Approach
Treatment for molluscum should be individualized, taking into consideration factors such as whether a patient is immunocompetent or immunocompromised, the location and extent of lesions, the presence of other skin conditions (e.g., atopic dermatitis), and patient preference.
Immunocompetent patients without other skin conditions are usually managed in primary care. One Cochrane review did not find strong evidence to support the use of one treatment over another in immunocompetent patients, and concluded that natural resolution is a strong option to consider first line.[21]
In immunocompromised patients (e.g., those with HIV infection) and those with atopic dermatitis, molluscum infection can be more prolonged and widespread. Referral to, or discussion with, a specialist (e.g., dermatology in the context of atopic dermatitis, or HIV team if there is coexisting HIV infection) may be required. Early treatment is usually needed for these patients, particularly if they have extensive lesions.[22] Referral to dermatology should also be considered if there is diagnostic uncertainty.[23]
Specialist referral is also required for patients with:[22]
Anogenital lesions: adults require referral to genitourinary medicine, and should be screened for other sexually transmitted infections (including HIV). Children with anogenital lesions should be referred for suspected sexual abuse if there is other evidence to suggest this.
Eyelid-margin or ocular lesions with associated red eye: these patients require urgent referral to an ophthalmologist.
Treatment for immunocompetent patients
In immunocompetent patients without other skin conditions, molluscum infection will naturally clear over time. Treatment is generally not required for these patients.
Patients should be reassured that in the majority of cases molluscum infection is a self-limiting condition that resolves spontaneously within 1-2 years. However, patients who desire treatment (e.g., due to anxiety, discomfort, appearance, and not wanting to infect others) should be considered for treatment.[8][24] If patients opt for treatment, they should be advised that new lesions can develop for a while, and they may need more than one course of treatment.[8] Treatment options include topical agents or physical treatments.
One Cochrane review found no single treatment to be convincingly effective in treating molluscum infection in immunocompetent patients, and concluded that natural resolution is a strong option to consider.[21]
In the US, there are currently no Food and Drug Administration (FDA)-approved treatments for molluscum.
Topical treatment
Topical potassium hydroxide may provide a modest benefit compared with placebo.[21] There is limited evidence for other topical treatments including salicylic acid, benzoyl peroxide, and tretinoin.[21]
Physical treatment
Cryotherapy may be considered as an in-office therapy or in primary care for nonextensive lesions in adults and children.[21][24]
Treatment for immunocompromised patients
In immunocompromised patients, effective management of the underlying condition (e.g., HIV or atopic dermatitis) will usually result in an improvement of molluscum infections.
The main causes of immunosuppression associated with molluscum contagiosum include HIV infection, solid organ transplants, immunosuppressive therapy (including biologic therapy), systemic lupus erythematosus, sarcoidosis, and neoplasia.[12] Treatment of the underlying condition should be optimized in the first instance, and this will involve liaison with the appropriate treating specialist.
In patients with HIV, immune restoration with antiretroviral therapy (ART) usually results in resolution of molluscum infection. However, molluscum can present with immune reconstitution inflammatory syndrome (IRIS) following initiation of ART. If molluscum lesions persist despite initiation of ART, and are disfiguring but not extensive, treatment may be pursued with cryotherapy or curettage, especially if on the face.[19] Cautery or cryotherapy using local anesthetic is widely available in the hospital and primary care and is an effective physical treatment for nonextensive lesions.
Topical treatments can also be used in patients with HIV, despite the limited evidence. Options include cidofovir, podofilox, imiquimod, and cantharidin.[12][21][25] Imiquimod is not recommended for use in children.[12]
Treatment for patients with atopic dermatitis
Patients with atopic dermatitis have impairment of the barrier function of the skin and an altered immunologic profile that makes them more susceptible to molluscum infections. They may be immunocompetent or, if they are on systemic medication (such as a corticosteroid or cyclosporine), immunocompromised. The likelihood of a secondary bacterial infection associated with itching and picking of molluscum is also higher in patients with atopic dermatitis.[7]
Extended or protracted molluscum infections are an indication that atopic dermatitis may be undertreated. Molluscum infections usually improve or resolve when treatment for atopic dermatitis is optimized, and therefore this should be the first step. This may include adding a topical antiseptic wash if there is secondary infection, increasing emollient amount and frequency, and adding a topical corticosteroid to control actively inflamed atopic dermatitis. See Atopic dermatitis (Management approach).
Phototherapy or a systemic therapy (e.g., methotrexate) should be considered if molluscum infection persists despite optimizing topical therapy.[4] Some systemic therapies used to treat atopic dermatitis (and psoriasis) may improve or exacerbate molluscum.[26]
Consultation with a dermatologist should be sought if extensive molluscum occurs following initiation of a systemic drug.
Treatment for patients with anogenital molluscum
Patients with anogenital molluscum may be either immunocompetent or immunocompromised. A full sexual health screen, including HIV test, should be performed as most anogenital molluscum are sexually transmitted.[12]
In immunocompetent patients, if molluscum are not extensive, the patients can usually be reassured that infection should resolve spontaneously, but should be advised to avoid shaving or waxing the anogenital area and to avoid sharing towels or bedding until lesions resolve. A full sexual health screen should be performed, even if only 1-2 molluscum are seen.
Indications for treatment of anogenital molluscum include patient preference, extensive and/or persistent disease, cosmetic reasons, fear of disease spread and scarring, and symptoms/complications (e.g., pruritus, inflammation, and secondary infection).
Physical or topical treatment may be recommended for patients with anogenital molluscum.[24] However, there is a lack of evidence to support their use in these patients.[12]
Cryotherapy
Cryotherapy is frequently used in sexual health and dermatology clinics to treat anogenital molluscum, although published evidence for efficacy is lacking. For optimal outcomes, weekly treatments over 6-8 weeks may be required.[27]
If available, cautery using local anesthetic may be preferred over curettage in anogenital skin as it is less traumatic and less painful.
Topical therapies for anogenital molluscum
Podofilox, potassium hydroxide, and imiquimod may be considered for treating anogenital molluscum.[12] Other topical treatments, such as benzoyl peroxide and tretinoin, may cause irritation and are inappropriate for sensitive anogenital skin.[12]
Imiquimod, a T cell modifier, is intended to stimulate an immune response to the molluscum virus. However, evidence for efficacy of imiquimod in the treatment of molluscum is poor. Imiquimod is not recommended for use in children.[12][24]
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