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Saturday, March 31, 2007

Molluscum Contagiosum

About this topic

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All ages

This guidance covers the management of molluscum contagiosum.

This guidance does not cover the management of other viral skin infections (e.g. warts).

There is a separate CKS topic on Warts (including verrucas).

The target audience for this guidance is healthcare professionals working within the NHS in England, who are providing first-contact or primary health care. Patient information from NHS Direct is intended to be printed and given to people, or parents of children, with this condition, and the Shared decision making sections are designed to provide a focus for discussion during the consultation about the treatment options.


Version 1.0.0, revision planned in 2010.
Last revised in January 2007

July–September 2006 — reviewed. Validated in December 2006 and issued in January 2007.

This guidance has been reviewed, restructured and updated following a full literature review.There have been no major changes to the guidance. An overview on management is given. Practical advice on avoidance has also been incorporated. An evidence section has been added to support the recommendations given.

Previous changes

November 2002 — written. Validated in June 2003 and issued in July 2003.


New evidence
Evidence-based guidelines

No new evidence-based guidelines since 1 March 2007.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2007.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2007.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 March 2007.

Primary evidence

No new high quality randomized controlled trials since 1 March 2007.

New policies

No new national policies or guidelines since 1 March 2007.

New safety alerts

No new safety alerts since 1 March 2007.

Changes in product availability

No changes in product availability since 1 March 2007.

Concise knowledge for clinical scenarios

Molluscum contagiosum

Which therapy?
  • Watchful waiting and reassurance should be considered as first-line management of molluscum contagiosum.
  • Advice on prevention and limiting the spread is needed but no restriction from school, work, or swimming pools is necessary.
  • If treatment is needed, consider physical destruction:
    • Squeezing of individual lesions using gloved fingers or tweezers (after bathing) to express white core material. Limit to only a few lesions at a time, as the process can be painful. Allow 1–2 weeks for resolution of traumatized lesions. Normally, an area of redness surrounding the lesion will suggest an immune response and clearance.
    • Piercing of lesions with an orange stick or a clean needle (after bathing) to express white core material.
    • Cryotherapy, giving one brief freeze of 5–10 seconds to allow a halo of ice to form over lesion and 1–2 mm of surrounding skin. Repeat at 2–3-weekly intervals until clearance. Improve accuracy by using a cotton-tip applicator or a disposable ear speculum (small end held over the lesion), directing the freeze onto the lesion.
Should I refer or investigate?
  • Refer:
    • Anyone who is HIV-positive who has extensive lesions to an HIV specialist, as extensive molluscum contagiosum is a marker that the person might be severely immunocompromised
    • People with ocular and lid-margin lesions and associated red eyes (suggestive of conjunctivitis) to an ophthalmologist, as lesions around the eyes can rarely cause a chronic keratoconjunctivitis
  • Consider referring to a dermatologist if:
    • Uncertain of the diagnosis
    • The person is known to be immunocompromised
  • Depending on local policy and guidelines, consider referral if:
  • Consider referring adults with anogenital molluscum contagiosum to a genito-urinary medicine clinic for screening for sexually transmitted infections.
  • Consider the possibility of immunocompromise in anyone with extensive or atypical lesions. Investigate (in particular, to exclude HIV) and refer appropriately.
Follow-up advice
  • Follow-up is not usually necessary.
Drug rationale
  • No prescriptions are included because lesions usually resolve without treatment.
Shared decision making
  • Molluscum contagiosum usually clears without treatment within 18 months. Therefore it is usually best to leave it alone.
  • Some people want treatment for cosmetic reasons. The best options are ‘squeezing’ or ‘freezing’ the molluscum lumps.
  • Other treatments such as acid or silver nitrate are sometimes used, but success is not guaranteed. Also:
    • These treatments can be painful.
    • Some treatments have a risk of burning the surrounding skin.
    • All treatments have a small risk of scarring the skin.
  • Children with molluscum contagiosum can mix normally with others and should not be barred from swimming.

Detailed knowledge about this topic

Goals and outcome measures

  • To offer appropriate reassurance and management until natural resolution occurs
  • To identify and refer individuals who might be immunocompromised

Background information

What is it?
  • Molluscum contagiosum is a viral skin infection caused by molluscum contagiosum virus (MCV), a member of the the Poxviridae family.
    • There are four distinct subclasses of MCV, with MCV1 being the most common cause of molluscum contagiosum.
    • Transmission occurs by close personal contact, or indirectly via fomites (contaminated surfaces) such as shared towels and flannels.
    • The incubation period is between 2 weeks and 8 weeks.
    • Replication of the virus in infected cells causes hyperplasia and development of the characteristic flesh-coloured, umbilicated papules.

[Bhatia, 2005; Crowe, 2005]

How common is it?
  • Molluscum contagiosum is common, but the exact prevalence is uncertain as many people never seek medical care and most studies have looked at selected populations, such as people attending genito-urinary medicine clinics or dermatology outpatient departments.
  • A large UK general practice-based survey of patients' records [Pannell et al, 2005] found that:
    • The annual incidence of new presentations of molluscum was 261/100,000.
    • The annual incidence of new presentations of molluscum in children aged under 15 years was 1265/100,000.
    • Over 80% of reported cases occurred in children aged under 15 years, with the maximum incidence in preschool children aged 1–4 years.
    • In a general practice population of 10,000 people, about 24 new cases of molluscum contagiosum would present each year.
  • Molluscum contagiosum is said to disproportionately affect children with atopic eczema, although there is little evidence to support this [Sladden and Johnston, 2004].
  • Molluscum contagiosum occurs more commonly in people who are immunocompromised. For example, in people with HIV the prevalence of molluscum contagiosum is reported to range between 5% and 33%, the prevalence increasing with decreasing CD4 counts [Schwartz and Myskowski, 1992; Crowe, 2005].
How do I know my patient has it?
  • Diagnosis is based on the characteristic appearance of the lesion.
  • Investigations are usually not necessary unless the diagnosis is uncertain or if immunosuppression is suspected.
  • Lesions do not usually cause symptoms.
  • Itching and occasionally pain can occur if:
    • The lesions become inflamed or infected
    • Eczematous patches develop around the lesions (this occurs in 10% of people and is especially likely to occur in people with a history of atopy [Kakourou et al, 2005; van der Wouden et al, 2006]
  • There may be a history of other members of the family or partners being affected.
  • The diagnosis should be particularly considered in people who are immunocompromised (e.g. HIV infection, transplant patients) or who are using topical immunosuppressants such as steroids or tacrolimus [Lerbaek and Agner, 2004; Wilson and Reid, 2004; Bhatia, 2005; Crowe, 2005].
  • The following are typical features of molluscum contagiosum [Lowy, 1999]:
    • Discrete, smooth, flesh-coloured, pinkish or pearly white papules.
    • There may be a central umbilication or depression, particularly in mature lesions.
    • A white curd-like material can often be expressed by squeezing mature lesions.
    • Lesions grow over several weeks to a size ranging from 1 mm to 5 mm in diameter (but they can be much larger if the person is immunocompromised).
    • An eczematous reaction can occur around the lesions.
    • Lesions can become irritated and inflamed (this seems to be particularly common prior to spontaneous resolution).
    • If bacterial superinfection occurs, spreading erythema, oedema, crusting, or pus might be seen.
  • On average, the number of lesions is no more than 20 (but there can be hundreds, particularly if the person is immunocompromised) [Lynch and Minkin, 1968; Rosenberg and Yusk, 1970; Hellier, 1971].
  • Lesions can occur anywhere on the body, except on the palms of the hands and soles of the feet [Owens, 2005].
    • In children, they commonly occur in flexures and anogenital regions, but this does not imply sexual abuse (unless other factors suggest this).
    • In adults, lesions also often involve the genitalia, pubis, thighs, and lower abdomen, as a result of sexual transmission.
    • In people who are immunocompromised, lesions are often widespread.
    • Rarely, lesions can occur on the oral mucosa and on the eyelids (which can lead to chronic keratoconjunctivitis) [Laxmisha et al, 2003; Redmond, 2004].
  • Lesions are usually clustered in one or two areas, but can be widely scattered.
  • For images, see
  • Investigations are rarely required, as the diagnosis can usually be made clinically.
  • In cases of diagnostic uncertainty, the following investigations might be carried out in secondary care:
    • Smears of individual lesions (with either light microscopy to look for characteristic intracytoplasmic inclusion bodies or electron microscopy to look for poxvirus-like particles)
    • Skin biopsy

[Scott, 2001; Smolinski and Yan, 2005]

What else might it be?
  • The differential diagnosis of multiple lesions includes:
    • Warts
    • Milia — white keratinous cysts on the face, most frequent around the eyes
    • Lichen planus (uncommon) — an inflammatory pruritic disease characterized by distinctive, usually purplish papules
    • Syringomata (uncommon) — small pale papules, usually around the eyes
    • Cutaneous cryptococcosis — umbilicated papules not uncommon on the face, found in patients with immunosuppression (especially HIV)
  • Solitary molluscum can be difficult to diagnose, and it might be best to refer for diagnosis, particularly in the older age group. A solitary molluscum can resemble:
    • Pyogenic granuloma — small, usually solitary, sessile or pedunculated, raspberry-like, friable granulation tissue; they occur most often in children
    • Keratoacanthoma — a rapidly growing papule that develops into a skin-coloured nodule with a smooth crater and a central keratin plug
    • Basal-cell carcinoma — a tumour composed of a waxy semitranslucent nodule, forming around a central depression that can be ulcerated, crusted, or bleeding
    • Intradermal naevus (mole) — a papule that varies in colour from normal skin colour to brown or black
    • Sebaceous gland hyperplasia — single or multiple yellowish papules on the face; more common in people who are chronically immunocompromised
    • Spitz naevus (epithelial naevus) — a smooth-surfaced, raised, round, slightly scaly, firm papule with a pink, yellow-brown, brownish-red, or purplish-red colour

[Arnold et al, 1990]

Complications and prognosis
  • Complications from molluscum contagiosum are uncommon, but the following can occur:
    • Emotional and psychological distress arising from the cosmetic appearance [Tyring, 2003].
    • Scarring if lesions become inflamed or infected, or due to treatment. More likely to occur in areas of adipose tissue (such as the thighs).
    • Bacterial superinfection, especially in people with atopic eczema or impaired immune function [Lowy, 1999; Tyring, 2003].
    • Conjunctivitis and keratitis can complicate lesions around the eyelid (rare) [Lowy, 1999; Redmond, 2004].
  • Spontaneous resolution usually occurs within 18 months, but this can take from 6 months to 5 years [Tyring, 2003].
    • The mean duration of each lesion is 8 months, but autoinoculation leads to new lesions [Sladden and Johnston, 2004].
    • One study found that 16% of people had spontaneous clearance at 1 year.
  • In people who are immunocompromised, individual molluscum contagiosum lesions can persist for 5 years or longer [Crowe, 2005].
  • Once molluscum contagiosum has cleared completely, recurrence is rare [Ginsburg, 1986].

Management issues

Overview of management
  • Molluscum contagiosum is contagious; exclusion from school, gym, or swimming is not necessary, but consider simple to reduce the risk of transmission to others.
  • Most lesions resolve spontaneously in 18 months and do not recur.
  • No treatment should be recommended first-line.
  • If intervention is decided on, consider simple trauma to the lesions by squeezing, piercing, or cryotherapy/diathermy.
  • Consider referring if uncertain of the diagnosis or if the person is immunosuppressed.
  • In adults with anogenital molluscum contagiosum, exclude other sexually transmitted diseases.
What advice should I give about reducing the risk of spread?
  • Lesions are contagious until the last one has gone [HPA, 2003].
  • No exclusion from school, gym, or swimming pools is necessary [HPA, 2003].
  • It is sensible to consider measures to reduce the risk of transmission to others. Although there is no evidence on the effectiveness of such measures [Smolinski and Yan, 2005]:
    • Keeping affected areas covered with clothing (where practical) will help to prevent spread of the virus.
    • Avoid sharing towels and clothing, as molluscum contagiosum can be caught via fomites (contaminated objects).
    • Avoid sharing baths.
    • In adults with anogenital lesions, advise on the use of a condom and screen for any other sexually transmitted diseases. However, latex condoms will only offer partial protection. The molluscum virus does not need mucous membrane for transmission, so other skin areas that are not protected will allow spread of infection (i.e. thighs, anus). Also, after treatment, people should be aware of recurrence and the risk of further transmission [Tyring, 2003].
  • Limit personal spread by not scratching the lesions, as this will lead to autoinoculation at other sites and persistence of infection.
Does molluscum contagiosum need to be treated?
  • The decision on whether or not to treat molluscum contagiosum should be taken on an individual basis, and the discussion should involve the following points:
    • There is a strong case for no treatment:
      • Lesions do not usually cause symptoms.
      • Individual lesions usually resolve within a few months, with complete clearance of all lesions within 1–2 years.
      • Treatments can be painful and are often poorly tolerated by children.
      • Treatments can cause scarring, but scarring rarely occurs if lesions are allowed to resolve spontaneously.
      • There is little available evidence regarding the effectiveness of treatments.
      • The presence of molluscum contagiosum should not limit activities such as sport, swimming, school, or work.
    • Treatment might be preferred if:
      • Lesions are cosmetically unsightly (although treatments can themselves result in unsightly scarring)
      • Lesions are uncomfortable, itching, or bleeding
      • Lesions are persistent, recurrent, or extensive
  • Although treatment is often advocated to prevent autoinoculation or transmission to close contacts, there is no evidence to support this.
What treatments are available in primary care?
  • The evidence regarding treatments for molluscum contagiosum is very limited, and no evidence-based recommendations can be made.
  • The best management is to leave the lesions alone and await spontaneous resolution, particularly as treatment can be painful and lead to scarring.
  • If treatment is decided on, the following are most commonly used in a primary care setting:
  • Simple trauma, either by squeezing or piercing individual lesions, to evoke an immune response to initiate resolution.This can be carried out by patients, parents, or a care-giver. This process can be painful and the most sensible children might not cooperate. There is no clear guidance on the optimal method and frequency needed:
    • Squeezing the lesions between the fingernails (ideally while wearing gloves to limit spread of the virus) or with tweezers, to remove the white core material is best carried out after a bath, when the lesions are softer. Limit treatment to a few lesions at a time. Discard white curd-like material carefully (contains infective virus). Leave 1–2 weeks for resolution [Crowe, 2005; NHS direct, 2006].
    • Another option is to pierce the lesions with an orange stick to express the white core.
  • Cryotherapy or diathermy:
    • This is poorly tolerated by young children, so is usually only appropriate for older children or adults.
    • The pain associated with cryotherapy or diathermy can be reduced by the application of a topical anaesthetic (such as lidocaine/prilocaine cream) 1 hour before treatment. This is particularly useful if a cluster of lesions is being treated.
    • If only a few lesions are being treated with cryotherapy, then the use of a topical anaesthetic might not be necessary. Diathermy is generally a more painful procedure and topical anaesthesia is usually necessary.
    • Cryotherapy with liquid nitrogen should be applied once for 5–10 seconds directly to lesions to achieve a halo of ice over the lesion and 1–2 mm of the surrounding skin. Repeat 2–3-weekly until the lesion has gone. Use of a cotton-tip applicator chilled in liquid nitrogen or a disposable ear speculum (with the small end held over the lesion and spraying into the funnel end) can help make the freezing more accurate [Crowe, 2005; Smolinski and Yan, 2005].
      • If cotton buds are used, reduce possible transmission of viruses by decanting liquid nitrogen into a separate disposable container (from a Dewar flask), use one cotton bud for each patient, disregard leftover liquid nitrogen, and keep the Dewar flask cleaned and full [Jones and Darville, 1989].
  • Other treatments are generally carried out in secondary care but are sometimes carried out in primary care, depending on the experience of the practitioner.
When should I refer somebody with molluscum contagiosum?
  • Molluscum contagiosum can usually be managed in primary care.
  • Refer:
    • Anyone who is HIV-positive with extensive lesions to an HIV specialist, as extensive molluscum contagiosum is a marker that the person could be severely immunocompromised
    • People with lid-margin or ocular lesions and associated red eyes (suggestive of conjunctivitis) to an ophthalmologist, as lesions around the eyes can rarely cause a chronic keratoconjunctivitis
  • Consider referring to a dermatologist if:
    • Uncertain of the diagnosis
    • The patient is known to be immunocompromised
  • Depending on local policy and guidelines, consider referral if:
    • Extensive, painful, inflamed lesions — but remember that itchy lesions are suggestive of resolution and self-destruction, so might not need referral.
    • Not responding to primary care management
  • Consider referring adults with anogenital molluscum contagiosum to a genito-urinary medicine clinic for screening for sexually transmitted infections.

[Scott, 2001; Centre for Change & Innovation, 2005]

What treatments are available in secondary care?
  • For people referred to secondary care, treatments other than simple trauma to the lesions, cryotherapy, or diathermy might be considered (see Table 1).
  • The evidence regarding these treatments is very limited, and the choice of treatment is usually based on the personal experience of the treating physician.
Table 1. Some treatments for molluscum contagiosum that might be considered in secondary care.
Surgical treatments
Curettage and cautery
Curettage is commonly used. A Cochrane review was unable to find any studies evaluating its effectiveness [van der Wouden et al, 2006]. Experience suggests that it is effective, although there is a risk of scarring. Topical anaesthesia is usually necessary [de Waard-van der Spek et al, 1990].
Pulsed dye laser
Case reports suggest effectiveness (over 90% clearance with one treatment), but cost, availability, and high recurrence rates (65%) limit its use in the UK [Smolinski and Yan, 2005].
Topical treatments
Phenol ablation
One small study found an increased risk of scarring compared with simply squeezing the lesions, with no difference in cure rates (1 month after treatment, complete resolution had occurred in 75% of lesions treated with phenol and in 77% of lesions treated by squeezing) [Weller et al, 1999].
A randomized controlled trial compared the effectiveness of two different strengths of podophyllotoxin cream (0.5% and 0.3%) and placebo in 150 people with predominantly genital lesions [Syed et al, 1994]. After 12 weeks of treatment, 92% of the 0.5% cream group were cured, compared with 52% of the 0.3% cream group and 16% of the placebo group (p <>
There have been a number of case reports of success with topical tretinoin 0.05% [Smolinski and Yan, 2005].
Imiquimod 5%
A number of uncontrolled studies suggest that imiquimod cream (an immunomodulatory drug) might be a safe and effective treatment [van der Wouden et al, 2006]. A case series, follow-up trial of 15 children showed that after 4 months 5% imiquimod led to complete clearance in two children and a partial clearance (average 65% of lesions cleared) in a further seven children [Bayerl et al, 2003]. A randomized, placebo-controlled trial of 100 people with thigh or genital lesions found that after 4 weeks' treatment, 82% of people treated with imiquimod 1% cream were cured, compared with 16% of those treated with placebo cream (p < class="cit">[Syed et al, 1998].
Benzoyl peroxide 10%
A small randomized controlled trial found that benzoyl peroxide 10% cream was more effective than tretinoin 0.05% cream (after 6 weeks of treatment, 92% of the benzyol peroxide group were lesion-free, compared with 45% of the tretinoin group; p = 0.02) [Saryazdi, 2004].
Silver nitrate paste
An uncontrolled study found that silver nitrate paste cleared molluscum contagiosum in over 90% of people after 1 month of treatment [Niizeki and Hashimoto, 1999]. However, it is rarely used because of the risk of silver tattooing.
Potassium hydroxide solution 10%
A small randomized controlled trial (n = 20) comparing potassium hydroxide 10% solution with a saline palcebo showed clearance of molluscum with topical potassium hydroxide in 6/10 children at 90 days' follow-up; 2/10 children reported 'no change' in the potassium hydroxide group, compared with 8/10 children in the control group (though this difference did not reach statistical significance). Recognized stinging and postinflammatory pigmentary changes were recorded [Short et al, 2002].
A large retrospective study (n = 300) involving children showed 90% clearance of molluscum after two applications of topical cantharidin, with limited adverse effects. Not suitable for use on the face [Smolinski and Yan, 2005].
How do I manage associated eczema?
  • Molluscum contagiosum is often seen in children who have eczema.
    • If eczema is troublesome, this should generally be managed in the usual manner, irrespective of whether molluscum lesions are present or not (see the CKS topic on Eczema — atopic). Leaving eczema untreated could result in further scratching and spread of the virus.
    • Use the least potent topical steroid that is effective.
    • Some experts recommend avoiding application of topical steroid to the immediate vicinity of molluscum lesions, because of concerns about allowing proliferation of the virus (due to local immunosuppression). We could find no evidence to support this concern.
  • Eczematous patches often develop around molluscum lesions, without evidence of eczema elsewhere [DeOreo et al, 1956; Crowe, 2005].
    • This is thought to be an immune response to the molluscum virus.
    • Anecdotal experience suggests that this reaction often precedes clearance of the virus.
    • Treatment is not usually required but, if necessary, emollients and a mild topical steroid can be used.
How do I manage lesions that look inflamed or infected?
  • It is common for individual lesions to become inflamed, and it can be difficult to distinguish between a normal host immune response, trauma, and infection.
    • Prior to molluscum contagiosum resolving, lesions can become mildly inflamed, with redness and irritation. It is thought that this represents the development of a cellular immune response, and no treatment is required.
    • Individual lesions also commonly become inflamed following treatment — if mild and with no evidence of infection, then no action is needed.
    • If lesions become inflamed, with evidence of infection (such as spreading erythema, oedema, crusting, or pus), antibiotics are recommended. The decision on whether to prescribe a topical or a systemic antibiotic depends on the severity of the clinical signs.

[Smolinski and Yan, 2005]

What issues do I need to consider in a person with anogenital lesions?
  • The treatment of molluscum contagiosum lesions in the anogenital area is the same as for lesions elsewhere on the body.
  • Increasingly, treatments for genital warts, such as podophyllotoxin 0.5% cream and imiquimod 5% cream, are being used to treat genital molluscum. There is encouraging evidence to support this. These treatments would usually only be used in a genito-urinary medicine clinic.
  • In adults with anogenital lesions, screening for sexually transmitted infections (STIs) is recommended [Scott, 2001; Ting and Dytoc, 2004]. Contact tracing of partners is not required unless an STI is diagnosed [Scott, 2001].
  • In children, lesions are commonly seen in the genital and perineal areas (14%) but referral for suspected sexual abuse should only be arranged if there is other evidence to suggest this [Highet, 1992].
What issues do I need to consider in a person who has HIV?
  • People infected with HIV who have molluscum contagiosum often require management in secondary care.
    • Lesions can be atypical (e.g. giant lesions), multiple, and in unusual locations [Ficarra and Gaglioti, 1989; Petersen and Gerstoft, 1992; Schwartz and Myskowski, 1992].
    • Lesions can mimic other cutaneous diseases (e.g. cutaneous cryptococcosis), and a biopsy might be required for diagnosis [Rico and Penneys, 1985].
    • Molluscum contagiosum can be a sign of significant immunocompromise, the severity of the infection varying inversely with the CD4 count [Schwartz and Myskowski, 1992].
    • Although the treatment options are similar to those in people without HIV infection, molluscum contagiosum is usually more resistant to treatment.
    • In people with severe immunodeficiency, molluscum contagiosum is usually progressive and resistant to conventional treatments [Schwartz and Myskowski, 1992; Gottlieb and Myskowski, 1994].
      • The new immune modulators such as cidofovir (systemic and topical), topical imiquimod, intralesional interferon, and topical streptococcal antigen OK-432 can be useful in such individuals [Crowe, 2005].
      • Widely disseminated molluscum contagiosum can improve with antiretroviral therapy as the CD4 count improves [Calista et al, 1999].
What issues do I need to consider in a person with lid-margin or ocular lesions?
  • Molluscum contagiosum on the eyelids can rarely cause a chronic keratoconjunctivitis.
    • It is unclear whether asymptomatic lid-margin or ocular molluscum contagiosum routinely requires treatment [Margo and Katz, 1983].
    • If the child develops eye symptoms thought to be secondary to molluscum contagiosum (e.g. red or sticky eyes), seek advice from an ophthalmologist [Redmond, 2004].
Supporting evidence
Evidence for treating non-genital molluscum contagiosum

In most people, molluscum contagiosum is a mild condition which resolves completely within a year or two without leaving scarring, and watchful waiting and reassurance of patients and parents is often the preferred management. If treatment is thought to be indicated, there is a lack of good-quality data to guide choice. In particular, there is very limited information on the effectiveness and safety of the commonly used 'destructive' treatments, such as cryotherapy and curettage. There is evidence from one small trial that simple trauma to the lesions by squeezing is as effective as the more aggressive treatment of phenol ablation, with less risk of scarring. However, even squeezing increased the risk of scarring, with 65% of lesions leaving scars on healing.

  • A Cochrane review (search date to March 2004) evaluated the evidence for treatments for molluscum contagiosum (five randomized controlled trials [RCTs], n = 137) [van der Wouden et al, 2006].
    • Most of the studies identified could not be included in the review because they were uncontrolled case series. Such studies are open to significant biases, and results are particularly difficult to evaluate for molluscum contagiosum due to the high rate of spontaneous resolution.
    • Only five RCTs suitable for inclusion in the review were identified.
      • Three RCTs examined the use of topical treatments and two examined the use of systemic treatments (one of oral cimetidine, the other of a homeopathic remedy).
      • All of these studies were small and had methodological problems.
      • Only one study, which compared 5% sodium nitrite applied daily with 5% salicylic acid under occlusion with 5% salicylic acid alone, found a statistically significant effect, but this finding is difficult to interpret as there was no placebo arm in this study.
    • No studies on curettage were found.
    • One study was found that compared two types of cryotherapy for cutaneous skin lesions (but only 10 participants had molluscum contagiosum).
    • One study was found that compared physical expression (squeezing) with phenol ablation, but this was non-randomized and lesions were the unit of treatment and analysis [Weller et al, 1999]. Cure rates at 1 month were 75% for physical expression and 77% for phenol ablation, which is higher than would be expected from natural resolution. Phenol ablation was associated with more scarring (80%), but squeezing lesions also resulted in scarring (65%).
    • The authors of the review concluded that, at present, no reliable evidence-based recommendations can be given for the treatment of non-genital molluscum contagiosum in immunocompetent people, and until robust evidence emerges for effective and safe treatment, clinicians should consider expectant management (i.e. waiting for spontaneous resolution of the molluscum lesions).
  • A number of alternative/complementary therapies are promoted for the treatment of molluscum, but their effectiveness is unproved.
    • In addition to the trial of a homeopathic remedy included in the Cochrane review, we found a small RCT of an essential oil [Burke et al, 2004]. Results from this trial suggest that application of essential oil of Australian lemon myrtle might be an effective treatment, but further research is needed.
Evidence for treating anogenital molluscum contagiosum

The treatment options for anogenital molluscum contagiosum are similar to those for non-genital molluscum, although there is little evidence regarding effectiveness specifically in people with anogenital molluscum. There is limited evidence that treatments commonly used for the treatment of genital warts (podophyllotoxin and imiquimod) are also effective for the treatment of genital molluscum contagiosum — such treatments would usually only be offered in a genito-urinary medicine clinic.

  • Podophyllotoxin:
    • A randomized controlled trial (RCT) (n = 120) of people with mainly genital molluscum contagiosum compared treatment with podophyllotoxin 0.5% cream, podophyllotoxin 0.3% cream, and placebo [Syed et al, 1994].
    • Patients self-administered the cream to their lesions twice daily for three consecutive days per week for up to 4 weeks. Cure was defined as total clearance of the lesions.
    • After 1 month, cure was achieved in 92% of the podophyllotoxin 0.5% group, in 52% of the podophyllotoxin 0.3% group, and in 16% of the placebo group (p <>
  • Imiquimod:
    • An RCT (n = 100) of people with thigh or genital molluscum contagiosum compared treatment with 1% imiquimod cream with placebo cream [Syed et al, 1998].
    • Patients self-administered the cream to their lesions three times daily for five consecutive days per week. Cure was defined as total clearance of the lesions.
    • After 4 weeks' treatment, 82% of the imiquimod group were cured, compared with 16% of the placebo group (p <>
    • Among 49 cured patients, three had relapses after 10 months.


NHS staff in England can link, free of charge, from references to the full-text journal articles by clicking on [NHS Full-text]. You will need an NHS Athens password to access these resources. Click here for Athens registration.

All references with links to [Free Full-text] are freely available online to users in England and Wales. This includes the full text of Department of Health papers and Cochrane Library reviews.

  1. Arnold, H., Odam, R.B. and James, W.D. (Eds.) (1990) Andrews’ diseases of the skin: clinical dermatology. 8th edn. Philadelphia: Saunders.
  2. Bayerl, C., Feller, G. and Goerdt, S. (2003) Experience in treating molluscum contagiosum in children with imiquimod 5% cream. British Journal of Dermatology 149(Suppl 66), 25-29.
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