Not a day goes by without pediatric dermatologist Elizabeth (Lisa) Swanson, MD, seeing a case of molluscum contagiosum. Most often, the patient’s family has rightly been told by the pediatrician that treatment is not necessary and that the lesions will resolve with time.

“But I’m always happy to treat, and I do think we get pretty good success,” Swanson told Medscape Medical News. In her practice in Boise, Idaho, she employs a range of treatments, including imiquimod cream, candida antigen injections, potassium hydroxide KOH, and cimetidine, and the two recently FDA-approved topical treatments, a drug-device combination product that delivers cantharidin and berdazimer gel.

Swanson discussed available treatments for molluscum at the 2025 Integrative Dermatology Symposium (IDS) and in a recent interview with Medscape Medical News. To “cushion the blow” for parents, who often “want these things gone yesterday,” Swanson said at the meeting that she tells families that almost every child gets the poxvirus-caused bumps at some point and explains that indeed, treatment is not mandatory but that it is available. “The silver lining is that you only get them once,” she assured parents.

She also reassures parents that molluscum “pose no increased danger in areas like the face or the underwear area,” and often explains that “the uglier they look, the happier I am…as that ugliness is a sign of immune response.”

Molluscum in adults is rare, implying immunity, yet most adults don’t remember having molluscum as a child. This issue comes up often during visits, she told Medscape Medical News. “There are two possible explanations that I share: One is that the virus used to manifest with different symptoms,” and the other is the theory that occurrence today in children is related to waning smallpox immunity compared with prior generations who received the smallpox vaccine.

Swanson, who also practices at St. Luke’s Children’s Hospital: Boise in Boise, Idaho, provided the following advice regarding treatment options for this common condition:

Cantharidin: Both the compounded, long-used version of cantharidin (also referred to as “beetle juice”) and Ycanth, the drug-device combination product approved by the FDA for patients aged 2 years or older in 2023 — the first FDA-approved treatment for molluscum — are administered in the office every 3 weeks. The product contains a cantharidin 0.7% solution, was studied and is used to treat all areas affected by the virus, but Swanson recommends consideration of more limited treatment at the first visit.

“Treating only four to five [lesions] at the first visit allows [patients and families] to experience the blister journey before you apply it to 30,” she said at the IDS meeting, noting that despite her counseling about consequent blisters, which last about 3 days, parents often call the office once blisters appear. Most are small, she said, but they “sometimes can be big and uncomfortable.”

Lesions should not be covered or occluded after application of cantharidin, and “I tell patients to wash it off in 4 hours,” Swanson said, referring to both the compounded and branded versions. In her opinion, the axilla or underwear area should never be treated with cantharidin as the blisters can be larger and more intense in these locations, she noted in the interview.

Swanson’s success with compounded cantharidin has been approximately 50% resolution with each treatment, which she considers reasonable. She expects the same outcomes with the FDA-approved product, she told Medscape Medical News.

Access to Ycanth has been frustrating, however, since its initial rollout, Swanson and others said at the IDS 2025 meeting. Advance purchase for a practice is a significant upfront expense for potentially uncertain patient demand, she explained in the interview. And while clinicians can order it individually, insurance coverage has been poor and difficult to navigate. In the meantime, obtaining compounded cantharidin has become more difficult as well.

Steve Daveluy, MD, professor and program director of dermatology at Wayne State University in Detroit, who moderated Swanson’s presentation at the IDS meeting, told Medscape Medical News that compounded cantharidin is still obtainable, but “it’s been more of a struggle to get it…we’ve had to switch pharmacies multiple times.”

This is “unfortunate because the pricing of the [branded product] reduced access for patients,” he said, noting that many of his patients are insured through Medicaid.

Berdazimer gel, 10.3%: Approved by the FDA in January 2024 for treating molluscum in patients aged 1 year or older, this nitric oxide-releasing gel (Zelsuvmi) can be applied at home and is well-tolerated. An analysis of three randomized controlled trials of children and adolescents with molluscum (mean age, almost 7 years) showed that 30% of patients treated with berdazimer gel had complete clearance of molluscum at week 12 compared with 20% of those using vehicle. “I’d go slow and steady because it’s a new medicine for us,” Swanson said at the IDS meeting. “I tell patients, start Monday, Wednesday, Friday and get a sense for it, and it that goes well, use it every night.”

Based on her recent experience with this new topical, it seems possible that its real-world efficacy “is better than the studies indicated,” she added in the interview.

Imiquimod cream, 5%: Several studies have shown little benefit for childhood molluscum, and concerns about safety have been raised, making this treatment choice “controversial,” Swanson said at the IDS 2025 meeting. But in her experience, she said, “it’s cheap and it’s easy and it’s well tolerated, and I really think it works in some cases, so I use it.”

Her preferred regimen: Apply to two to three lesions on Monday, Wednesday, and Friday at bedtime and follow-up at 8 weeks. “Either we’ll see signs of response and can continue until they’re all cleared up, or we won’t see response and it’s time to move on to something else,” she said. “I also tell parents, a little bit of irritation can be a good thing, but a lot is bad so call me,” if that occurs.

Candida antigen intralesional injections: “I use this a lot for molluscum and for warts, it’s so easy and effective,” she said at the IDS 2025 meeting, referring to a 2008 retrospective chart review of patients treated with candida antigen therapy for molluscum and warts published in Pediatric Dermatology.

Her regimen: Treat one lesion with 0.3 ml of candida antigen, every 3-4 weeks, for “at least three treatments before moving on.” It can take three to five treatments to see complete resolution of both the treated and untreated lesions, according to Swanson.

A small number of children will develop redness and swelling around the injection site that lasts up to 72 hours, which is a positive sign of response. In her 15-plus years of practice, “with the formulation I use, I’ve had only two patients experience flu-like symptoms for a day or two,” she said. (Formulations may vary with regard to efficacy and side effects, she said in the interview.)

“Candida becomes appealing the more molluscum the child has because you only need to treat one lesion with each treatment,” she added in the interview. “Candida antigen works to trigger an immune response.... The immune system is attracted to the candida and then notices the molluscum and goes on a molluscum hunt.”

KOH: A 2018 randomized controlled trial comparing topical application of KOH 15%, KOH 10%, and placebo in children aged 2-6 years with molluscum found that the two concentrations were not significantly different in efficacy, but that KOH 10% was better tolerated. “I would agree,” Swanson said at the IDS meeting. “I only prescribe 10% and even that can be irritating.”

She instructs parents to “dab it on to four to five spots with a Q-tip Monday, Wednesday, Friday to get a sense of how your child is going to experience this, and if that goes well, then bump it up to treat all spots, every night.” The price at the compounding pharmacy she uses is $30 for 30 ml, she noted.

Curettage: For older, highly motivated children and parents, curettage can be considered, Swanson said at the meeting, referring to a retrospective study showing that 70% of 1879 children with molluscum who underwent curettage were cured after one treatment and 26% were cured after two treatments, with a high degree of satisfaction among children and their parents.

“It definitely has a place, but it’s not the first thing I reach for,” she said. “It hurts, and depending on how many [lesions] they have, it can be a big deal. There’s also a small risk of scarring…so it should be done in areas where having a scar won’t be devastating.”

Oral cimetidine and other treatments: Cimetidine is worthy of consideration for molluscum lesions on the face — where other treatment options are not appealing — and as part of combination treatment. “If I have a patient who is on a treatment like beetle juice or candida antigen or imiquimod and it’s going kind of so-so, I’ll include as an option to add cimetidine to help boost the efficacy of the other agent,” Swanson said in the interview.

She prescribes a dose of 30-40 mg/kg/d, divided into two doses, with a maximum daily dose of 800 mg. The drug is currently largely available only in pill form, she noted.

Liquid nitrogen and topical retinoids can both be effective for molluscum, but the former is painful and the latter can increase the risk for molluscum dermatitis. Still, “they have a place” in the treatment armamentarium, she said at the IDS meeting.

Over-the-counter remedies such as ZymaDerm, a topical homeopathic remedy made of essential oils and other ingredients, have been hard to find in the wake of the FDA’s approval of Ycanth, Swanson said. “Most of the natural remedies are gone — an unexpected consequence of the approval of the branded version of cantharidin,” she said at the meeting.

“I always like being able to have natural home remedies as an option. Often times, by the time patients are seeing me, they want something more aggressive. But it was nice to have that as a choice,” Swanson told Medscape Medical News.

[In August 2023, a month after the Ycanth approval, retailers were warned by the FDA against marketing or distributing unapproved over-the-counter products to treat molluscum.]

Tea tree oil is often touted as a natural remedy for molluscum on the internet, she noted at the meeting, “and it still can be recommended, but it can be irritating and create more molluscum dermatitis.”

Molluscum can take up to 2-3 years to resolve without treatment, but the average is about 1 year, Swanson said. A retrospective study published in 2015 looked at 170 children younger than 16 years with molluscum, half of whom were treated and half of whom were not treated. In both groups, “molluscum resolved in the same amount of time” she said at the meeting.

(Complete clearance was achieved within 12 months in 46% and 48% of the treated and untreated groups, respectively, and within 18 months in 70% of those treated and 73% of untreated.)

Swanson sometimes shares these findings with parents, but most are intent on treatment for their children, which she said, is “OK when the molluscum [lesions] are annoying, irritating, causing an eczema flare, in a visible location or interfering with ADLs [activities of daily living], and are frustrating to patients and their families.” Overall, she added, the condition is “distressing” to parents.

Molluscum Dermatitis

Molluscum dermatitis must be treated, she emphasized, to reduce itchiness, scratching, and spread of the molluscum. She uses the Aron regimen— a compounded mix of betamethasone valerate, mupirocin, and a moisturizing base — to treat molluscum dermatitis. “It’s fantastic,” she said. “I really like it for kids where our options are really limited.”

This treatment approach was also described in a 2017 case series study on the efficacy of the regimen, coined CASM (compounded antibacterial, steroid and moisturizer), for atopic dermatitis, she said in the interview.

Swanson disclosed being a speaker and consultant for both Pelthos and Verrica. Daveluy reported having no relevant disclosures.