Do periungual warts respond to bleomycin?

Bleomycin for Periungual Warts

Yes, periungual warts respond very well to intralesional bleomycin, which appears to be the most effective treatment specifically for this location. 1

Evidence Supporting Bleomycin Efficacy

Intralesional bleomycin demonstrates excellent response rates for periungual warts across multiple studies:

• Complete clearance rates of 86.6% with just one injection using the translesional multipuncture technique with diluted bleomycin (0.1 U/mL), with results maintained at 6-month follow-up 2
• 68.4% complete clearance when bleomycin (1 U/mL) was applied after ablative fractional CO2 laser, with an additional 7.8% showing excellent partial response (>75% improvement) 3
• 92% success rate using a "prick" technique where bleomycin solution is dropped onto the wart and pricked in with a needle 4
• A retrospective analysis of 250 periungual and subungual warts showed complete resolution with an average of 2.61 treatment sessions per patient 5

Guideline Positioning

The British Association of Dermatologists (2014) lists intralesional bleomycin as a third-line treatment option for hand warts, with a strength C recommendation 6. However, this conservative positioning reflects the general wart population; the research evidence specifically for periungual warts shows bleomycin to be particularly effective at this anatomical site 1.

Treatment Protocol

Concentration and technique:

• Use 0.1-1 U/mL bleomycin solution 7
• Lower concentrations (0.1 U/mL) appear equally effective with fewer side effects compared to higher concentrations 2
• Apply after local anesthesia (topical EMLA cream is sufficient) 4
• Use translesional multipuncture technique: either inject the solution or drop it onto the wart and "prick" it in with a needle 2, 4

Treatment schedule:

• Administer injections every 3-4 weeks 5, 2
• Most patients require 1-3 treatment sessions 7, 5
• Discontinue if adverse events occur 3

Safety Profile

Common side effects (generally mild and transient):

• Moderate localized pain for 2-3 days after injection occurs in 60-81% of patients 5, 2
• Transitory perilesional hyperpigmentation in 62% of lesions, which resolves within 1 month 5, 2

Rare complications:

• Severe pain and necrosis in 1.2% of lesions, but reversible without residual scarring or nail deformity 5
• No significant long-term adverse effects or permanent nail changes reported 5, 2

Critical Advantages for Periungual Location

Bleomycin is particularly suited for periungual warts because:

• It avoids the risk of permanent nail dystrophy that commonly occurs with destructive methods like aggressive cryotherapy or surgical excision 5
• It minimizes scarring risk compared to ablative techniques 5
• It targets the wart tissue specifically without damaging surrounding nail structures 1

Treatment Algorithm Position

While first-line treatment should still begin with salicylic acid (15-26% daily after paring) for 3 months 7, followed by cryotherapy if needed 7, intralesional bleomycin should be strongly considered as the preferred third-line option for periungual warts given its superior efficacy and safety profile at this specific anatomical site 1.