Is bleomycin (Bleomycin sulfate) suitable for treating warts near the fingernail?

Bleomycin for Warts Near Fingernails

Bleomycin is not recommended as a first-line treatment for warts near fingernails due to potential risks of nail dystrophy, but can be considered for recalcitrant periungual warts that have failed conventional therapies.

First-Line Treatment Options

For warts near fingernails (periungual warts), the following treatments should be tried first:

• Salicylic acid (15-40%): Apply daily after paring down the wart, for 3-4 months 1, 2
• Cryotherapy: Gentle freeze with liquid nitrogen every 1-2 weeks for 3-4 months 1

When to Consider Bleomycin

Bleomycin should only be considered when:

1. The wart is resistant to first-line treatments
2. The wart has persisted for several months
3. Other treatment options have failed

Bleomycin Administration Protocol

If bleomycin is deemed necessary for recalcitrant periungual warts:

• Concentration: 0.5-1 mg/mL solution 3, 4
• Administration: Intralesional injection after local anesthesia 5, 4
• Technique:
  • Inject until blanching occurs
  • Total dose should not exceed 2 mg in one session 4
  • Alternative: Prick technique using a bifurcated needle for introduction 6
• Follow-up: Review after 2-4 weeks; repeat if necessary 4

Efficacy for Periungual Warts

Research shows that bleomycin can be particularly effective for periungual warts:

• 94% cure rate for periungual warts in one study 5
• 80-89% overall cure rate for resistant warts 3, 4

Risks and Side Effects

Important cautions when using bleomycin near fingernails:

• Pain: Most common side effect, lasting 2-3 days post-injection 4
• Nail dystrophy: Risk of permanent nail damage
• Eschar formation: Hemorrhagic eschar typically forms after treatment 5
• Tissue necrosis: Risk of damage to surrounding healthy tissue
• Raynaud's phenomenon: Potential risk, especially with digital injections

Technique to Minimize Complications

To reduce risks when treating periungual warts:

1. Use the lowest effective concentration (0.5 IU/mL) 3
2. Inject precisely into the wart base
3. Avoid infiltration of normal surrounding skin
4. Consider combining with pulsed dye laser to improve delivery 3

Alternative Options for Periungual Warts

If bleomycin is contraindicated or unavailable, consider:

• Imiquimod 5% cream: Apply 3 times weekly for up to 16 weeks 1
• Surgical approaches: Curettage or electrosurgery for filiform warts 1
• Trichloroacetic acid (TCA) 80-90%: Applied weekly 1

Periungual warts are challenging to treat and often require combination or sequential therapies for complete resolution. While bleomycin shows high efficacy, its use should be reserved for cases that have failed conventional treatments due to its potential side effects.