How should molluscum contagiosum be managed in a healthy patient—what are the first‑line treatment options and when is watchful waiting appropriate?

Molluscum Contagiosum Management in Healthy Patients

Direct Recommendation

In healthy patients with molluscum contagiosum, physical removal methods (curettage, excision, or cryotherapy) are first-line treatment for symptomatic lesions, multiple lesions, or periocular involvement, while watchful waiting is appropriate for asymptomatic, limited disease away from the eyes. 1, 2, 3

Treatment Algorithm

When to Treat Actively

Proceed with active treatment if any of the following are present:

• Symptomatic lesions (pain, itching, redness) 1, 3
• Multiple lesions (increased risk of autoinoculation and transmission) 1, 2
• Periocular lesions causing associated conjunctivitis 1, 2, 3
• Patient preference to reduce transmission risk or for cosmetic concerns 4, 5

When Watchful Waiting is Appropriate

Observation alone is reasonable when:

• Lesions are asymptomatic 3
• Limited number of lesions present 3
• No periocular involvement 3
• Patient accepts spontaneous resolution timeline of 6-12 months (though can extend to 4-5 years) 1, 3

First-Line Treatment Options

Physical Removal Methods (Preferred)

The American Academy of Ophthalmology recommends physical removal as first-line therapy: 1, 2

• Curettage (incision and curettage) 1, 2
• Simple excision or excision with cautery 1, 2
• Cryotherapy with liquid nitrogen - achieves 93% complete response rate 1, 3

Critical technique point: Identify and treat ALL lesions including nascent (early) ones during the initial treatment session, as missing these is the most common cause of recurrence 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 with 86% parent satisfaction and no serious adverse events in large retrospective review of 405 children 1

Comparative Considerations Between Treatment Modalities

Cryotherapy advantages: Higher complete response rate (93%) 3

Cryotherapy disadvantages: Risk of postinflammatory hyperpigmentation (especially in darker skin tones) and uncommon scarring; avoid on sensitive areas (eyelids, lips, nose, ears) 1, 3

Potassium hydroxide advantages: Better cosmetic outcomes, lower hyperpigmentation risk 1, 3

Physical removal rationale: Reducing viral load allows host immune response to eliminate residual virus 1, 2

Special Situations Requiring Immediate Treatment

Periocular Lesions with Conjunctivitis

Physical removal is imperative when lesions are on or near eyelids with associated conjunctivitis 1, 2

• Conjunctivitis may require several weeks to resolve after lesion removal 1, 2
• Follow-up monitoring is necessary if conjunctivitis persists 1, 2

Red Flags for Immunocompromised State

Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency and dermatology referral 1, 2

Treatments to AVOID

Imiquimod should NOT be used - showed no benefit compared to placebo in randomized controlled trials 1, 3

Prevention Counseling

Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1, 3

Avoid sharing:

• Towels, clothing, personal items 1, 3
• Swimming pools associated with known outbreaks 1

Cover all lesions with waterproof bandages if water exposure is unavoidable 1, 3

Avoid scratching to prevent autoinoculation and spread 1

Common Pitfalls

• Missing nascent lesions during initial treatment leads to recurrence 1
• Undertreating periocular lesions can result in persistent conjunctivitis 1, 2
• Not screening for immunodeficiency when extensive disease with minimal inflammation is present 1, 2
• Using imiquimod despite lack of efficacy evidence 1, 3

Follow-Up

Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop 1, 2