A Practical Algorithm for the Treatment of Molluscum Contagiosum: Clinical Guidance Based on Current Evidence and Expert Consensus

Background: Molluscum contagiosum is a common, highly transmissible viral dermatosis of childhood that is often underrecognized and undertreated. Although considered self-limited, lesions may persist for months to years and are associated with discomfort, psychosocial distress, social stigma, secondary complications, and substantial household transmission. Following recent approval of new on-label therapies, practical management guidance is needed. Objective: To develop a pragmatic, consensus-based treatment algorithm for pediatric molluscum integrating current evidence and expert clinical experience. This tool supports real-world decision-making and is not a formal guideline. Methods: A multidisciplinary panel of pediatric dermatology experts reviewed evidence on epidemiology, transmission, disease burden, and treatment efficacy and safety. Approved therapies, off-label agents, and procedural interventions were evaluated. Through structured discussion and iterative refinement, a practical algorithm emphasizing patient-centered care and shared decision-making was developed. Results: The algorithm begins with diagnostic confirmation and multifactorial severity assessment, incorporating lesion number, location, symptoms, and psychosocial impact. Evaluation and treatment of comorbid atopic dermatitis (AD) are prioritized. Given the quality-of-life burden and high rate of household transmission, routine watchful waiting is generally discouraged. Education should address transmission reduction, skin barrier support, and treatment expectations. On-label therapies are preferred. Topical berdazimer, a nitric oxide–releasing antiviral for home use, and topical cantharidin, an in-office vesicant, demonstrates favorable efficacy and safety. Selection should consider ease of use, tolerability, lesion location, risk of autoinoculation, patient age and neurodevelopmental status, and access or cost. Off-label topical agents (e.g., imiquimod, retinoids, keratolytics, potassium hydroxide, podophyllotoxin) show limited or inconsistent efficacy and may increase irritation. Destructive modalities such as cryotherapy and curettage may be appropriate in select cases but require caution due to pain and scarring risk. Combination therapy and adjunctive emollients also benefits patients and supports rapid healing. Shared decision-making aligns treatment with severity, family circumstances, and preferences. Conclusions: Molluscum contagiosum has meaningful physical and psychosocial impact. Safe, effective on- label treatments are available, shifting management away from observation and off-label approaches. Therapy should be individualized based on severity, location, comorbid AD, and family context.