Cutaneous toxicity of intralesional bleomycin administration in the treatment of periungual warts

A comparative study of intralesional bleomycin versus cryotherapy in the treatment of condyloma accuminata

Bleomycin is an antineoplastic agent, which is used off label for various dermatologic conditions. There are numerous reports on the use of intralesional bleomycin (ILB) for the treatment of common warts. However, reports on the efficacy of bleomycin in the treatment of anogenital warts (AGWs) are still limited. The aim is to compare the efficacy/tolerability and recurrence rates of AGW treatment with ILB versus cryotherapy. In this prospective study, 50 patients with AGWs were assigned either to receive triple freeze-thaw cycle of cryotherapy or to receive 1.5 mg/mL ILB for a maximum of four sessions with 3-week intervals. Clinical efficacy was determined by the percentage of the patients with complete clearance. The patients with complete clearance were visited by passing 3 months from the last treatment session to evaluate any recurrence. Of 44 patients completing the study, 16 of 21 (76.19%) patients in the ILB group and 15 of 23 (65.22%) patients in the cryotherapy group showed complete resolution (p value = .425). Moreover, recurrence occurred after 3 months in 18.75% and 46.66% of the ILB and the cryotherapy groups' patients, respectively (p value = .096). The most common local adverse events in both treatment groups were pain, dyspigmentation, and ulceration/erosion, while the delayed ulceration and secondary infection were only observed in the bleomycin group. Intralesional bleomycin is as effective as cryotherapy in the treatment of AGWs, but it is more invasive and associated with post-treatment pain, the delayed ulceration, and cutaneous infection. Intralesional bleomycin is not accompanied with the major risk of necrosis or fibrosis, so the use of ILB in the anogenital area is likely to be safe.This clinical trial was registered in Iranian Registry of Clinical Trials site with code: IRCT20190519043631N1.

Efficacy and Safety of Intralesional Bleomycin in the Management of Ungual Warts

INTRODUCTION

Ungual warts are common fibroepithelial tumours of the nail unit caused by human papillomavirus. Although various treatment modalities are available, their management is challenging due to high potential for recurrence and treatment-related nail dystrophy.

OBJECTIVE

This study evaluates the efficacy and safety of intralesional bleomycin injections in the treatment of ungual warts.

METHODS

Medical records of 80 patients with ungual warts, treated by us from 2015 to 2019, were analysed retrospectively with respect to the number of warts, site, morphology, and treatment outcome. Children <5 years of age, and pregnant and lactating women were excluded. All ungual warts were treated with intralesional injections of bleomycin 3 Units/mL, given at 3-4 weeks interval.

RESULTS AND CONCLUSIONS

A total of 250 periungual and subungual warts were treated in 80 patients. An average of 2.61 sessions per patient was required for complete resolution. Moderate pain was reported by 65 patients (81.2%), and transitory perilesional hyperpigmentation was observed in 155 lesions (62%). Severe pain and necrosis developed in 3 lesions (1.2%) that were reversible without any residual scarring and deformity. We conclude that intralesional bleomycin is an effective and safe therapeutic modality for ungual warts.

Advancements in Pharmacotherapy for Noncancerous Manifestations of HPV

Human papillomavirus (HPV) is the most common sexually transmitted disease. Via infection of the basal epithelial cells, HPV causes numerous malignancies and noncancerous cutaneous manifestations. Noncancerous cutaneous manifestations of HPV, including common, plantar, plane, and anogenital warts, are among the most common reasons for an office visit. Although there are various therapies available, they are notoriously difficult to treat. HPV treatments can be grouped into destructive (cantharidin, salicylic acid), virucidal (cidofovir, interferon-α), antimitotic (bleomycin, podophyllotoxin, 5-fluorouracil), immunotherapy (Candida antigen, contact allergen immunotherapy, imiquimod) or miscellaneous (trichloroacetic acid, polyphenon E). The mechanism of action, recent efficacy data, safety profile and recommended regimen for each of these treatment modalities is discussed.

Successful Treatment of Plantar Warts with Very Diluted Bleomycin Using a Translesional Multipuncture Technique: Pilot Prospective Study

Background:

Plantar warts are common and often painful. Treatment of plantar warts is difficult and requires multiple treatments. Several clinical trials have proven the efficacy of bleomycin, but relatively high concentrations have been required and considerable side effects have been experienced.

Objective:

To evaluate the efficacy and safety of low-concentration (0.1 U/mL) bleomycin using a translesional injection technique for the treatment of plantar warts.

Methods:

The study included 23 patients with single or multiple plantar warts. Very low-concentration bleomycin was injected into a single wart or the largest plantar wart in the case of multiple lesions. Injections were performed at 4-week intervals until resolution of the warts or development of side effects. The translesional multipuncture technique was used.

Results:

Thirteen patients were male (56.5%), and the mean age was 27.7 years. The results revealed complete clearance of warts in 17 of 23 (74%) patients, partial response in 1 (4.3%) patient, and no response in 3 (13%) patients. Recurrence was observed in 2 patients at 3 months of follow-up. Among those two, one patient showed complete clearance after the second injection at 6 months of follow-up. All patients were followed for 6 months after the initial treatment. No significant long-term adverse effects were noted. Only three patients (13%) had localized moderate pain for 2 to 3 days after the injection.

Conclusion:

Translesional injection by very low-concentration (0.1 U/mL) bleomycin appears to be a simple, effective, and safe treatment modality for plantar warts.

Bleomycin in dermatology: a review of intralesional applications

Intralesional bleomycin has been favorably used off-label to treat various skin conditions. These include warts, hemangiomas, vascular malformations, telangiectasias, several types of cutaneous malignancies, condyloma acuminata, and the lesions of leishmaniasis cutis. Currently, there is a limited amount of evidence from randomized placebo-controlled trials comparing intralesional bleomycin with other local treatments for these disorders. In this article, we review the pharmacodynamics, mechanism of action, safety profile, and clinical applications of intralesional bleomycin. Dosages, techniques for administration, and efficacy of intralesional bleomycin for each aforementioned clinical entity are also provided. Given its ease and safety in administration, efficacy, and availability, off-label use of intralesional bleomycin can be considered another primary and/or adjunctive therapy for various common cutaneous conditions by practitioners in dermatology today.

Bleomycin and the skin

Bleomycin is frequently used as a chemotherapeutic agent to treat various kinds of malignancy. However, the cytotoxic effects of bleomycin cause a number of adverse responses, in particular in the lung and the skin. Bleomycin is used by dermatologists as a treatment for various skin cancers, recalcitrant warts, keloid and hypertrophic scars. This article discusses the use of bleomycin for various skin disorders, as well as the risk factors and cutaneous side-effects resulting from its use.

Treatment of viral warts by intralesional injection of zinc sulphate

BACKGROUND

The aim of this study was to verify the efficacy of the intralesional injection of 2% zinc sulphate as compared to an injection of 7% hypertonic sodium chloride solution in the treatment of viral warts.

PATIENTS AND METHODS

One hundred patients (53 females and 47 males) aged 4-45 years (mean+/-SD 19.93+/-7.92) and diagnosed with multiple verruca vulgaris (common warts) were the subject of the study. The duration of the viral warts ranged from 0.1-17 years (mean+/- SD 1.87+/-2.73). A total of 623 lesions were included in the study (mean+/- SD of lesions, 10.8+/-8.05). The treated number of lesions were 316 (mean+/- SD 4.78+/-5.09), with the untreated 307 lesions left as control.

RESULTS

In 53 patients (30 females, 23 males), 173 lesions were treated with 2% zinc sulphate intralesionally, while 176 lesion were left untreated as control. The total clearance rate of the treated lesions were 98.2% within 6 weeks of follow-up (80.92% of lesions needed a single injection and showed total clearance within 2 weeks), while none of the control lesions showed any spontaneous clearance within the same period. In 47 patients (27 females, 20 males), 143 lesions were treated with 7% hypertonic sodium chloride solution intralesinally, with the remaining 131 lesions left untreated as control. Only 8.3% of treated lesions showed total clearance within 10 weeks of follow-up.

CONCLUSION

Two percent zinc sulphate can be recommended as a new and effective local mode of therapy of viral warts, especially for the recalcitrant form.

A new method of intralesional bleomycin therapy in the treatment of recalcitrant warts

We have used a new technique of bleomycin injection to treat intractable palmar, plantar and periungual warts. Following local anaesthesia with topical EMLA (lignocaine and prilocaine) cream, 1 mg/ml bleomycin solution was dropped on to the wart and 'pricked' into the wart using a Monolet needle. We achieved 92% success rate which compares well with other authors whose success rates with intralesional bleomycin vary between 33 and 92%. We conclude that this technique of intralesional bleomycin therapy is an effective, safe and generally well tolerated treatment for recalcitrant warts.

Recalcitrant periungual verrucae: the role of carbon dioxide laser vaporization

Recalcitrant periungual verrucae (24 lesions) in 17 patients were vaporized with the carbon dioxide laser. The lesions had been present for 1 to 15 years and treated an average of nine times previously. Vaporization of these warts, in combination with partial or complete nail avulsion, resulted in complete cures in 71% of patients who had one or two treatments. The cure rate was 94% when the patients who had clearing after one or two laser treatments in combination with other therapies are included. Further follow-up indicates that infection and significant onychodystrophy are uncommon. Pain occurs, but in most cases it is short lived and manageable.