Pulsed dye laser and intralesional bleomycin for treatment of resistant viol hand warts

BACKGROUND AND OBJECTIVE: Viral warts affect 7-10% of the population and are a major burden on time and resources of dermatology departments everywhere. Some warts prove resistant to multiple therapies, and this is particularly common in the immunosuppressed patient. Numerous treatments are available, but no one treatment has emerged as the treatment of choice. Bleomycin has been shown to be effective in treating warts, but administration can be difficult with risk of local complications. To demonstrate a new technique for easily and safely administrating bleomycin into warts, we undertook an open study to assess the practicality, efficacy, and tolerability of pulsed dye laser immediately followed by intralesional bleomycin in resistant viral hand warts. STUDY DESIGN/MATERIALS AND METHODS: Ten subjects, all with resistant viral hand warts of at least 3 years duration were recruited. Four subjects were on long-term immunosuppressant drugs. Eighteen warts treated in total. Area of the wart was anaesthetized with 1% lignocaine, then treated with a pulsed dye laser (7 mm spot, fluence 10 J/cm2). Immediately following this bleomycin (0.5 IU/ml) was injected into the base of the wart. Monthly follow-up and treatment until satisfactory clearance. RESULTS: Sixteen out of eighteen warts cleared (89%). Eight out of ten warts in the immunosuppressed subjects cleared. The remaining two warts responded partially to two treatments, but the patient was happy with the result and did not wish further treatment. All warts in the immunocompetent subjects cleared. No serious side effects were seen. CONCLUSIONS: The initial treatment of the wart with pulsed dye laser serves to "prepare" the wart for the bleomycin injection, which can then be given very easily. This ensures the drug is deposited into the base of the wart where it is most needed and minimises the risk of infiltration of normal skin or the operative environment. This method of combining pulsed dye laser and intralesional bleomycin appears to be a safe, rapid, well tolerated, and successful treatment for resistant hand warts. It has proven to be effective in warts in immunosuppressed patients and at difficult sites (e.g., subungual warts). These findings need confirmation from a larger controlled study.