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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 68-70

Intralesional bleomycin for the management of recalcitrant periungual warts


Department of Dermatology, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India

Date of Submission13-Apr-2022
Date of Decision20-Apr-2022
Date of Acceptance25-Apr-2022
Date of Web Publication21-Jul-2022

Correspondence Address:
Priyal Rhenjen Garbyal
Department of Dermatology, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sujhs.sujhs_15_22

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  Abstract 


Ungual warts are very common benign growths in the dermatological outpatient department that are often tough to treat as they are resistant to available treatments and frequently recur. A variety of therapeutic modalities have been used with varying degrees of success. Intralesional bleomycin has emerged as an effective treatment option for recalcitrant periungual warts with minimal side effects. We report the case of a 22-year-old male with recalcitrant ungual warts which responded dramatically to intralesional bleomycin.

Keywords: Bleomycin, periungual, wart


How to cite this article:
Garbyal PR, Garg VK, Karira S, Yadav G. Intralesional bleomycin for the management of recalcitrant periungual warts. Santosh Univ J Health Sci 2022;8:68-70

How to cite this URL:
Garbyal PR, Garg VK, Karira S, Yadav G. Intralesional bleomycin for the management of recalcitrant periungual warts. Santosh Univ J Health Sci [serial online] 2022 [cited 2022 Aug 11];8:68-70. Available from: http://www.sujhs.org/text.asp?2022/8/1/68/351563




  Introduction Top


Periungual warts are common fibroepithelial tumors of the nail unit caused by human papillomavirus. Although various treatment modalities are available such as parring, chemical cautery, electrocautery, and cryosurgery, their management is challenging due to the high potential for recurrence and treatment-related nail dystrophy. Intralesional injection of bleomycin has been reported to be a promising new approach in the treatment of recalcitrant periungual warts.[1]


  Case Report Top


A 22-year-old male presented with multiple asymptomatic skin-colored growths over the periungual areas of the right ring and index fingers for the past 1 year. On examination, skin-colored warty growths were seen over the medial aspect of periungual and subungual areas of the right index and ring fingers. Onycholysis of the right index fingernail and dystrophy of the right ring fingernail were present [Figure 1]. Histopathological examination revealed hyperkeratosis, papillomatosis, hypergranulosis with columns of parakeratosis, and vacuolated superficial keratinocytes (koilocytes) [Figure 2] and [Figure 3]. There was no response with various topical, systemic, as well as surgical therapeutic modalities. Therefore, we decided to give intralesional bleomycin injection. Bleomycin for injection was obtained in vials containing 15 mg (15 U) of powder. It was first reconstituted with 5 ml sterile water for injection to prepare the stock solution, which was stored at 4°C–8°C for a maximum of 60 days. Then, one part of bleomycin stock solution and two parts of 2% lignocaine were taken in a 26-G insulin syringe to make a final concentration of 1 U/mL (1 mg/mL) just before injection. Each wart and the adjacent skin were cleaned with isopropyl alcohol before injection. The injection was given at the base of each wart until the lesion was blanched. The amount of injection was decided depending on the size of the warts: warts up to 5 mm, 10 mm, and more than 10 mm received 0.2 mL, 0.5 mL, and 1.0 mL of bleomycin, respectively. The total volume injected at one treatment session was limited to 2 mL. The lesions started showing response after the first sitting and completely resolved after total of three sittings, given 3 weeks apart. Mild pain was the only reported side effect after injection. The patient was followed up for 3 months of the past intervention with no recurrence [Figure 4].
Figure 1: Periungual warts on the right index and ring fingers

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Figure 2: H&E 100×

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Figure 3: H&E 400×

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Figure 4: Complete clearance of warts after 3 treatment sessions with intralesional Bleomycin injections

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  Discussion Top


Periungual warts are a common problem, especially in adults, that often recur even after repeated treatments with different ablative modalities. Bleomycin has emerged as a successful and well-tolerated treatment option for warts in adults, especially those warts recalcitrant to other conventional methods of treatment.[1] It is derived from Streptomyces verticillus and has antitumor, antibacterial, and antiviral properties which could be due to its ability to bind with deoxyribonucleic acid (DNA), causing DNA strand scission and removal of purine and pyrimidine bases.[2],[3] It does not bind to HPV directly. The bleomycin hydrolase enzyme which is known to inactivate bleomycin is normally found in all the body tissues, but it is present in very small amounts in the skin. Thus, after injecting it intralesionally, a significant amount of the active drug is available for the action at the site, and so even a small amount is enough for the treatment of warts.[4] The probable mechanism of action of bleomycin in warts is by affecting cellular DNA synthesis, leading to focal dermal necrosis, dyskeratosis, and a neutrophil predominant inflammation, and also by controlling keratinocyte turnover, thereby affecting viral survival.

Many studies have demonstrated the efficacy of intralesional bleomycin in the management of warts. A recent systematic review evaluated the various methods of bleomycin administration to treat warts, including the different doses and procedures used, and found intralesional bleomycin to be an effective treatment option for recalcitrant warts and reported significantly higher cure rates compared with other treatment modalities.[5] Kaul et al. reviewed different methods of bleomycin delivery that have been described in the literature, including intralesional injections as monotherapy as well as in combination with laser, multipuncture, microneedling, and adhesive tape. They concluded that intralesional injection and topical instillation of bleomycin with multiple punctures or microneedling methods are both effective. However, patient comfort is more with the multipuncture/microneedling methods. There was no additional advantage of combining laser or electroporation with intralesional bleomycin in terms of efficacy and safety profile.[1]

The most common side effect reported with intralesional bleomycin injection is injection site pain, which can be moderate to severe, lasting for about 2–7 days. Other reported side effects include erythema, edema, and eschar formation.[4],[6] Transient hyperpigmentation (1%–2%), infection (1%–3%), nail dystrophy, and Raynaud's phenomenon are rare adverse effects reported in few studies.[7],[8],[9] A study done on systemic absorption of bleomycin after intralesional injection into warts found that levels peak at 45 min and decrease by 50%–75% at 2 h. The interindividual plasma levels varied 10-fold and ranged from 7.1 to 113.5 ng/mL.[3] However, no systemic adverse effects have been reported in the literature.[5]


  Conclusion Top


Intralesional bleomycin is a safe, cheap, effective, and convenient treatment option for recalcitrant periungual warts, which have failed to respond to conventional treatment modalities. It does not require any special equipment and has a short course of therapy, reducing patient time and low recurrence rate with few and rare side effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaul S, Kaur I, Jakhar D, Edigin E, Caldito EG. The diverse methods of bleomycin delivery in cutaneous warts: A literature review. Dermatol Ther 2021;34:e14401.  Back to cited text no. 1
    
2.
Templeton SF, Solomon AR, Swerlick RA. Intradermal bleomycin injections into normal human skin. A histopathologic and immunopathologic study. Arch Dermatol 1994;130:577-83.  Back to cited text no. 2
    
3.
James MP, Collier PM, Aherne W, Hardcastle A, Lovegrove S. Histologic, pharmacologic, and immunocytochemical effects of injection of bleomycin into viral warts. J Am Acad Dermatol 1993;28:933-7.  Back to cited text no. 3
    
4.
Shumer SM, O'Keefe EJ. Bleomycin in the treatment of recalcitrant warts. J Am Acad Dermatol 1983;9:91-6.  Back to cited text no. 4
    
5.
Bik L, Sangers T, Greveling K, Prens E, Haedersdal M, van Doorn M. Efficacy and tolerability of intralesional bleomycin in dermatology: A systematic review. J Am Acad Dermatol 2020;83:888-903.  Back to cited text no. 5
    
6.
Singh Mehta KI, Mahajan VK, Chauhan PS, Chauhan S, Sharma V, Rawat R. Evaluation of efficacy and safety of intralesional bleomycin in the treatment of common warts: Results of a pilot study. Indian J Dermatol Venereol Leprol 2019;85:397-404.  Back to cited text no. 6
    
7.
Shumack PH, Haddock MJ. Bleomycin: An effective treatment for warts. Australas J Dermatol 1979;20:41-2.  Back to cited text no. 7
    
8.
Salk R, Douglas TS. Intralesional bleomycin sulfate injection for the treatment of verruca plantaris. J Am Podiatr Med Assoc 2006;96:220-5.  Back to cited text no. 8
    
9.
Kruter L, Saggar V, Akhavan A, Patel P, Umanoff N, Viola KV, et al. Intralesional bleomycin for warts: Patient satisfaction and treatment outcomes. J Cutan Med Surg 2015;19:470-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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