Can bleomycin be used to treat periungual (around the nail) warts?

Can Bleomycin Be Used for Periungual Warts?

Yes, intralesional bleomycin is an effective treatment option for periungual warts, particularly as a third-line therapy for refractory cases that have failed first-line salicylic acid and second-line cryotherapy. 1

Treatment Algorithm for Periungual Warts

First-Line: Salicylic Acid

• Apply salicylic acid 15-26% daily after carefully paring or debriding the wart to remove thick keratin that blocks penetration 1
• This carries the strongest evidence (Grade A recommendation) with the best safety profile 1
• Continue for up to 6 months before considering treatment failure 2

Second-Line: Cryotherapy

• Use liquid nitrogen cryotherapy if salicylic acid fails after adequate trial 1
• Freeze for 15-30 seconds and repeat every 1-2 weeks for at least 3 months or six treatment sessions 1
• This has Grade B recommendation strength 1

Third-Line: Intralesional Bleomycin

• Reserve bleomycin for refractory periungual warts that have failed both salicylic acid and cryotherapy 1
• The British Association of Dermatologists gives this a Grade C recommendation as a third-line option 1

Bleomycin Administration Techniques and Efficacy

Multipuncture Technique with Diluted Bleomycin

• Use bleomycin 0.1 U/mL concentration via translesional multipuncture technique 3
• This achieves 86.6% complete clearance, often with just one treatment session 3
• For periungual warts specifically, cure rates reach 94% with intralesional bleomycin 4
• Repeat treatment every 2-4 weeks if needed, with maximum cumulative dose not exceeding 2 mg per session 5, 3

Combination with Fractional CO2 Laser

• Ablative fractional CO2 laser followed by topical bleomycin application (1 U/mL) achieves 68.4% complete clearance 6
• This approach may be considered for patients who cannot tolerate intralesional injections 6
• Treatments are repeated every 2 weeks until lesions disappear 6

Expected Outcomes and Side Effects

Efficacy

• Periungual warts respond better to bleomycin (94% cure rate) compared to plantar warts (60% cure rate) 4
• Warts clearing completely typically do not recur over 6-month follow-up 6, 3
• Response is characterized by hemorrhagic eschar formation followed by healing without scarring 4

Common Adverse Effects

• Localized moderate pain for 2-3 days after injection occurs in 60% of patients 3
• Mild postinflammatory hyperpigmentation may occur but resolves within 1 month 6, 3
• No significant long-term adverse effects or systemic toxicity have been reported at these doses 5, 3, 4
• Patient acceptance is superior to liquid nitrogen cryotherapy 4

Critical Caveats

When NOT to Use Bleomycin

• Avoid in patients with significant risk factors for bleomycin pulmonary toxicity: age over 40, significant smoking history, pre-existing lung disease, or renal dysfunction 7
• While these contraindications are based on systemic bleomycin use for cancer treatment, caution is warranted even with intralesional administration 7

Proper Patient Selection

• Bleomycin should only be used after documented failure of first-line (salicylic acid) and second-line (cryotherapy) treatments 1
• The immunosuppressed population may benefit from bleomycin, as the British Association of Dermatologists specifically mentions "laser + intralesional bleomycin" as an option for warts in immunosuppressed patients 2

Administration Precautions

• Inject until blanching occurs to ensure adequate tissue penetration 5
• Do not exceed 2 mg cumulative dose per session to minimize systemic absorption 5
• Pain management should be discussed with patients beforehand, as 60% experience moderate localized pain 3