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Journal of Dermatology & Dermatologic Surgery xxx (2016) xxx–xxx

Original article

A comparative study of topical 10% KOH solution and topical

25% podophyllin solution as home-based treatments
of molluscum contagiosumq
Nameer K. Al-Sudany a,⇑, Dler R. Abdulkareem b
a
Ibn Sina University of Medical and Pharmaceutical Sciences, Department of Dermatology, Baghdad, Iraq
b
Al-Yarmouk Teaching Hospital, Department of Dermatology, Baghdad, Iraq

Received 6 January 2016; accepted 14 February 2016

Abstract

Background: Molluscum contagiosum is a common self-limiting viral infection of the skin. Many therapeutic agents have been used
with varying success rates. Objective: To evaluate and compare the effectiveness of topical 10% KOH solution and 25% podophyllin solu-
tion as home-based treatments of molluscum contagiosum. Patients and methods: This open randomized comparative therapeutic trial
was conducted in the department of dermatology, Al-Yarmouk Teaching Hospital, Baghdad, Iraq between January and October 2015.
The patients were divided randomly into two equal groups. Group A patients were treated with 10% KOH solution and those in group B
with 25% podophyllin solution. All patients were assessed weekly for 4 weeks for therapeutic response. Results: Fifty-two patients (age:
2–34 years) with MC were enrolled in this study, 25 patients in group A and 20 patients in group B completed the study. Sixteen (64%)
patients in group A showed complete clearance of lesions versus 14 (70%) patients in group B. No systemic side effects were reported in
both groups and the local side effects were comparable between both groups. Conclusion: Both 10% KOH solution and 25% podophyllin
solution are effective local therapies for the treatment of MC with comparable success rates (64% and 70% respectively).
Ó 2016 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Molluscum contagiosum; KOH solution; Podophyllin solution

1. Introduction 1.8% of the population were affected worldwide by MC

Molluscum contagiosum (MC) is a viral disease caused
by molluscum contagiosum virus (MCV) which is classified
within the Poxvirus family (Sterling, 2010). Approximately
q
The study is an independent one and not funded by any drug
company, academic institute or any health authority.
⇑ Corresponding author. Tel.: +964 7712216414; fax: +964 5410584.
E-mail address: nameeralsudany@yahoo.com (N.K. Al-Sudany).
Peer review under responsibility of King Saud University.
Production and hosting by Elsevier
with a higher distribution in the tropical areas (Vos et al.,
2012). The disease is more prevalent in children (peak inci-
dence between 2 and 5 years) (Sterling, 2010; Hanson and
Diven, 2003). A later incidence peak in young adults is
attributable to sexual transmission with lesions more com-
mon in the genital area (Hanson and Diven, 2003). There is
a clinical impression that MC is more common in patients
with atopic eczema (Leslie et al., 2005). MCV is passed
directly by skin contact with an infected individual to pro-
duce typical cutaneous and, rarely, mucosal lesions (Dohil
et al., 2006). The average incubation time is between 2 and
7 weeks with a range extending out to 6 months. Infection
with the virus causes acanthotic hyperplasia and hypertro-

http://dx.doi.org/10.1016/j.jdds.2016.02.002
2352-2410/Ó 2016 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Al-Sudany, N.K., Abdulkareem, D.R., A comparative study of topical 10% KOH solution and topical 25% podophyllin solution
as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002
2 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery xxx (2016) xxx–xxx
phy of the epidermis which consists of many lobes, each
lobe made up of many lobules separated from each other
by distinct basement membrane (Sharquie et al., 2015).
Clinically the disease produces a papular eruption of mul-
tiple umbilicated lesions. Individual lesions are discrete,
smooth, and dome shaped (Hanson and Diven, 2003).
Any cutaneous surface may be involved, but favored sites
include the face, neck, abdomen, arms, thighs, axilla, and
genital areas (Bikowski, 2004). MC is a self-limited disease,
which, left untreated, will eventually resolve in immuno-
competent hosts (Chen et al., 2013). In general, there are
four main therapeutic approaches to MC:
1. Physical therapies: like; cryosurgery (Silverberg, 2007),
evisceration (Hanson and Diven, 2003), phenol 10%
with pricking (Chen et al., 2013), curettage (Silverberg,
2007), tape stripping (Valentine and Diven, 2000), pho-
todynamic therapy (Chen et al., 2013), electron beam
therapy (Chen et al., 2013) and laser (Jones and
Muram, 1993; Binder et al., 2008).
2. Chemical destructive agents: like; trichloroacetic acid
(Chen et al., 2013), cantharidin (Chen et al., 2013), ben-
zoyl peroxide 10% (Chen et al., 2013), iodine solution
and salicylic acid (Valentine and Diven, 2000), tretinoin
(Rajouria et al., 2011), podophyllotoxin (Piggott et al.,
2012), podophyllin (Barefoot, 1951) and potassium
hydroxide (KOH) Romiti et al., 2000, 1999.
3. Immune modulators: like; imiquimod (Piggott et al.,
2012), diphencyprone (Chen et al., 2013), cimetidine
(Dohil and Prendiville, 1996) and intralesional candida
antigen (Chen et al., 2013).
4. Antiviral agents: like; cidofovir (Chen et al., 2013) and
subcutaneous IFN-a (Piggott et al., 2012).
The best way to prevent the spread of MC is through
good hygiene. (Centers for Disease Control and
Prevention, 2015)
Many therapeutic agents were used for the treatment of
MC with variable results. KOH in different concentrations
has been well studied whereas podophylline solution, to
our best knowledge, wasn’t tried in the treatment of MC
except once. The aim of the present study was to evaluate
and compare the effectiveness of topical 10% KOH solu-
tion and 25% podophyllin solution as home-based treat-
ments of molluscum contagiosum.
2. Patients and methods
An open comparative therapeutic study was conducted
in the Department of Dermatology and Venereology in
Al-Yarmouk Teaching Hospital, Baghdad-Iraq from 1st
of January 2015 to the end October 2015, where a total
number of 52 patients with MC were enrolled in this
study. The patients enrolled in this study were randomly
allocated into two groups through systematic random
sampling.
Please cite this article in press as: Al-Sudany, N.K., Abdulkareem, D.R., A comparative study of topical 10% KOH solution and topical 25% podophyllin solution
as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002
A full history was taken from each patient regarding
name, age, sex, occupation, marital status, sexual history,
duration of the disease, family history of similar condition,
past medical history, drug history especially for corticos-
teroids and other immune suppressants and any previous
treatment modality received for their MCs.
Every patient was examined to assess the number, size
and site of lesions; examination was aided by taking several
photos for each patient using the same digital camera
(Canon Power Shot SX260HS Camera 12.1 Megapixel)
from approximately the same distance and similar view.
Patients excluded from this study included those with
face involvement to avoid any possible side effect especially
of cosmetic concern, those who were previously treated,
pregnant and lactating women, uneducated (unreliable)
patient or his/her guardians and children less than 2 years
old.
An informed consent was obtained from each patient or
his/her parents prior to their inclusion in this study after
full explanation about the nature of the disease, its course
and prognosis and full information about therapeutic
agents intended to be used including the side effects and
method of application were given. An approval of the
Ethics Committee of Scientific Council of Dermatology
and Venereology of Iraqi Board for Medical Specializa-
tions was also obtained.
2.1. Preparation of the therapeutic agents
A KOH powder (produced by Sinopharm Chemical
Reagent Co., Ltd., Shanghai, China) was dissolved in dis-
tilled water to produce a 10% w/v solution. A podophyllin
resin powder (produced by Baoji Oasier Bio-Tech Co., Ltd.
Baoji, China) was dissolved in tincture benzoin to produce
a 25% w/v solution.
2.2. Method of application
Patients in group A were treated with 10% KOH solution
and those in group B were treated with 25% podophyllin
solution with instructions given to the patients or their guar-
dians to apply the agent topically using cotton swab soaked
in the solution after covering the surrounding area with
petrolatum, making gentle application to the MC lesion
and avoid any spillage over normal skin. First application
of therapeutic agent was done in the outpatient clinic trying
to learn the patients the correct way of application and how
to use it at home. Patients in group A were asked to apply
10% KOH solution once daily at night and those in group
B were instructed to apply 25% podophyllin solution every
other night and wash off 4 h after application.
All patients were asked to attend weekly to the outpa-
tient clinic for evaluation and to use therapeutic agents
for 4 weeks or until the lesions are cleared, whichever was
early. The importance of regular attendance was stressed
upon to prevent defaulting.
 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery xxx (2016) xxx–xxx 3

2.3. Evaluation and follow up
All patients were examined at the end of 1st, 2nd, 3rd,
and 4th weeks. On each visit the clinical response to treat-
ment; total disappearance of lesions, decrease in size and
number of lesions and any local or systemic side effect were
evaluated and recorded depending on clinical and photo-
graphic assessments. Photographs for lesions were taken
before and after treatment.
The patients were considered as respondent when there
was complete disappearance of the lesion; if there was no
change, the patients were considered as non-respondent;
if there was decrease in the number and size of lesions,
the patients were considered as partial respondent.
If complete response occurred during treatment period,
they were asked to attend one month later to assess for any
recurrence of the lesion, if no response occurred, they were
considered as treatment failure.
2.4. Statistical analysis
Data were coded and fed on a computer. Analysis was
done on SPSS (Statistical Package for Social Science
Analysis, Version 21). Both a descriptive statistics like
mean and SD (Standard Deviation) together with analytic
statistics like Chi-square (v2) test and t-test have been done
when appropriate. P-Values less than 0.05 were considered
significant. The results were presented in the form of fre-
quency table and graphs.
3. Results
A total of 52 patients have been enrolled in this thera-
peutic trial. Patients were divided into two equal groups;
each consists of 26 patients. Out of a total of 52 patients
with MC, 25 patients in group A and 20 patients in group
B completed the study. In group A, one patient discontin-
ued the treatment due to noncompliance, and in group B,
six patients did not complete the study, one of them didn’t
tolerate the local irritation caused by therapeutic agent he
used while others due to noncompliance (Fig. 1).
The age of patients ranged from 2 to 34 years, with a
mean ± SD of 10.84 ± 9.02 years, the youngest patient
was 2 years old and the oldest one was 34 years old. The
males outnumbered females (28 vs. 17) with a male to
female ratio 1.6:1. The two groups were well-matched in

Enrollment Assessed for eligibility (n=60)

Excluded (n=8)
Not meeting inclusion criteria (n=5)
Declined to participate (n=3)

Randomized (n=52)

Allocation
Allocated to intervention A (n=26) Allocated to intervention B (n=26)
Received allocated intervention (n=26) Received allocated intervention
Did not received allocated intervention (n=26)
(n=0) Did not received allocated
intervention (n=0)

Follow-up
Lost to follow up due to non- Lost to follow up due to non-
compliance (n=1) compliance (n=5)
Discontinued intervention (n=0) Discontinued intervention due to
severe local irritation caused by
therapeutic agent used (n=1)

Analysis
Analyzed (n=25) Analyzed (n=21)
Excluded from analysis (n=0) -1 excluded from analysis due to
missing data

Figure 1. Flowchart of participants’ progress through the phases of the trial.

Please cite this article in press as: Al-Sudany, N.K., Abdulkareem, D.R., A comparative study of topical 10% KOH solution and topical 25% podophyllin solution
as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002
4 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery xxx (2016) xxx–xxx

terms of pre-treatment clinical parameters and there was treatment developed new lesions whereas new lesions were
no significant variation between them in terms of age and seen in 2 (10%) out of 25 patients who were treated with
gender (Table 1). KOH solution at new sites other than those previously
The duration of the disease among all patients ranged involved. No recurrence of any treated lesions in patients
from 2 weeks to 6 months and a family history of MC of both groups could be detected.
was positive in 18 out of the 45 patients (40%). All side effects were transient and lasted just few weeks
The number of lesions per patient ranged from 1 to 75 and had totally disappeared.
lesions with a mean ± SD of 8.95 ± 9.32 lesions and the
total number of lesions was 403 lesions. Thirty-nine 4. Discussion
(86.6%) patients had 1–15 lesions, 4 (8.9%) patients had
16–30 patients and 2 patients had more than 30 lesions. In last few years, MC seems to be so common among
At the end of the study, 16 (64%) out of 25 patients in Iraqi patients especially children and a large proportion
group A showed complete clearance of lesions [181 of those patients or their guardians seek a suitable therapy
(82.3%) lesions out of 220], while cases in group B showed which is asked to be non-painful, non-disfiguring and with
total clearance of lesions in 14 (70%) out of 20 patients with an acceptable cost. Many topical therapeutic agents had
143 (78.1%) lesions out of 183 (Table 2). The results of both been tried in the treatment of MC with variable success
groups were comparable and there was no significant differ- rates, these included: phenol solution with a success rate
ence between them (P-value > 0.67). The time needed for (clearance of lesions) of (41%) Chen et al., 2013, TCA solu-
complete clearance of MC lesions in both groups ranged tion (60%) Goyal et al., 2014, salicylic and lactic acids
from 1 to 4 weeks (Table 3). Therapeutic response for both (100%) Kӧse et al., 2013, cantharidin (23%) Chen et al.,
10% KOH solution and 25% podophyllin solution is shown 2013, benzoyl peroxide (Chen et al., 2013), tretinoin
in (Figs. 2–5). (45%) Goyal et al., 2014, diphencyprone (64%) Kang
During the study period no systemic side effect in both et al., 2005, cidofovir (93%) Hanson and Diven, 2003;
groups was encountered whereas local side effects were Chen et al., 2013, podophyllotoxin (92%) Markos, 2001,
reported in 72% and 75% in group A and group B respec- and imiquimod (75–82%) Seo et al., 2010.
tively (Table 4). Since 1999, KOH solution in different concentrations
At follow up visit (one month after stopping the (2.5–20%) is tried in the treatment of MC (Romiti et al.,
treatment), 5 (25%) out of 20 patients used podophyllin 1999; Kӧse et al., 2013; Mahajan et al., 2003; Uçmak
Table 1
The frequency distribution of patients with molluscum contagiosum according to the age, gender and sites of lesions.
Age (Year) Group A Group B
Male No. (%) Female No. (%) Total No. (%) Male No. (%) Female No. (%) Total No. (%)
2–10 11 (44) 7 (28) 18 (72) 7 (35) 6 (30) 13 (65)
11–20 3 (12) 0 (0) 3 (12) 0 (0) 1 (5) 1 (5)
21–30 3 (12) 0 (0) 3 (12) 4 (20) 2 (10) 6 (30)
P31 0 (0) 1 (4) 1 (4) 0 (0) 0 (0) 0 (0)
Total* 17 (68) 8 (32) 25 (100) 11 (55) 9 (45) 20 (100)
Site Group A Group B Total
No. of Patients Lesions No. and (%) No. of Patients Lesions No. and (%) No. of Patients Lesions No. and (%)
Genitalia 5 99 (45) 5 60 (32.8) 10 159 (39.5)
Trunk 17 90 (41) 10 65 (35.4) 27 155 (38.5)
Extremities 11 31 (14) 9 58 (31.8) 20 89 (22)
Total** 220 (100) 183 (100) 403 (100)
*
Group A (mean ± SD = 9.56 ± 9.22) years. Group B (mean ± SD = 12.45 ± 8.73) years. P-Value > 0.284. Total (mean ± SD of 10.84 ± 9.02) years.
**
Group A (mean ± SD of 8.8 ± 11.33) lesions. Group B (mean + SD of 9.15 ± 5.90) lesions. Total (mean ± SD of 8.95 ± 9.32) lesions.

Table 2
Scores of therapeutic response in the patients with MC in both groups (A) and (B) at the end of 4th week of treatment.
Scores of response Group A Group B
No. and (%) of patients No. and (%) of lesions No. and (%) of patients No. and (%) of lesions
Complete clearance 16 (64) 181 (82.3) 14 (70) 143 (78.1)
Partial clearance 4 (16) 23 (10.4) 4 (20) 31 (16.9)
No response 5 (20) 16 (7.3) 2 (10) 9 (4.9)
Total 25 (100) 220 (100) 20 (100) 183 (100)
According to the number of patients P-value > 0.671, Chi Square = 0.18
According to the number of lesions P-value > 0.298, Chi Square = 1.08

Please cite this article in press as: Al-Sudany, N.K., Abdulkareem, D.R., A comparative study of topical 10% KOH solution and topical 25% podophyllin solution
as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002
 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery xxx (2016) xxx–xxx 5

Table 3
Time needed for complete clearance of MC lesions in both groups.
Duration of treatment Group A Group B
No. and (%) of patients No. and (%) of lesions No. and (%) of patients No. and (%) of lesions
1 week 1 (6.25) 1 (0.5) 3 (21.4) 20 (14)
2 weeks* 9 (56.25) 106 (58.6) 5 (35.7) 41 (28.7)
3 weeks 3 (18.75) 24 (13.3) 4 (28.6) 67 (46.8)
4 weeks 3 (18.75) 50 (27.6) 2(14.3) 15 (10.5)
Total 16 (100) 181 (100) 14 (100) 143 (100)
*
Within two weeks of treatment: P-value < 0.00, Chi Square = 8.67

A B

Figure 2. A photograph showing disappearance of MC lesions in a patient treated with 25% podophyllin solution. (A) Before treatment, (B) After 2 weeks
of treatment.

A B

Figure 3. A photograph showing complete clearance of huge number of MC lesions in a patient treated with 25% podophyllin solution. (A) Before
treatment, (B) after 4 weeks of treatment.

et al., 2014; Can et al., 2014; Short et al., 2006). Romiti
et al. (1999) reported a full remission in 32 out of the 35
(91.4%) patients treated with 10% KOH solution in an
average of 30 days. The same researchers carried out in
the year 2000 another study trying 5% KOH solution and
claimed a (100%) remission rate in an average of six weeks
(Romiti et al., 2000). Short et al in 2006 treated 10 patients
with 10% KOH solution in a placebo-controlled study and
they found 70% clearance rate for KOH versus 20% for the
placebo (Short et al., 2006). Also Can et al. (2014) treated
40 children with MC with 10% KOH solution but with
twice daily application and they reported (92.5%) clearance

Please cite this article in press as: Al-Sudany, N.K., Abdulkareem, D.R., A comparative study of topical 10% KOH solution and topical 25% podophyllin solution
as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002
6 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery xxx (2016) xxx–xxx

A B

Figure 4. Disappearance of MC lesions in a patient treated with 10% KOH solution, (A) before treatment, (B) after 4 weeks of treatment.

A B

Figure 5. Disappearance of MC lesions in a patient treated with 10% KOH solution, (A) before treatment, (B) after 4 weeks of treatment.

rate within a mean period of 4 weeks. Uçmak et al. (2014)
treated 25 patients with MC comparing (2.5% and 5%)
KOH solution for 2 months, they found significant differ-
ence between the success rates (23.1% and 66.7% respec-
tively). Mahajan et al. (2003) treated 27 patients with
20% KOH solution. All treated children were cleared of
their lesions within 17 days of treatment. However, stinging
sensation and postinflammatory pigmentation were fre-
quent side effects.
Our result regarding 10% KOH solution in the treat-
ment of MC seems to be comparable with previous men-
tioned studies that used same concentration of KOH and
similar duration of treatment (Kang et al., 2005;
Mahajan et al., 2003; Short et al., 2006).
Regarding podophyllin trials in MC, for our best knowl-
edge and search, only came across only one study dating to
1949 done by Barefoot at al. They reported only 3 patients
treated with topical application of 20% podophyllin and all
of them were cured. They considered it as a safe home ther-
apy but requires reliable patients (Barefoot, 1951). We have
found a success rate of 70% of patients treated with 25%
podophyllin solution.

Please cite this article in press as: Al-Sudany, N.K., Abdulkareem, D.R., A comparative study of topical 10% KOH solution and topical 25% podophyllin solution
as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002
 N.K. Al-Sudany, D.R. Abdulkareem / Journal of Dermatology & Dermatologic Surgery xxx (2016) xxx–xxx
Table 4
Comparison of local side effects noticed in both group (A) and (B).
Side effects Group (A) No. and (%) of patients
Burning 18 (72)
Erythema 11 (44)
Erosion 12 (48)
Hyperpigmentation 16 (64)
Hypopigmentation 3 (12)
Itching 7 (28)
Total patients with adverse effects 18 (72)
P-Value > 0.684
The present therapeutic trial has found both 10% KOH
and 25% podophyllin solutions to be effective in the treat-
ment of MC with comparable results. In terms of the num-
ber of patients cured podophyllin was slightly better than
KOH solution (70% versus 64%) with non-significant sta-
tistical difference (P > 0.67); while in terms of the number
of lesions cleared off the reverse was true (KOH 82% versus
podophyllin 78%) and also with non-significant difference
statistically (P > 0.29).
Many local side effects especially erythema, burning sen-
sation and dyspigmentation were seen in both groups of
patients enrolled in this study. Although the frequency of
these local side effects was slightly higher among patients
treated with podophyllin (75% versus 72%), however the
difference was statistically insignificant (P > 0.68). All
reported local adverse effects were mild and transient and
disappeared spontaneously shortly after the end of treat-
ment except one patient who suffered severe local irritation
caused by podophyllin that prevented him from continuing
the treatment due to intolerability. Most of these local side
effects are similarly reported in many other studies
(Barefoot, 1951; Romiti et al., 2000, 1999; Kӧse et al.,
2013; Mahajan et al., 2003; Uçmak et al., 2014; Can
et al., 2014; Short et al., 2006). Fortunately, neither sys-
temic side effects nor local scarring were encountered dur-
ing this study.
5. Conclusion
Both 10% KOH solution and 25% podophyllin solution
are effective local therapies for the treatment of MC with
comparable success rates (64% and 70% respectively).
Conflict of interest
There is no conflict of interest associated this study.
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as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002
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Please cite this article in press as: Al-Sudany, N.K., Abdulkareem, D.R., A comparative study of topical 10% KOH solution and topical 25% podophyllin solution
as home-based treatments of molluscum contagiosumq, Journal of Dermatology & Dermatologic Surgery (2016), http://dx.doi.org/10.1016/j.jdds.2016.02.002