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

228
 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
hypopigmentation
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
hyperpigmentation
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)
plaster
16 5 years F Face, armpits No Clear (15 days)
17 5 years F Face, neck, trunk, arms No Clear (90 days) Persistent
hyperpigmentation
18 5 years F Face, neck, trunk, armpits No Clear (60 days) Transitory
hypopigmentation
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
hypopigmentation
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
hyperpigmentation
27 7 years F Face, arms, legs Yes Clear (90 days) Transitory
hypopigmentation
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
hypopigmentation
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,
dry it, and reapply the solution.
Treatment was discontinued as soon as the lesions
underwent signs of inflammation or superficial ulcer-
ation. The assessment of therapeutic response was re-
corded by investigators on days 15, 30, 60, and 90. Chil-
dren who achieved complete clinical clearance before the
end of the study were only reevaluated 1 month after
clearance of the lesions. Those who developed postin-
flammatory local side effects were followed up for an
additional 3 months. If new lesions developed during the
study, these were also treated and included in the data.
In this open study 35 children were treated with topical
10% KOH aqueous solution, twice a day, until clearance
of all lesions was observed. A history of atopy was noted
in 15 patients (42.9%).
Thirty-two patients (91.4%) completed the study. All
achieved complete clearance of the lesions after a mean
period of 30 days (Figs. 1 and 2). Time until develop-
ment of inflammation and ulceration varied greatly ac-
cording to the sizes and locations of the lesions. No
recurrences were observed during the following months.
Most of the children who completed the trial reported
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.

after application. Of the dropouts, one child with dis-
seminated lesions and another with perivaginal mollus-
cum lesions did not comply with the regimen, reporting
severe stinging at application sites about a week after
initiating treatment. A third patient with giant molluscum
lesions (larger than 1 cm) on the chin developed a sec-
ondary bacterial infection with inflamed lesions and also
dropped out of the study.
At the end of the study, local side effects were ob-
served in nine children (28.1%) and included hyperpig-
mentation in one (3.1%), hypopigmentation in five
(15.6%) (Figs. 3 and 4), hyper- and hypopigmentation in
two (6.3%), and a single hypertrophic scar in one (3.1%).
Disturbances of pigmentation persisted in three children
(9.4%) after an additional 3-month period. A 13-year-old
boy who had initially presented with widespread MC
lesions developed a hypertrophic scar at the site of one
lesion on the right thigh despite correct application of
KOH solution. This particular patient was seen again
after an additional 6-month period at the end of the trial
and had a discrete scar without hypertrophic features.
DISCUSSION
MC is a common viral infection of the skin caused by the
MC virus, the largest human virus and sole member of
the genus Molluscipox (2,3). There is no specific treat-
ment for MC. The physical modalities of treatment are
generally regarded as most effective. Curettage and cryo-
therapy are among the most widely used (4). Alterna-
tively, chemical agents such as podophyllin, tretinoin,
cantharidin, trichloroacetic acid, silver nitrate, phenol,
salicylic acid, and tincture of iodine have been used with
variable results (5,6). It is thought that some of these
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-
agement of MC. The immunomodulatory effects of ci-
metidine seem to work via inhibition of suppresser lym-
phocyte function, enhancing T-cell immunity (8).
Alkalis are known to deeply penetrate and destroy the
skin because their compounds dissolve keratin. KOH is
used routinely by dermatologists to identify fungal ele-
ments in skin scrapings. It can also cause an irritant
reaction in the skin, varying with the concentration, body
region, and individual susceptibility (9). We tested the
effectiveness of a 10% KOH aqueous solution applied
topically to the skin in the destruction of MC, based on
its property of dissolving epithelial compounds.
Of 35 children with MC, 32 completed the study with
clearance of all lesions. Inflammation usually developed
after a mean treatment period of 5 to 7 days. Parents were
advised to stop the treatment as soon as inflammation or
superficial ulceration became evident. Although ulcer-
Romiti et al: KOH for Molluscum Contagiosum 231
ated lesions led to more intense postinflammatory pig-
mentary changes (data not recorded), the occurrence of
ulceration could not always be avoided, even with brief
careful applications. MC lesions that did not undergo
inflammation during the follow-up period could always
be traced back to having been overlooked by the parents,
and were additionally included in the trial. Children with
eyelid lesions were excluded due to the risk of eye inju-
ries.
Most children felt a transitory stinging sensation
shortly after the applications. This stinging impeded fur-
ther treatment in only two patients, one with perivaginal
and another with widespread MC lesions. Perhaps in the
future lower concentrations of KOH solution may be
tried with less irritation to these areas. A child with giant
MC on the face also dropped out of the study due to
secondary infection. Since the action of caustics may
become increased in skin folds, special attention should
be paid to these areas to avoid severe irritation. Of the
responders, 25% developed hyper- and/or hypopigmen-
tation after treatment which in most cases resolved spon-
taneously over time.
All parents reported that it was easy to apply the
solution and all stated that they preferred to treat their
children at home instead of using a more aggressive,
physical modality of treatment such as cryosurgery or
curettage in the physicians office.
Spontaneous clearing of MC lesions during our study
cannot be excluded. A placebo-controlled trial will be
necessary to establish the exact efficacy of KOH treat-
ment. Nevertheless, topical KOH solution proved to be a
safe, effective, and inexpensive, noninvasive alternative
treatment of MC in children, inducing a favorable clini-
cal response in the majority of patients in our study.
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