What is the recommended treatment approach for molluscum contagiosum in otherwise healthy children?

Treatment of Molluscum Contagiosum in Pediatrics

Primary Recommendation

For otherwise healthy children with molluscum contagiosum, watchful waiting without active treatment is the most appropriate approach for asymptomatic, limited lesions, as spontaneous resolution typically occurs within 6-12 months and treatment does not shorten time to resolution. 1, 2, 3

Treatment Algorithm

When to Observe (No Active Treatment)

• Asymptomatic lesions with limited number and no periocular involvement should be managed with watchful waiting 2
• Approximately 50% of children will have complete clearance within 12 months and 70% within 18 months without any intervention 3
• Treatment does not shorten time to resolution compared to observation in otherwise healthy children 3

When Active Treatment is Indicated

Active intervention is warranted in the following scenarios:

1. Symptomatic lesions (pain, itching, or inflammation) 1, 2

2. Multiple or extensive lesions 1, 2

3. Periocular lesions causing conjunctivitis - this is an absolute indication for treatment 1, 2

4. Lesions causing significant psychosocial distress or cosmetic concerns 1

First-Line Treatment Options

Physical Removal Methods (Preferred)

Physical removal through curettage, simple excision, or cryotherapy is recommended as first-line therapy when active treatment is indicated 1, 2

• Cryotherapy with liquid nitrogen: Achieves complete response in approximately 93% of cases 1, 2
  • Risk of postinflammatory hyperpigmentation (most common adverse effect, may persist 6-12 months) 1
  • Uncommonly causes scarring 1, 2
  • Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1

Chemical Treatments

10% potassium hydroxide solution: Similar efficacy to cryotherapy (86.6% complete response) with better cosmetic results due to lower risk of hyperpigmentation 1, 2

Cantharidin: Effective in observational studies with 86% parent satisfaction and no serious adverse events in 405 children over 1,056 treatment visits 1

Critical Treatment Principle

When treating, identify and treat ALL lesions including nascent (early) ones to reduce recurrence risk, as reducing viral load allows the host immune response to eliminate residual virus 1, 2

Special Considerations

Periocular Lesions with Conjunctivitis

• Physical removal is mandatory 1, 2
• Conjunctivitis may require several weeks to resolve after lesion removal 1
• Follow-up monitoring is necessary to ensure conjunctivitis resolution 1

Children with Atopic Dermatitis

• Expect more widespread lesions and complicated presentations 4, 3
• Children with atopic dermatitis have significantly more lesions than those without 3
• Treatment approach remains the same, though symptom management becomes more important 4

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency 1
• Consider dermatology referral for extensive or recalcitrant disease 1

Treatments to AVOID

Imiquimod is NOT effective and should NOT be used 2, 5

• Showed no benefit compared to placebo in randomized controlled trials in both adults and children 1, 2
• In pediatric studies of 702 children, complete clearance rates were 24% with imiquimod versus 26-28% with vehicle (placebo) 5

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

Prevention and Transmission Control

Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1, 2

Additional measures:

• Avoid sharing towels, clothing, and personal items 1, 2
• Cover all lesions with waterproof bandages if water exposure is unavoidable 1, 2
• Limit exposure to swimming pools associated with known outbreaks 1
• Avoid scratching lesions to prevent autoinoculation 1

Common Pitfalls to Avoid

Do not overlook nascent (early) lesions during initial treatment - their omission is a frequent cause of recurrence 1

Do not neglect periocular lesions - they require active treatment to prevent ocular complications 1

Do not assume treatment accelerates resolution - in healthy children, treatment does not shorten time to clearance compared to observation 3

Do not use imiquimod despite its availability - it has been definitively shown to be ineffective 1, 2, 5