny surface 1

2. Assess disease extent: Look for number of lesions, location (particularly genital area in adults), and presence of complications like conjunctivitis if lesions are near eyes 1

3. Screen for immunocompromised state if multiple large lesions are present with minimal inflammation 1

4. Treat all lesions including nascent ones to reduce viral load and allow host immune response to eliminate residual virus, thereby reducing recurrence risk 2, 1

5. For genital lesions: Treatment is recommended to reduce sexual transmission risk, prevent autoinoculation, and improve quality of life 4, 5

Special Considerations for Adults

• In sexually active adults with genital molluscum contagiosum, offer screening for other sexually transmitted infections 4
• While lesions may spontaneously resolve in 6 months to 5 years, treatment is generally recommended in adults to prevent sexual transmission 1, 5
• For genital lesions, curettage is commonly chosen by OB/GYNs, while cryotherapy is preferred by other specialties 6

Important Caveats

What NOT to Use

• Imiquimod was not shown to be of benefit compared with placebo in randomized controlled trials for molluscum contagiosum and should not be used 2
• However, imiquimod may have a role in severely immunocompromised HIV-positive patients with resistant lesions 7

Watchful Waiting

• Watchful waiting is reasonable for asymptomatic, limited disease in immunocompetent patients, as spontaneous resolution typically occurs in 6-12 months 2
• However, many clinicians recommend treatment of genital lesions to reduce sexual transmission risk 5

Treatment Technique

• Identify and treat all lesions, including nascent ones, as missing early lesions is a common cause of recurrence 2
• The goal is to reduce viral load sufficiently to allow the host immune response to eliminate residual virus 1

Follow-Up

• Follow-up is not usually necessary unless new lesions develop or complications persist 1
• For lesions near eyes with associated conjunctivitis, the conjunctivitis may require weeks to resolve after lesion removal 1