What are the recommended treatment options for molluscum contagiosum in healthy children or adults with few lesions versus patients with numerous lesions or immunosuppression?

Treatment of Molluscum Contagiosum

For healthy children and adults with few lesions, watchful waiting is reasonable as spontaneous resolution typically occurs within 6-12 months, but for symptomatic lesions, multiple lesions, periocular involvement, or immunocompromised patients, physical removal methods (curettage, excision, or cryotherapy) are first-line therapy. 1, 2, 3

Treatment Algorithm by Clinical Scenario

Limited Disease in Immunocompetent Patients

Watchful waiting is appropriate when:

• Lesions are asymptomatic 3
• Limited number of lesions present 3
• No periocular involvement 3
• Patient/family accepts natural course of 6-12 months (up to 4-5 years possible) 1, 3

Active treatment is indicated when:

• Lesions are symptomatic (painful, itchy, inflamed) 1, 3
• Multiple lesions present 1, 2, 3
• Lesions near eyes causing conjunctivitis 1, 2, 3
• Patient desires treatment to prevent autoinoculation and transmission 3, 4
• Cosmetic concerns (though warn that treatment may cause hyperpigmentation or scarring) 1, 4

First-Line Physical Removal Methods

Cryotherapy with liquid nitrogen:

• Achieves complete response in approximately 93% of cases 1, 3
• Apply until visible freezing extends slightly beyond lesion margin into normal skin 1
• Major caveat: Risk of postinflammatory hyperpigmentation (may persist 6-12 months) or scarring, particularly in darker skin tones 1, 3
• Avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk 1
• No anesthesia typically needed 1

Curettage, excision, or excision with cautery:

• Equally effective first-line options recommended by the American Academy of Ophthalmology 1, 2, 3
• Particularly useful for periocular lesions 2, 3

First-Line Chemical Treatments (Children)

10% potassium hydroxide solution:

• Similar efficacy to cryotherapy (86.6% vs 93.3% complete response) 1
• Better cosmetic results with lower risk of hyperpigmentation compared to cryotherapy 1
• Recommended by the American Academy of Pediatrics as first-line chemical treatment 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

Identify and treat ALL lesions, including nascent ones:

• Reducing viral load allows host immune response to eliminate residual virus 1, 2
• Failure to treat early lesions is a common cause of recurrence 1
• Examine carefully for nascent lesions during initial treatment 1

Periocular lesions with conjunctivitis:

• Physical removal is imperative 1, 2
• Conjunctivitis may require several weeks to resolve after lesion elimination 1, 2
• Monitor for resolution at follow-up 2, 3

Extensive Disease or Immunocompromised Patients

Red flags suggesting immunocompromised state:

• Multiple large lesions with minimal inflammation 1, 2
• Giant, disseminated, necrotic, polypoidal, or nodular forms 1
• Extensive or recalcitrant disease 1

Management approach:

• Consider screening for HIV or other immunodeficiency 1, 5
• Refer to dermatology for examination of suspicious lesions 1, 2
• More aggressive treatment needed as spontaneous resolution is impaired 4, 6

Treatments to AVOID

Imiquimod:

• Not effective—showed no benefit compared to placebo in randomized controlled trials 1, 3
• Explicitly not recommended by the American Academy of Pediatrics 1, 3

Salicylic acid in young children:

• Contraindicated in children under 2 years due to risk of systemic toxicity 3

Age-Specific Considerations

Children:

• Physical removal or 10% potassium hydroxide are preferred first-line options 1, 3
• Cryotherapy effective but higher risk of cosmetic complications 1, 3
• Hand hygiene is most important prevention method 1, 3
• Cover lesions with waterproof bandages if water exposure unavoidable 1, 3

Adults:

• Same physical removal methods (curettage, excision, cryotherapy) recommended 2
• Genital lesions warrant treatment to reduce sexual transmission risk 6
• Follow-up not usually necessary unless conjunctivitis persists or new lesions develop 2

Common Pitfalls

• Missing nascent lesions during initial treatment leads to recurrence 1
• Undertreating periocular lesions can result in persistent conjunctivitis 1, 2
• Not recognizing immunocompromised state when multiple large lesions present with minimal inflammation 1, 2, 5
• Using imiquimod despite lack of evidence for efficacy 1, 3
• Expecting immediate resolution of conjunctivitis after lesion removal—may take weeks 1, 2