What are the recommended management and treatment options for molluscum contagiosum?

Management and Treatment of Molluscum Contagiosum

Primary Treatment Recommendation

Physical removal methods—including cryotherapy with liquid nitrogen, curettage, or excision—are the first-line treatment for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those near the eyes causing conjunctivitis. 1

Treatment Algorithm

When to Treat vs. Observe

Actively treat in these situations:

• Lesions causing symptoms (pain, itching, redness) 1, 2
• Multiple or extensive lesions 1
• Lesions on or near eyelids with associated conjunctivitis 1
• Genital lesions in sexually active individuals (to reduce transmission risk and improve quality of life) 3, 4, 5
• Immunocompromised patients (lesions persist longer and spread more extensively) 6, 2

Watchful waiting is reasonable for:

• Asymptomatic, limited disease in immunocompetent patients 1
• Lesions typically resolve spontaneously in 6-12 months, though can persist up to 4-5 years 1, 2

First-Line Treatment Options

1. Cryotherapy with Liquid Nitrogen

• Achieves complete response in approximately 93% of cases 1
• Apply until visible freezing extends slightly beyond lesion margin into normal skin 1
• Major caveat: Higher risk of postinflammatory hyperpigmentation (may persist 6-12 months) and uncommonly scarring, particularly problematic in darker skin tones and facial lesions 1
• Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1
• No anesthesia needed—has not been shown helpful 1

2. 10% Potassium Hydroxide Solution

• Similar efficacy to cryotherapy (86.6% complete response) 1
• Better cosmetic results due to lower risk of hyperpigmentation 1
• Preferred for facial lesions or patients with darker skin 1

3. Cantharidin

• Creates controlled blistering that destroys infected epithelium 1
• Large retrospective review of 405 children showed no serious adverse events, with 86% parent satisfaction 1
• Effectiveness demonstrated in observational studies, though randomized controlled trial evidence is limited 1

Critical Treatment Principles

Treat ALL lesions, including nascent ones, during the initial visit:

• Carefully examine for early lesions that may appear as simple dome-shaped papules without umbilication 1
• Treating nascent lesions simultaneously reduces recurrence risk 1
• Reducing viral load allows host immune response to eliminate residual virus 1

What NOT to Use

Imiquimod is NOT recommended:

• FDA-labeled studies in pediatric molluscum contagiosum showed no benefit compared to placebo (24% clearance with imiquimod vs. 26-28% with vehicle) 7
• The American Academy of Pediatrics explicitly states imiquimod should not be used 1

Special Populations

Periocular Lesions

• Physical removal is imperative when lesions cause conjunctivitis 1
• Conjunctivitis may take several weeks to resolve after lesion removal 1
• Monitor for persistent conjunctivitis requiring follow-up 1

Immunocompromised Patients

• Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency 1
• May require referral to dermatology for extensive or recalcitrant disease 1
• Consider cryptococcal infection as differential diagnosis (can present with umbilicated papules resembling molluscum in HIV patients) 6, 2

Genital Lesions

• Treatment recommended to reduce sexual transmission risk 3, 4, 5
• Screen for other sexually transmitted infections 5
• Physical procedures like cryotherapy are safe in pregnancy 5

Common Pitfalls to Avoid

• Missing nascent lesions is the most frequent cause of recurrence 1
• Neglecting periocular lesions can lead to persistent conjunctivitis and ocular complications 1
• Assuming all genital papules are molluscum—laboratory confirmation should be sought for genital ulcerative lesions, as HSV is the most common cause of sexually acquired genital ulceration 8
• Treating sensitive areas with cryotherapy (eyelids, lips, nose, ears) increases complication risk 1

Prevention and Transmission Control

• Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1
• Avoid direct skin contact with infected individuals 1
• Do not share towels, clothing, or personal items 1
• 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