Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

immunocompetent

1st line – observation

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ACUTE
|
immunocompetent
|
without anogenital lesions, atopic dermatitis, or eyelid lesions
1st line – 

observation

Expectant management is generally considered as the initial approach for the majority of immunocompetent patients.

People should be reassured that molluscum contagiosum is a self-limiting condition and spontaneous resolution usually occurs within 1-2 years.

2nd line – topical treatment

Back
ACUTE
|
immunocompetent
|
without anogenital lesions, atopic dermatitis, or eyelid lesions
2nd line – 

topical treatment

Most patients do not require treatment, but topical therapy may be considered in those who desire treatment (e.g., due to anxiety, discomfort, appearance, and not wanting to infect others).[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]

Topical potassium hydroxide may provide a modest benefit.[21]

There is limited evidence for other topical agents including salicylic acid, benzoyl peroxide, and tretinoin, but none of these agents are recommended above the others.[21]

Primary options

potassium hydroxide topical: consult specialist for guidance on formulation and dose

Secondary options

salicylic acid topical: consult specialist for guidance on formulation and dose

OR

benzoyl peroxide topical: consult specialist for guidance on formulation and dose

OR

tretinoin topical: consult specialist for guidance on formulation and dose

2nd line – cryotherapy

Back
ACUTE
|
immunocompetent
|
without anogenital lesions, atopic dermatitis, or eyelid lesions
2nd line – 

cryotherapy

Most patients do not require treatment, but cryotherapy may be considered in those who desire treatment (e.g., due to anxiety, discomfort, appearance, and not wanting to infect others) and have only a small number of discrete lesions.

Cryotherapy may also be considered as an in-office therapy or in primary care for nonextensive molluscum in both adults and children.[21][24]

1st line – conservative measures and sexual health screen

Back
ACUTE
|
immunocompetent
|
with anogenital lesions
1st line – 

conservative measures and sexual health screen

Patients should be advised to avoid shaving or waxing the anogenital area and to avoid sharing towels or bedding if possible until lesions resolve.

A full sexual health screen (which may involve referral to genitourinary medicine, dependent on local setting) should be performed in all patients presenting with anogenital molluscum even if only 1-2 molluscum are seen.[12]

Expectant management may be considered for immunocompetent patients. However, physical or topical treatment may be recommended for patients with anogenital lesions.[24]

2nd line – cryotherapy, cautery, or curettage

Back
ACUTE
|
immunocompetent
|
with anogenital lesions
2nd line – 

cryotherapy, cautery, or curettage

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).

Cryotherapy is frequently used in sexual health and dermatology clinics to treat discrete 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.

2nd line – topical treatment

Back
ACUTE
|
immunocompetent
|
with anogenital lesions
2nd line – 

topical treatment

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).

Topical treatment may be considered, especially if molluscum are more widespread.

Podofilox, potassium hydroxide, and imiquimod may be considered for treating anogenital molluscum.[12] Evidence for efficacy of imiquimod in the treatment of molluscum is poor. Imiquimod is not recommended for use in children.[12][24]

Other topical treatments, such as benzoyl peroxide and tretinoin, may cause irritation and are inappropriate for sensitive anogenital skin.[12]

Primary options

podofilox topical: consult specialist for guidance on formulation and dose

OR

potassium hydroxide topical: consult specialist for guidance on formulation and dose

OR

imiquimod topical: consult specialist for guidance on formulation and dose

1st line – optimize treatment of atopic dermatitis

Back
ACUTE
|
immunocompetent
|
with atopic dermatitis
1st line – 

optimize treatment of atopic dermatitis

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. See Atopic dermatitis (Management approach).

This may include adding a topical antiseptic wash if there is secondary infection, increasing emollient amount and frequency, and adding a topical corticosteroid.

Consider – consider referral to dermatology

Back
ACUTE
|
immunocompetent
|
with atopic dermatitis
Consider – 

consider referral to dermatology

Treatment recommended for SOME patients in selected patient group

If molluscum is widespread or refractory to optimization of topical therapy, or the patient has recently started on a systemic medication, refer to dermatology for a review.

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]

1st line – observation and consider referral to ophthalmology

Back
ACUTE
|
immunocompetent
|
with eyelid lesions
1st line – 

observation and consider referral to ophthalmology

Expectant management is generally considered as the initial approach for the majority of immunocompetent patients.

People should be reassured that molluscum contagiosum is a self-limiting condition and spontaneous resolution usually occurs within 1-2 years.

Consider urgent referral to ophthalmology if there is eyelid-margin involvement, or ocular lesions and associated red eye.

immunocompromised

1st line – treat underlying cause

Back
ACUTE
|
immunocompromised
|
without anogenital lesions, atopic dermatitis, or eyelid lesions
1st line – 

treat underlying cause

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.

HIV specialists will consider commencing or reviewing antiretroviral therapy (ART). Protracted or extensive disease may be a sign of immunocompromise in HIV patients. In adults with HIV, immune restoration with ART usually results in resolution of molluscum contagiosum. However, molluscum can also present with immune reconstitution inflammatory syndrome (IRIS) in the management of HIV.

Consult an HIV specialist for advice on management.

Consider – physical or topical treatment

Back
ACUTE
|
immunocompromised
|
without anogenital lesions, atopic dermatitis, or eyelid lesions
Consider – 

physical or topical treatment

Treatment recommended for SOME patients in selected patient group

After liaison with an appropriate specialist and treatment of the primary condition, topical and physical treatments can be considered.

If molluscum lesions persist despite initiation of antiretroviral therapy (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] Imiquimod is not recommended for use in children.[12][24]

Primary options

podofilox topical: consult specialist for guidance on formulation and dose

OR

cidofovir topical: consult specialist for guidance on formulation and dose

OR

imiquimod topical: consult specialist for guidance on formulation and dose

OR

cantharidin topical: consult specialist for guidance on formulation and dose

1st line – treat underlying cause

Back
ACUTE
|
immunocompromised
|
with anogenital lesions
1st line – 

treat underlying cause

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.

HIV specialists will consider commencing or reviewing antiretroviral therapy (ART). Protracted or extensive disease may be a sign of immunocompromise in HIV patients. In adults with HIV, immune restoration with ART usually results in resolution of molluscum contagiosum. However, molluscum can also present with immune reconstitution inflammatory syndrome (IRIS) in the management of HIV. Consult an HIV specialist for advice on management.

A full sexual health screen (which may involve referral to genitourinary medicine, dependent on local setting) should be performed in all patients presenting with anogenital molluscum even if only 1-2 molluscum are seen.[12]

Consider – physical or topical treatment

Back
ACUTE
|
immunocompromised
|
with anogenital lesions
Consider – 

physical or topical treatment

Treatment recommended for SOME patients in selected patient group

After optimization of treatment of the primary condition, physical or topical treatment may be considered.

If there are a few discrete lesions, cautery or cryotherapy may be considered for discrete genital lesions in the context of immunocompromise.

For genital lesions in the context of HIV, topical antivirals (e.g., cidofovir) or podofilox can be used.[12]

Primary options

podofilox topical: consult specialist for guidance on formulation and dose

OR

cidofovir topical: consult specialist for guidance on formulation and dose

1st line – optimize treatment of atopic dermatitis

Back
ACUTE
|
immunocompromised
|
with atopic dermatitis
1st line – 

optimize treatment of atopic dermatitis

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.

Consider – consider referral to dermatology

Back
ACUTE
|
immunocompromised
|
with atopic dermatitis
Consider – 

consider referral to dermatology

Treatment recommended for SOME patients in selected patient group

If molluscum is widespread or refractory to optimization of topical therapy, or the patient has recently started on a systemic medication, refer to dermatology for a review.

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]

1st line – referral to ophthalmology

Back
ACUTE
|
immunocompromised
|
with eyelid lesions
1st line – 

referral to ophthalmology

Consider urgent referral to ophthalmology if there is eyelid-margin involvement, or ocular lesions and associated red eye.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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