Successful treatment of plantar warts with intralesional bleomycin and electroporation: pilot prospective study

Clinical Efficacy of 5-Fluorouracil and Bleomycin in Dermatology

Bleomycin and 5-fluorouracil (5-FU) are widely used in various dermatological disorders. Both drugs are well-recognized as antineoplastic drugs and exert their effect by blocking the cell cycle. Topical and intralesional formulations are available and have been studied in both non-neoplastic and cancerous lesions. However, data comparing the effect of bleomycin and 5-FU in the dermatological disorders are limited. This review outlines the action mechanisms of both drugs and compares their clinical efficacies in a wide range of dermatologic diseases including hypertrophic scar, wart, skin cancer, vascular malformation, hemangioma, and vitiligo, and discusses the overall safety of the drugs. Intralesional bleomycin treatment is effective in hypertrophic scars and warts, but intralesional 5-FU may also be considered since it is cheaper and less painful. Moreover, intralesional 5-FU and bleomycin injection is a viable option for premalignant lesions (i.e., actinic keratosis) and inoperable skin cancers. Both bleomycin and 5-FU have been applied as treatment adjuncts for vitiligo, with 5-FU showing a slightly better outcome. Both agents have a good safety profile, and no serious side effects have been reported following their use in the field of dermatology.

Intralesional Bleomycin for the Treatment of Resistant Palmoplantar and Periungual Warts

INTRODUCTION

Periungual, palmar, and plantar warts are difficult to treat with poor treatment response. Intralesional (IL) bleomycin has shown promising results for their treatment in a few reports. However, we need further evidence before opting it for treating difficult sites and resistant warts. Hence, we conducted this study to assess the efficacy and safety of IL bleomycin for the treatment of resistant palmoplantar and periungual warts.

METHODS

In this retrospective study, we included all patients who were given IL bleomycin for warts over a year. Maximum three sittings of bleomycin (1 mg/ml) were given monthly, and they were followed up for 3 months after the procedure. The response was categorized as complete, near-complete, significant, moderate, mild, and no clearance for 100%, 75-99%, 50-74%, 25-49%, 1-25%, and 0% clearance, respectively.

RESULTS

Out of 29 patients, follow-up details were available only in 19 patients (53 warts). The mean duration was 2.5 ± 1.47 years. The number of past interventions ranged from 2-4. Wart clearance after the first intervention was complete in 36.84%, near-complete in 26.31%, significant in 26.31%, and moderate in 10.53%. Wart clearance after the last intervention was complete in 89.47% and near-complete in 10.52% of patients. However, during 3 months of follow-up after the last injection, 15.78% had a recurrence. None of them had severe local and systemic side effects.

CONCLUSIONS

IL bleomycin could be a better treatment option for the treatment of resistant and difficult warts. However, we observed a higher recurrence rate even in a shorter follow-up. Hence, we need further studies with larger samples.

The diverse methods of bleomycin delivery in cutaneous warts: A literature review

Bleomycin is a useful treatment option for recalcitrant verrucae. Several different methods of bleomycin delivery have been described, including intralesional injection, intralesional injection combined with laser, microneedling, multiple puncture and adhesive tape. We reviewed the literature to evaluate the various methods of bleomycin administration to treat warts, including the different doses, instruments and procedures used. Intralesional injection (cure rate ranged from 67.8% to 99.23%) and topical bleomycin with multipuncture or microneedling methods (63.6% to 100%) were found to be effective in the treatment of warts. Overall, pain is significantly less with microneedling and multipuncture techniques compared with intralesional injection. Bleomycin injection combined with pulsed dye laser, electroporation, or by other methods, such as, microneedle patches or adhesive tape do not seem to be more beneficial than bleomycin administered by intralesional injection, multipuncture or microneedling techniques.

Definition of a Novel Plasmid-Based Gene Transfection Protocol of Mammalian Skeletal Muscles by Means of In Vivo Electroporation

We describe an original electroporation protocol for in vivo plasmid DNA transfection. The right hind limbs of C57 mice are exposed to a specifically designed train of permeabilizing electric pulses by transcutaneous application of tailored needle electrodes, immediately after the injection of pEGFP-C1 plasmid encoding GFP (Green Fluorescente Protein). The electroporated rodents show a greater GFP expression than the controls at three different time points (4, 10, and 15 days). The electroporated muscles display only mild interstitial myositis, with a significant increase in inflammatory cell infiltrates. Finally, mild gait abnormalities are registered in electroporated mice only in the first 48 h after the treatment. This protocol has proven to be highly efficient in terms of expression levels of the construct, is easy to apply since it does not require surgical exposure of the muscle and is well tolerated by the animals because it does not cause evident morphological and functional damage to the electroporated muscle.

Efficacy and tolerability of intralesional bleomycin in dermatology: A systematic review

Bleomycin is widely used as an off-label treatment for various dermatologic indications. However, a much-needed critical appraisal of the currently available evidence is lacking. We therefore evaluated the quality of clinical evidence for the efficacy and safety of intralesional bleomycin treatment for dermatologic indications with the aim to provide evidence-based recommendations for clinical practice. The PubMed, Embase, Medline Ovid, Web of Science, Cochrane Central, and Google Scholar databases were systematically searched. Two authors independently selected relevant studies according to predefined inclusion and exclusion criteria. We assessed the methodologic quality with the Cochrane Collaboration risk-of-bias assessment tool and selected 10 randomized clinical trials and 15 clinical controlled trials. Treatment indications included common warts, nonmelanoma skin cancer, cutaneous metastases, keloid and hypertrophic scars, and hemangioma. Intralesional bleomycin treatment showed significantly higher cure rates for warts compared with other treatments. Local adverse events included erythema, blackening, eschar formation, and superficial ulceration. None of the studies reported systemic adverse events. Methodologic quality of the studies was generally low. Consequently, no firm recommendations can be made for intralesional bleomycin treatment in clinical practice. However, this review suggests that intralesional bleomycin is a successful and well-tolerated treatment for recalcitrant warts.

Intralesional bleomycin injection vs microneedling-assisted topical bleomycin spraying in treatment of plantar warts

BACKGROUND

Warts, or verrucae, are benign epithelial profilerations of skin and mucosa caused by infection with HPV and poses a challenge to treat.

OBJECTIVE

To compare between single and microneedling-assisted multipuncture techniques of intralesional application in treatment of plantar warts.

METHODS

The study included 60 Patients who were divided into two groups (A&B). Each group consisted of (30) patients. Group (A) subjects received intralesional bleomycin with a single injection using syringe needle. For Group (B) subjects, we combined microneedling with topical spraying of bleomycin (MN + Bleo) and followed by occlusion for 2 hours.

RESULTS

The results revealed complete clearance of warts in 21 patients in group (A) (70%) whom were treated by intralesional (IL) bleomycin vs 25 patients (83.3%) in group (B) whom were treated by spraying of bleomycin following microneedling. Side effects other than pain, erythema, and transient induration were relatively infrequent, and no nail changes or Raynaud's phenomenon was observed in both groups.

CONCLUSION

We established a good safety and efficacy profile for bleomycin in plantar wart treatment and we demonstrated that microneedling followed by bleomycin spraying had a higher clearance and proved less painful as opposed to bleomycin injection.

Successful Treatment of a Keratoacanthoma with Electrochemotherapy: A Case Report

Introduction

Few studies have evaluated the efficacy of intralesional bleomycin injection combined with electroporation for the treatment of cutaneous tumors. However, the phenomenon that electroporation can enhance the cytotoxicity of bleomycin in vivo by 300–700 fold has been intensely investigated.

Case Presentation

Keratoacanthoma in an 86-year-old patient was treated with intralesional bleomycin combined with electroporation. Treatment consisted of local application of shorty and intense electric pulses followed by local injection of bleomycin. Electroporation was always well tolerated by the patient, with no significant complaints, and the tumor had completely regressed by day 71 of the follow-up.

Conclusion

The results suggest that intralesional bleomycin injection combined with electroporation could represent a valid alternative therapeutic approach for the treatment of keratoacanthomas.