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

Molluscum Contagiosum Management

Primary Treatment Recommendation

For symptomatic lesions, multiple lesions, or periocular involvement, physical removal methods (curettage, excision, or cryotherapy) are first-line therapy, while watchful waiting is appropriate for asymptomatic, limited disease given spontaneous resolution typically occurs within 6-12 months. 1

Treatment Algorithm

When to Treat Actively

• Symptomatic lesions causing pain, itching, or redness 1
• Multiple lesions to reduce viral load and prevent autoinoculation 1
• Periocular lesions with associated conjunctivitis (physical removal is imperative) 1
• Cosmetic or social concerns affecting quality of life 2, 3
• Prevention of transmission in sexually active adults or communal settings 3, 4

When Watchful Waiting is Reasonable

• Asymptomatic lesions with limited number 5
• No periocular involvement 5
• Immunocompetent patients where lesions typically resolve in 6-12 months (though can persist up to 4-5 years) 1, 2

First-Line Treatment Options

Physical Removal Methods (Preferred by American Academy of Ophthalmology)

• Cryotherapy with liquid nitrogen: Achieves 93% complete response rate 1, 5

  • Apply until visible freezing extends slightly beyond lesion margin 1
  • Caution: Risk of postinflammatory hyperpigmentation (most common adverse effect, may persist 6-12 months) and scarring 1, 5
  • Avoid on sensitive areas (eyelids, lips, nose, ears) 1
  • No anesthesia needed (not shown to be helpful) 1

• Curettage, excision, or excision with cautery: Recommended first-line for periocular lesions 1, 5

Topical Chemical Treatments

• 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, 5

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

  • Creates controlled blistering to destroy infected epithelium 1

Critical Treatment Principles

Comprehensive Lesion Management

• Identify and treat ALL lesions, including nascent (early) ones that may appear as simple dome-shaped papules without umbilication 1
• Reducing viral load allows host immune response to eliminate residual virus 1
• Pitfall: Missing nascent lesions is the most common cause of recurrence 1

Special Populations

Children Under 2 Years:

• Contraindication: Salicylic acid due to systemic toxicity risk 6, 5

Immunocompromised Patients:

• Multiple large lesions with minimal inflammation suggest immunodeficiency 1
• Screen for HIV if extensive or recalcitrant disease 1
• Atypical presentations may include giant, disseminated, necrotic, or nodular forms without classic umbilication 1
• Consider cryptococcal infection as differential diagnosis 1

Periocular Lesions:

• Physical removal mandatory to resolve associated conjunctivitis 1, 5
• Conjunctivitis may take several weeks to resolve after lesion removal 1
• Monitor at follow-up for conjunctivitis resolution 1

Treatments to AVOID

Imiquimod: Explicitly NOT recommended - showed no benefit compared to placebo in randomized controlled trials 1, 5

Ranitidine or H2 blockers: No evidence supporting efficacy for molluscum contagiosum; not included in current American Academy of Pediatrics or American Academy of Dermatology guidelines 6, 5

Transmission Prevention

Essential Hygiene Measures

• Hand hygiene with alcohol-based disinfectant or soap and water is the most important prevention method 1, 5
• Avoid sharing towels, clothing, personal items, and equipment 1, 5
• Avoid scratching lesions to prevent autoinoculation 1

Water Exposure Guidelines

• Cover all lesions with waterproof bandages if water exposure unavoidable 1, 5
• Limit exposure to swimming pools associated with known outbreaks 1
• Higher risk in hot tubs due to warmer water, closer proximity, and shared seating surfaces 1
• Return to hot tub use only when all lesions completely resolved, skin normal, and no new lesions for several weeks 1

Sexual Transmission (Adults)

• MC in adults is commonly sexually transmitted and should prompt screening for other STIs including HIV, syphilis, chlamydia, condyloma acuminata, and genital herpes 4, 7
• Treatment recommended to reduce sexual transmission risk and improve quality of life 3, 4

Follow-Up Considerations

• Not usually necessary unless conjunctivitis persists 1
• Referral to dermatology if extensive/recalcitrant disease or other suspicious lesions present 1
• Lesions remain infectious throughout their course until complete resolution 1