In patients with molluscum contagiosum, which groups require active treatment rather than observation?

Which Groups with Molluscum Contagiosum Require Active Treatment?

Active treatment should be provided to sexually active adolescents and immunocompromised individuals, while children under 5 years (including those under 3) with simple, asymptomatic lesions can be observed without treatment if the patient/family concurs. 1, 2

Treatment Indications by Population

Sexually Active Adolescents - TREAT

• Treatment of genital molluscum contagiosum lesions is recommended to reduce the risk of sexual transmission, prevent autoinoculation, and increase patient quality of life. 3, 4
• Molluscum contagiosum in sexually active adults has become increasingly common over the past 25 years and can serve as a marker for other sexually transmitted infections. 3
• Physical removal methods (curettage, excision, cryotherapy) are first-line therapy for these patients. 1, 5

Immunocompromised Patients - TREAT

• Immunocompromised individuals require active treatment due to increased difficulty clearing lesions, risk of chronic ulcerated lesions with ongoing viral replication, and potential for secondary bacterial and fungal superinfections. 1, 6, 4
• These patients may present with atypical manifestations including giant, disseminated, necrotic, or polypoidal forms with minimal inflammation. 1
• Multiple large lesions with minimal inflammation should prompt screening for immunodeficiency. 1, 2
• Extensive or recalcitrant disease warrants referral to dermatology. 1

Children Under 5 Years (Including Under 3) - OBSERVATION IS ACCEPTABLE

• For immunocompetent children with clinically simple, asymptomatic lesions that are healing spontaneously, observation without treatment is appropriate if the patient/family concurs. 2
• Lesions typically persist for 6-12 months but can last up to 4-5 years, with spontaneous resolution occurring in most cases. 1, 6
• Physical removal (curettage, excision, cryotherapy) combined with emollients is first-line treatment when intervention is chosen. 2
• Potassium hydroxide 10% solution is an effective alternative that can be applied at home by parents. 2

Specific Treatment Triggers Regardless of Age

Always Treat These Scenarios:

• Lesions on or near the eyelids causing associated follicular conjunctivitis - physical removal is imperative to resolve conjunctivitis. 1, 2
• Multiple or symptomatic lesions causing pain, itching, or significant cosmetic concerns. 1
• Lesions with true bacterial superinfection - purulent drainage, marked cellulitis, or systemic signs require culture confirmation and antibiotics. 1
• Extensive disease with numerous lesions across multiple body sites. 6, 7

Treatment Approach Algorithm

1. Assess immune status - screen for immunodeficiency if multiple large lesions with minimal inflammation are present. 1, 2

2. Evaluate lesion characteristics:

   • Location (periocular lesions require treatment) 1, 2
   • Number (extensive disease favors treatment) 6
   • Symptoms (symptomatic lesions warrant intervention) 1
   • Associated complications (conjunctivitis, eczema, superinfection) 1, 6

3. Consider transmission risk:

   • Sexually active individuals should be treated to prevent transmission 3, 4
   • Immunocompetent children with limited disease can be observed 2

4. First-line treatment options:

   • Cryotherapy with liquid nitrogen (93% complete response rate) 1
   • Curettage, excision, or excision with cautery 1, 5
   • Potassium hydroxide 10% solution (86.6% complete response, better cosmetic outcome) 1, 2

5. Treat ALL lesions including nascent ones - reducing viral load allows host immune response to eliminate residual virus and reduces recurrence risk. 1, 2

Critical Pitfalls to Avoid

• Do not neglect nascent lesions during initial treatment - this is a common cause of recurrence. 1, 2
• Do not use imiquimod - it has not shown benefit compared to placebo in randomized controlled trials. 1, 2
• Do not use salicylic acid in children under 2 years due to risk of systemic toxicity. 2
• Do not assume simple erythema around lesions is bacterial superinfection - this often represents normal inflammatory response as the immune system clears the virus. 1
• In immunocompromised patients with atypical lesions, consider cryptococcal infection in the differential diagnosis. 1