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Pediatric Dermatology Vol. 16 No.

3 228231, 1999

Treatment of Molluscum Contagiosum with

Potassium Hydroxide: A Clinical Approach
in 35 Children
Ricardo Romiti, M.D.,* Alessandra P. Ribeiro, M.D.,* Beni M. Grinblat, M.D.,*
Evandro A. Rivitti, M.D.,* and Ney Romiti, M.D.

*Department of Dermatology, University of Sao Paulo, and Department of Dermatology, Faculty of Medicine of
Santos, Sao Paulo, Brazil

Abstract: Potassium hydroxide (KOH) is a strong alkali that has long

been known to digest proteins, lipids, and most other epithelial debris of
skin scrapings to identify fungal infections. To our knowledge, KOH has
never been used for the treatment of molluscum contagiosum (MC). We
evaluated 35 children with MC for the clinical effectiveness of treatment
with topical 10% KOH aqueous solution. The solution was applied by the
parents of affected children, twice daily, on each MC lesion. The therapy
was continued until all lesions underwent inflammation and superficial
ulceration. Thirty-two of 35 patients achieved complete clinical cure after
a mean treatment period of 30 days. Three children discontinued treat-
ment: two reported severe stinging of the lesions and refused further
applications; the other, with giant MC lesions, developed a secondary
infection with prolonged treatment. Therapy with KOH was found to be
effective and safe in the treatment of MC in children.

Molluscum contagiosum (MC) is a common world- tion. Their ages ranged from 7 months to 15 years (mean
wide viral infection most frequently seen in school-age 6 years). MC lesions were present for at least 30 days
children. Although the disease may resolve spontane- before patients entered the study and no therapeutic pro-
ously, the spreading of localized MC, with the resulting cedures with systemic or topical agents were performed
psychological impact of widespread lesions, often war- during this period. Children with known immunodefi-
rants a therapeutic approach. No data exist on the effi- ciency or periorbital lesions were excluded in this trial.
cacy of treatment with topical KOH solution for MC. In The following information was recorded: age, sex, lesion
this report we show that 10% KOH aqueous solution sites, history of atopy, previous treatments, and response
may be an effective alternative for the management of to KOH treatment (Table 1). Diagnostic criteria for
MC in children. atopic dermatitis were recorded according to the features
established by Hanifin and Rajka (1).
MATERIALS AND METHODS Parents were instructed to apply a 10% KOH aqueous
In an open-label, uncontrolled study, 35 children with solution, twice daily, with a cotton swab to all lesions.
MC were treated with topical 10% KOH aqueous solu- They were encouraged to apply a small amount of the

Address correspondence to Ricardo Romiti, M.D., Rua Viradouro,

29 ap. 123, CEP: 04538-110, Sao Paulo S.P. Brazil.

Romiti et al: KOH for Molluscum Contagiosum 229

TABLE 1. Clinical Data, Efficacy, and Localized Adverse Symptoms of Patients Treated with 10% KOH Aqueous Solution

Patient Previous Response to KOH

No. Age Sex Lesion Sites Treatment Atopy (in days) Side Effects
1 7 months F Face, neck, trunk Curettage No Clear (30 days)
2 1 year F Vagina No Noncompliant Severe Stinging
3 2 years F Legs, groins Yes Clear (30 days)
4 2 years F Trunk No Clear (30 days)
5 2 years F Trunk, armpits No Clear (30 days) Transitory
6 2 years M Face, neck, trunk No Noncompliant Severe stinging
7 3 years F Face, arms No Clear (15 days)
8 3 years F Trunk, legs No Clear (30 days)
9 3 years M Neck No Clear (15 days)
10 3 years M Trunk, legs Curettage Yes Clear (30 days) Persistent hypo- and
11 4 years M Trunk, scrotum Yes Clear (15 days)
12 5 years F Face, neck No Clear (60 days)
13 5 years M Arms, groins, trunk No Clear (30 days)
14 5 years F Neck, ears, trunk, arms No Clear (30 days)
15 5 years M Face, trunk, legs Salicylic acid Yes Clear (15 days)
16 5 years F Face, armpits No Clear (15 days)
17 5 years F Face, neck, trunk, arms No Clear (90 days) Persistent
18 5 years F Face, neck, trunk, armpits No Clear (60 days) Transitory
19 6 years F Face, ears, trunk No Clear (30 days)
20 6 years M Face Yes Clear (15 days)
21 6 years M Face, trunk Curettage Yes Clear (60 days)
22 6 years F Face, neck, trunk, legs Yes Clear (60 days)
23 6 years M Face, trunk, legs No Clear (30 days) Persistent
24 7 years M Trunk, arms, legs Yes Clear (30 days)
25 7 years M Face, neck, armpit Curettage Yes Clear (30 days)
26 7 years M Trunk Yes Clear (30 days) Transitory hypo- and
27 7 years F Face, arms, legs Yes Clear (90 days) Transitory
28 9 years F Trunk, legs, arms Curettage No Clear (15 days)
29 9 years M Trunk No Clear (15 days)
30 9 years F Arms Yes Clear (15 days)
31 9 years F Neck No Clear (30 days)
32 13 years M Legs, buttocks Yes Clear (60 days) Transitory
33 13 years M Trunk, scrotum, arms No Clear (30 days) Hypertrophic scar
34 13 years F Chin Yes Noncompliant Secondary infection
35 15 years F Face Yes Clear (15 days)

solution and not to saturate the cotton swabs in order to RESULTS

avoid irritation of normal skin. If this should occur, they
were advised to wash the skin with water immediately, In this open study 35 children were treated with topical
dry it, and reapply the solution. 10% KOH aqueous solution, twice a day, until clearance
Treatment was discontinued as soon as the lesions of all lesions was observed. A history of atopy was noted
underwent signs of inflammation or superficial ulcer- in 15 patients (42.9%).
ation. The assessment of therapeutic response was re- Thirty-two patients (91.4%) completed the study. All
corded by investigators on days 15, 30, 60, and 90. Chil- achieved complete clearance of the lesions after a mean
dren who achieved complete clinical clearance before the period of 30 days (Figs. 1 and 2). Time until develop-
end of the study were only reevaluated 1 month after ment of inflammation and ulceration varied greatly ac-
clearance of the lesions. Those who developed postin- cording to the sizes and locations of the lesions. No
flammatory local side effects were followed up for an recurrences were observed during the following months.
additional 3 months. If new lesions developed during the Most of the children who completed the trial reported
study, these were also treated and included in the data. a mild stinging sensation that lasted for 1 to 2 minutes
Figure 1. Molluscum contagiosum lesions with inflamma- Figure 3. Molluscum lesions on the buttocks of a 13-year-
tory signs on the back of a 5-year-old girl after 15 days of old boy before treatment.
therapy with 10% KOH aqueous solution.

Figure 4. Two months after initiating the treatment, all

Figure 2. The same patient after 1 month of treatment. lesions have disappeared leaving transient hypopigmen-
Note the complete disappearance of all lesions. tation.
Romiti et al: KOH for Molluscum Contagiosum 231

after application. Of the dropouts, one child with dis- ated lesions led to more intense postinflammatory pig-
seminated lesions and another with perivaginal mollus- mentary changes (data not recorded), the occurrence of
cum lesions did not comply with the regimen, reporting ulceration could not always be avoided, even with brief
severe stinging at application sites about a week after careful applications. MC lesions that did not undergo
initiating treatment. A third patient with giant molluscum inflammation during the follow-up period could always
lesions (larger than 1 cm) on the chin developed a sec- be traced back to having been overlooked by the parents,
ondary bacterial infection with inflamed lesions and also and were additionally included in the trial. Children with
dropped out of the study. eyelid lesions were excluded due to the risk of eye inju-
At the end of the study, local side effects were ob- ries.
served in nine children (28.1%) and included hyperpig- Most children felt a transitory stinging sensation
mentation in one (3.1%), hypopigmentation in five shortly after the applications. This stinging impeded fur-
(15.6%) (Figs. 3 and 4), hyper- and hypopigmentation in ther treatment in only two patients, one with perivaginal
two (6.3%), and a single hypertrophic scar in one (3.1%). and another with widespread MC lesions. Perhaps in the
Disturbances of pigmentation persisted in three children future lower concentrations of KOH solution may be
(9.4%) after an additional 3-month period. A 13-year-old tried with less irritation to these areas. A child with giant
boy who had initially presented with widespread MC MC on the face also dropped out of the study due to
lesions developed a hypertrophic scar at the site of one secondary infection. Since the action of caustics may
lesion on the right thigh despite correct application of become increased in skin folds, special attention should
KOH solution. This particular patient was seen again be paid to these areas to avoid severe irritation. Of the
after an additional 6-month period at the end of the trial responders, 25% developed hyper- and/or hypopigmen-
and had a discrete scar without hypertrophic features. tation after treatment which in most cases resolved spon-
taneously over time.
DISCUSSION All parents reported that it was easy to apply the
solution and all stated that they preferred to treat their
MC is a common viral infection of the skin caused by the children at home instead of using a more aggressive,
MC virus, the largest human virus and sole member of physical modality of treatment such as cryosurgery or
the genus Molluscipox (2,3). There is no specific treat- curettage in the physicians office.
ment for MC. The physical modalities of treatment are Spontaneous clearing of MC lesions during our study
generally regarded as most effective. Curettage and cryo- cannot be excluded. A placebo-controlled trial will be
therapy are among the most widely used (4). Alterna- necessary to establish the exact efficacy of KOH treat-
tively, chemical agents such as podophyllin, tretinoin, ment. Nevertheless, topical KOH solution proved to be a
cantharidin, trichloroacetic acid, silver nitrate, phenol, safe, effective, and inexpensive, noninvasive alternative
salicylic acid, and tincture of iodine have been used with treatment of MC in children, inducing a favorable clini-
variable results (5,6). It is thought that some of these cal response in the majority of patients in our study.
treatments work via an immunologic response following
injury to the epidermis with release of viral antigens (7).
Oral cimetidine has proved to be of benefit in the man- 1. Hanifin JM, Rajka RG. Diagnosis features of atopic der-
agement of MC. The immunomodulatory effects of ci- matitis. Acta Derm Venereol 1980;92:4447.
metidine seem to work via inhibition of suppresser lym- 2. Epstein WL. Molluscum contagiosum. Semin Dermatol
phocyte function, enhancing T-cell immunity (8). 1992;11:184189.
3. Myskowsky PL. Molluscum contagiosum. Arch Dermatol
Alkalis are known to deeply penetrate and destroy the 1997;133:10391041.
skin because their compounds dissolve keratin. KOH is 4. Williams LR, Webster G. Warts and molluscum contagio-
used routinely by dermatologists to identify fungal ele- sum. Clin Dermatol 1991;9:8793.
ments in skin scrapings. It can also cause an irritant 5. Ohkuma M. Molluscum contagiosum treated with iodine
reaction in the skin, varying with the concentration, body solution and salicylic acid plaster. Int J Dermatol 1990;29:
region, and individual susceptibility (9). We tested the 6. Gottlieb SL, Myskowsky PL. Molluscum contagiosum. Int
effectiveness of a 10% KOH aqueous solution applied J Dermatol 1994;33:453461.
topically to the skin in the destruction of MC, based on 7. Lewis EJ, Lam M, Crutchfield CE III. An update on mol-
its property of dissolving epithelial compounds. luscum contagiosum. Cutis 1997;60:2934.
Of 35 children with MC, 32 completed the study with 8. Dohil M, Prendiville JS. Treatment of molluscum conta-
giosum with oral cimetidine: clinical experience in 13 pa-
clearance of all lesions. Inflammation usually developed tients. Pediatr Dermatol 1996;13:310312.
after a mean treatment period of 5 to 7 days. Parents were 9. Frosh PJ. Cutaneous irritation. In: Rycroft RJG, Menne T,
advised to stop the treatment as soon as inflammation or Frosch PJ, eds. Textbook of contact dermatitis, 2nd ed.
superficial ulceration became evident. Although ulcer- Berlin: Springer-Verlag, 1995.