Treatment of Molluscum Contagiosum
Primary Recommendation
Physical removal methods—including curettage, simple excision, excision with cautery, or cryotherapy with liquid nitrogen—are the first-line treatments for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those near the eyes causing conjunctivitis. 1, 2, 3
Treatment Algorithm
Step 1: Assess Disease Severity and Location
- Asymptomatic, limited lesions without periocular involvement: Watchful waiting is reasonable, as spontaneous resolution typically occurs in 6-12 months (though can persist up to 4-5 years) 1, 2
- Symptomatic lesions, multiple lesions, or periocular involvement: Proceed with active treatment to prevent autoinoculation, transmission, and complications 1, 2
- Periocular lesions with conjunctivitis: Physical removal is mandatory, as conjunctivitis will not resolve until the lesion is eliminated 1, 3
- Multiple large lesions with minimal inflammation: Screen for immunocompromised state and consider dermatology referral 1, 3
Step 2: Select Treatment Modality
Physical Removal Methods (First-Line)
Cryotherapy with liquid nitrogen: Achieves complete response in approximately 93% of cases 1, 2
Curettage, excision, or excision with cautery: Equally effective first-line options recommended by the American Academy of Ophthalmology 1, 3
Chemical Treatments (Alternative First-Line)
10% potassium hydroxide solution: Similar efficacy to cryotherapy (86.6% vs 93.3% complete response) with better cosmetic results due to lower hyperpigmentation risk 1, 2
Cantharidin: Effective in observational studies with 86% parent satisfaction and no serious adverse events in 405 children over 1,056 visits 1
Step 3: Critical Treatment Principles
- Identify and treat ALL lesions, including nascent ones: This is the most common pitfall—missing early lesions is a frequent cause of recurrence 1, 3
- Reducing viral load allows host immune response to eliminate residual virus 1, 3
- For periocular lesions with conjunctivitis: Monitor for resolution, which may require several weeks after lesion removal 1, 3
Treatments to AVOID
- Imiquimod: Explicitly not recommended—showed no benefit compared to placebo in randomized controlled trials 1, 2
- Salicylic acid in children under 2 years: Contraindicated due to risk of systemic toxicity 2
Special Populations
Children
- Physical removal or 10% potassium hydroxide are first-line options 1, 2
- Cantharidin is well-tolerated with high parent satisfaction 1
- Destructive therapies may be poorly tolerated in young children 4
Adults
- Same treatment approach as children: physical removal methods (curettage, excision, cryotherapy) are first-line 3
- In sexually active adults, treatment is recommended to reduce sexual transmission risk and improve quality of life 5
Immunocompromised Patients
- Extensive or recalcitrant disease warrants dermatology referral 1, 3
- Lesions may present atypically (giant, disseminated, necrotic forms) without classic umbilication 1
- Consider cryptococcal infection as differential diagnosis 1
Prevention and Transmission Control
- Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1, 2
- 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 and hot tubs associated with known outbreaks 1
- Return to communal water facilities only when all lesions have completely resolved 1