Why Molluscum Is Everywhere Now
Buchi Neita, PA-C, and Shanna Miranti, PA-C, open with a reality familiar to any APP working in pediatric dermatology: molluscum contagiosum walks through the door constantly. Miranti notes she saw three or four molluscum patients in a single day, including a pair of siblings. As Neita points out, molluscum wasn't nearly as visible when the hosts were growing up, and Miranti offers a compelling explanation — it's a pox virus in the same family as chickenpox and smallpox, caused by the molluscum contagiosum virus (types 1 through 4, which are all treated the same way). Because kids today are largely vaccinated against varicella around 12 months of age, they no longer build up the harder immune experience earlier generations got from chickenpox. That makes molluscum the most common pox virus now showing up in clinic.
Miranti stresses the importance of the transmission conversation to squash the blame game. It spreads through skin-to-skin contact, and it can lie dormant and emerge when a child gets a cold, has an eczema flare, or otherwise has a compromised skin barrier. It's common in the 2-to-10 age group and spreads easily in daycare, school, and contact sports like wrestling and gymnastics — and, of course, between siblings in the 'puppy pile' on the living room floor. Neita frames the parent conversation around reassurance: this is extremely common, it's not a hygiene failure, and it carries no stigma.
Making the Diagnosis (and the Eczema Clue)
Clinically, both hosts agree molluscum is usually a straightforward visual diagnosis: shiny, firm, dome-shaped papules with central umbilication, often clustered where skin rubs skin. Miranti recommends using a dermatoscope to find those umbilicated papules and reminds listeners that a biopsy is usually unnecessary. Lesions can auto-inoculate through scratching, shared towels or bath linens, and clothing friction — which is why a parent may report going from four or five bumps to dozens. Giant molluscum (6–8 mm or larger) can develop when lesions go untreated for a long time, sometimes with an inflammatory abscess underneath, which Miranti actually frames for parents as a good sign the immune system has finally noticed the virus.
A standout pearl from Miranti's former collaborating pediatric dermatologist: when you see asymmetric eczema, look for molluscum. Atopic dermatitis should be symmetric, so eczema that's markedly worse on one side of the body should be considered molluscum dermatitis until proven otherwise. Neita adds that for atopic patients, treating the background inflammation matters — reducing that inflammation and scratching helps curb auto-inoculation, even though parents are often fixated only on the bumps.
On genital or buttock lesions in children, Miranti is direct: sexually transmitted molluscum is far more a phenomenon of the adult population. In kids, these areas almost always reflect auto-inoculation from scratching elsewhere plus local friction and sweat. She counsels squashing that blame, while noting that any genuine concern for neglect or abuse should always be investigated to keep the child safe.
Treatment: Two FDA-Approved Options
Miranti offers treatment right off the bat because parents are frustrated — many arrive self-referred after being told to 'let it ride,' only to watch the virus persist and spread. She notes the natural course can average two to five years because the virus provokes little inflammatory response on healthy skin. Her preferred approach centers on the two FDA-approved therapies. The first is cantharidin 0.7% in a GMP-controlled drug-delivery device, applied in office by the provider once every three weeks, FDA-approved in July 2023. It's a vesicant that produces blistering, typically clearing lesions in about two to three treatments on average.
The second is berdazimir 10.3% gel in a nitric oxide-releasing agent, FDA-approved in January 2024, though Miranti notes it wasn't commercially available until 2025 and access through specialty pharmacies didn't really improve until early 2026. This is an at-home topical applied twice daily; parents mix two tubes together and apply to each individual bump. Miranti reports it causes irritation and an inflammatory response—enough to trigger the immune reaction that clears the virus—but not the blistering seen with cantharidin. She lets parents choose: some prefer she do the work in office every three weeks, while others who can't manage repeat visits prefer the take-home prescription.
Miranti issues a strong caution about compounded cantharidin ('beetle juice'), which has been banned by the FDA. Products entering U.S. offices are likely imported, and because they can evaporate and concentrate over time, providers may not know the true percentage being applied—plus the legal exposure. She favors FDA-approved products, which are on many formularies including Medicaid, over older non-approved options like imiquimod, tretinoin, and compounded cantharidin.
Setting Expectations and Answering the Common Parent Questions
Both hosts emphasize counseling on what to expect before treatment starts. Vesication is expected with cantharidin and inflammation is expected with berdazimir — Miranti reminds patients that everyone reacts to cantharidin, so a blister isn't an allergy. All treatments carry risk of post-inflammatory erythema, hyperpigmentation, or hypopigmentation, and the pox virus itself can leave permanent scars even with no treatment at all. Her key line for parents: the pox virus caused the scars, not the treatment. Sun protection counseling is part of every visit.
On Neita's rapid-fire closing questions: yes, keep kids out of public pools and shared bathtubs with siblings during the vesication/blistering stage, keep lesions covered for school and sports, and check state athletic association rules for return to contact sports. For atopic kids, expect roughly a 50% reduction in lesion count per treatment and counsel that clearance may take longer than the usual two to three treatments (or about six months for the at-home route) — while treating the eczema concurrently, ideally with a barrier-repairing nonsteroidal therapy. For facial lesions, Miranti notes that both FDA-approved therapies included facial lesions in their trials, treating every lesion except those within one centimeter of a mucosal membrane (eyelids, mouth), so she no longer relies on old off-label workarounds for the face.