Management

Often no specific treatment is required - this is a self-limiting infection and it may resolve spontaneously in 6-9 months (but some cases may persist up to 4 years) (1).

Patients should be educated about prevention of spread of the disease - by use of separate towels and other measures of basic hygiene (1).

Treatment options, if required, include

• cryotherapy – application of liquid nitrogen to the lesion
• expression of the contents of the pearly core (manually or using forceps)
• piercing with an orange stick , with or without the application of tincture of iodine or phenol
• curettage or diathermy (2)
• itching might be a problem for the patient and may require an emollient and a mild topical corticosteroid (e.g. hydrocortisone 1%) (1).

Other treatment options that have been employed include:

• topical 0.5% podophyllotoxin (applied to lesions twice a day for 3 consecutive days and repeated weekly cycles until the lesions cleared) (contraindicated in pregnant and breast feeding women) may be useful in anogenital molluscum (3)
• home-applied imiquimod 5% cream is sometimes used but evidence for efficacy of imiquimod in the treatment of molluscum is poor (3)
• 5% potassium hydroxide solution may provide a modest benefit compared with placebo (4)

However a systematic review concluded that "..no single intervention has been shown to be convincingly effective in the treatment of molluscum contagiosum. We found moderate-quality evidence that topical 5% imiquimod was no more effective than vehicle in terms of clinical cure, but led to more application site reactions.." (4)

Eczema around the lesion can be treated with emollients, 1% ichthammol paste or mild topical or mild topical steroid (5)

For ano-genital molluscum contagiosum:

• podophyllotoxin paint once weekly can be used
• consider referring adults to genitourinary medicine for infection screen (2)

Highly active antiretroviral therapy may be necessary in HIV patients for the resolution of the disease (2).

Recurrences of the disease are common and the patient should be educated about reappearance of lesions and treatment failure before starting treatment (1).

A more aggressive, widespread form occurs in immunocompromised patients.

Criteria for referral to a secondary care facility:

• diagnostic uncertainty
• extensive, painful, inflamed lesions
• immunosuppressed patients

If there is associated conjunctivitis the patient should be referred to an ophthalmologist.

Reference:

1. Meza-Romero R, Navarrete-Dechent C, Downey C. Molluscum contagiosum: an update and review of new perspectives in etiology, diagnosis, and treatment. Clin Cosmet Investig Dermatol. 2019;12:373-381.
2. Fernando I, K Edwards S, Grover D. British Association for Sexual Health and HIV national guideline for the management of genital molluscum in adults (2021). Int J STD AIDS. 2022 Apr;33(5):422-32
3. Edwards S, Boffa MJ, Janier M, et al. 2020 European guideline on the management of genital molluscum contagiosum. J Eur Acad Dermatol Venereol. 2021 Jan;35(1):17-26.
4. van der Wouden JC, van der Sande R, Kruithof EJ, et al. Interventions for cutaneous molluscum contagiosum. Cochrane Database Syst Rev. 2017 May 17;(5):CD004767.
5. Ren Z, Silverberg JI. Association of atopic dermatitis with bacterial, fungal, viral, and sexually transmitted skin infections. Dermatitis. 2020 Mar/Apr;31(2):157-64.