Therapeutic evaluation for intralesional injection of bleomycin sulfate in 143 resistant warts

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.

Chemotherapeutical treatment of basal cell carcinoma with bleomycin via microinfusion of the drug into the skin (MMP®)

BACKGROUND

Bleomycin is a chemotherapeutical drug used to treat several neoplasias, including non-melanoma skin cancer; it is effective in the treatment of basal cell carcinoma (BCC) via intralesional infiltration. Transdermal drug delivery, which includes technologies such as CO2 Laser, Dermapen, Dermaroller and MMP®, delivers the desired medication to treat skin neoplasias and also acts in skin rejuvenation.

OBJECTIVE

To treat BCC lesions using bleomycin via MMP®.

METHODS

Ninety-eight BCC lesions in different anatomical areas were treated using MMP® technology to administer and uniformly distribute bleomycin throughout the lesion and in the established safety margin.

RESULTS

The cure rate after six months was 96.94%; and recurrences were not associated with lesion size and/or depth. Adverse effects were the expected ones.

STUDY LIMITATIONS

The follow-up time was only six months.

CONCLUSION

This therapeutic route showed to be promising and effective.

Treatment efficacy of 0.9% saline and mepivacaine infiltration with Dermojet® in eliminating plantar warts

BACKGROUND

Plantar warts are benign, epidermal neoformations, viral, and easily transmitted. Although 30% of these warts disappear spontaneously, the American Association of Dermatology recommends treatment if they cause pain or bleeding.

OBJECTIVES

The aim of this study was to determine the efficacy of Dermojet® infiltration using a solution composed of equal parts of 0.9% saline and 2% mepivacaine in the treatment of plantar warts, and to identify the type of necrosis achieved at 7-10 days after the infiltration (M1 sample) and at 15-17 days (M2 sample).

METHOD

In this analytical prospective observational study, 102 histories were reviewed by the same researcher. The patients were treated with this technique at four private podiatry clinics.

RESULTS

A total of 61.8% of the patients were male. The patients' mean age was 26.6 ± 14.10 years. A total percentage of 78.4% of the patients achieved complete elimination of the lesion by the second evaluation and after a single infiltration. Bivariate analysis revealed a significant inverse relationship between treatment efficacy and a history of previous disease (p < 0.001) and the period of evolution of the lesion (p < 0.001; 95% CI [0.78-7.91]). Multivariate linear regression analysis revealed an association with the number of evaluation sessions (p < 0.001) and with previous illnesses (p = 0.014). A total percentage of 82.35% presented partial necrosis in the M1 sample and 76.92% had complete necrosis in the M2 sample.

CONCLUSIONS

In 78.4% of the patients considered, the plantar warts treated disappeared after a single infiltration. The variables associated with treatment efficacy were the number of follow-up visits and the existence of associated diseases.

Intralesional bleomycin for treatment of a recalcitrant wart in an immunocompromised patient: A safe, effective, and underutilized therapy

Injectable bleomycin is infrequently used for recalcitrant warts despite its efficacy, acceptable safety profile, and high patient satisfaction compared with other treatment modalities. We present an immunocompromised patient with a large recalcitrant wart successfully treated with intralesional bleomycin to provide greater clinical exposure, training, and practice with intralesional bleomycin.

A comparative study of intralesional bleomycin versus cryotherapy in the treatment of condyloma accuminata

Bleomycin is an antineoplastic agent, which is used off label for various dermatologic conditions. There are numerous reports on the use of intralesional bleomycin (ILB) for the treatment of common warts. However, reports on the efficacy of bleomycin in the treatment of anogenital warts (AGWs) are still limited. The aim is to compare the efficacy/tolerability and recurrence rates of AGW treatment with ILB versus cryotherapy. In this prospective study, 50 patients with AGWs were assigned either to receive triple freeze-thaw cycle of cryotherapy or to receive 1.5 mg/mL ILB for a maximum of four sessions with 3-week intervals. Clinical efficacy was determined by the percentage of the patients with complete clearance. The patients with complete clearance were visited by passing 3 months from the last treatment session to evaluate any recurrence. Of 44 patients completing the study, 16 of 21 (76.19%) patients in the ILB group and 15 of 23 (65.22%) patients in the cryotherapy group showed complete resolution (p value = .425). Moreover, recurrence occurred after 3 months in 18.75% and 46.66% of the ILB and the cryotherapy groups' patients, respectively (p value = .096). The most common local adverse events in both treatment groups were pain, dyspigmentation, and ulceration/erosion, while the delayed ulceration and secondary infection were only observed in the bleomycin group. Intralesional bleomycin is as effective as cryotherapy in the treatment of AGWs, but it is more invasive and associated with post-treatment pain, the delayed ulceration, and cutaneous infection. Intralesional bleomycin is not accompanied with the major risk of necrosis or fibrosis, so the use of ILB in the anogenital area is likely to be safe.This clinical trial was registered in Iranian Registry of Clinical Trials site with code: IRCT20190519043631N1.

Efficacy and Safety of Intralesional Bleomycin in the Management of Ungual Warts

INTRODUCTION

Ungual warts are common fibroepithelial tumours of the nail unit caused by human papillomavirus. Although various treatment modalities are available, their management is challenging due to high potential for recurrence and treatment-related nail dystrophy.

OBJECTIVE

This study evaluates the efficacy and safety of intralesional bleomycin injections in the treatment of ungual warts.

METHODS

Medical records of 80 patients with ungual warts, treated by us from 2015 to 2019, were analysed retrospectively with respect to the number of warts, site, morphology, and treatment outcome. Children <5 years of age, and pregnant and lactating women were excluded. All ungual warts were treated with intralesional injections of bleomycin 3 Units/mL, given at 3-4 weeks interval.

RESULTS AND CONCLUSIONS

A total of 250 periungual and subungual warts were treated in 80 patients. An average of 2.61 sessions per patient was required for complete resolution. Moderate pain was reported by 65 patients (81.2%), and transitory perilesional hyperpigmentation was observed in 155 lesions (62%). Severe pain and necrosis developed in 3 lesions (1.2%) that were reversible without any residual scarring and deformity. We conclude that intralesional bleomycin is an effective and safe therapeutic modality for ungual warts.

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.

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 for Warts

Background:

The treatment of warts is challenging with regards to both tolerability and efficacy.

Objective:

Ascertain the efficacy, tolerability, and patient satisfaction of intralesional bleomycin in the treatment of warts.

Methods:

Retrospective chart review followed by telephone interviews with patients from university-based dermatology referral centers.

Results:

Seventy-four percent (34/46) of patients had complete resolution (CR) of all warts. Of 34 patients who experienced CR, an average of 1.7 treatments were required. Pain experienced during the procedure and recovery, irrespective of outcome, was rated 5.8 out of 10 (range, 1-10; SD, 2.72; SEM, 0.40). Approximately 70% of patients had pain that lasted less than 2 days after treatment. Seventy-eight percent (36/46) of patients in the study were satisfied with treatment and would recommend it to others.

Conclusion:

Patients felt bleomycin to be an effective treatment modality for warts, offering high rates of CR in lesions resistant to more traditional therapies.

Therapeutic Evaluation of Intralesional 5% 5-Fluorouracil in Condyloma Acuminata

Condyloma acumianata is one of the most common virally transmitted diseases. Its prevalence has increased many fold throughout the world. Because all the currently available treatments yield low cure rates with side effects, the search for a new alternative continues. Topically, 5-fluorouracil (5-FU) has been in used for many years to treat various skin diseases. When applied topically in condyloma acuminata, 5-FU results in low cure rates with high recurrences. Therefore, intralesional 5% 5-FU is being evaluated to determine its therapeutic efficacy in condyloma acuminata.

Treatment of common and plane warts in children with topical viable Bacillus Calmette-Guerin

Treatment of verrucae in children is difficult and may be painful using traditional methods, especially if they are multiple or on the face. The objective of the current study was to evaluate the efficacy and safety of topical application of viable Bacillus Calmette-Guérin (BCG) in a paste formula as a new immunotherapeutic modality in the treatment of common and plane warts in children. The present study included 80 children with common and plane warts at different sites on the body. They were divided into two groups. Group A (40 patients) received topical viable BCG and group B (40 patients) received topical saline as control. All patients and controls had received a previous vaccination of BCG. BCG was applied once weekly for six consecutive weeks. Patients who had partial or no response received another course of treatment for another 6 weeks. Follow-up was at 6 months to detect any recurrences. A highly significant difference was found between the therapeutic response of common and plane warts to BCG and saline (placebo) (p < 0.001). Complete response was achieved in 65% of children with common warts and 45% of patients with plane warts. No response was detected in the control group. No recurrences or side effects were observed in the BCG group. Topical immunotherapeutic BCG is a new, effective, safe treatment option for children with common and plane warts.

Topical treatments for cutaneous warts

BACKGROUND

Viral warts are a common skin condition, which can range in severity from a minor nuisance that resolve spontaneously to a troublesome, chronic condition. Many different topical treatments are available.

OBJECTIVES

To evaluate the efficacy of local treatments for cutaneous non-genital warts in healthy, immunocompetent adults and children.

SEARCH METHODS

We updated our searches of the following databases to May 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2010), AMED (from 1985), LILACS (from 1982), and CINAHL (from 1981). We searched reference lists of articles and online trials registries for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of topical treatments for cutaneous non-genital warts.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials and extracted data; a third author resolved any disagreements.

MAIN RESULTS

We included 85 trials involving a total of 8815 randomised participants (26 new studies were included in this update). There was a wide range of different treatments and a variety of trial designs. Many of the studies were judged to be at high risk of bias in one or more areas of trial design.Trials of salicylic acid (SA) versus placebo showed that the former significantly increased the chance of clearance of warts at all sites (RR (risk ratio) 1.56, 95% CI (confidence interval) 1.20 to 2.03). Subgroup analysis for different sites, hands (RR 2.67, 95% CI 1.43 to 5.01) and feet (RR 1.29, 95% CI 1.07 to 1.55), suggested it might be more effective for hands than feet.A meta-analysis of cryotherapy versus placebo for warts at all sites favoured neither intervention nor control (RR 1.45, 95% CI 0.65 to 3.23). Subgroup analysis for different sites, hands (RR 2.63, 95% CI 0.43 to 15.94) and feet (RR 0.90, 95% CI 0.26 to 3.07), again suggested better outcomes for hands than feet. One trial showed cryotherapy to be better than both placebo and SA, but only for hand warts.There was no significant difference in cure rates between cryotherapy at 2-, 3-, and 4-weekly intervals.Aggressive cryotherapy appeared more effective than gentle cryotherapy (RR 1.90, 95% CI 1.15 to 3.15), but with increased adverse effects.Meta-analysis did not demonstrate a significant difference in effectiveness between cryotherapy and SA at all sites (RR 1.23, 95% CI 0.88 to 1.71) or in subgroup analyses for hands and feet.Two trials with 328 participants showed that SA and cryotherapy combined appeared more effective than SA alone (RR 1.24, 95% CI 1.07 to 1.43).The benefit of intralesional bleomycin remains uncertain as the evidence was inconsistent. The most informative trial with 31 participants showed no significant difference in cure rate between bleomycin and saline injections (RR 1.28, 95% CI 0.92 to 1.78).Dinitrochlorobenzene was more than twice as effective as placebo in 2 trials with 80 participants (RR 2.12, 95% CI 1.38 to 3.26).Two trials of clear duct tape with 193 participants demonstrated no advantage over placebo (RR 1.43, 95% CI 0.51 to 4.05).We could not combine data from trials of the following treatments: intralesional 5-fluorouracil, topical zinc, silver nitrate (which demonstrated possible beneficial effects), topical 5-fluorouracil, pulsed dye laser, photodynamic therapy, 80% phenol, 5% imiquimod cream, intralesional antigen, and topical alpha-lactalbumin-oleic acid (which showed no advantage over placebo).We did not identify any RCTs that evaluated surgery (curettage, excision), formaldehyde, podophyllotoxin, cantharidin, diphencyprone, or squaric acid dibutylester.

AUTHORS' CONCLUSIONS

Data from two new trials comparing SA and cryotherapy have allowed a better appraisal of their effectiveness. The evidence remains more consistent for SA, but only shows a modest therapeutic effect. Overall, trials comparing cryotherapy with placebo showed no significant difference in effectiveness, but the same was also true for trials comparing cryotherapy with SA. Only one trial showed cryotherapy to be better than both SA and placebo, and this was only for hand warts. Adverse effects, such as pain, blistering, and scarring, were not consistently reported but are probably more common with cryotherapy.None of the other reviewed treatments appeared safer or more effective than SA and cryotherapy. Two trials of clear duct tape demonstrated no advantage over placebo. Dinitrochlorobenzene (and possibly other similar contact sensitisers) may be useful for the treatment of refractory warts.

Nonsurgical treatment of nonmelanoma skin cancer

The ever-increasing incidence of primary cutaneous malignancies has heralded the need for multiple treatment options. Surgical modalities remain the mainstay of treatment of nonmelanoma skin cancer. However, it is important for the dermatologic surgeon to have an understanding of all treatment options to assist the patient in making the most informed decision possible, ultimately leading to the most favorable outcome. This article explores the available nonsurgical treatment options, their indications, and their efficacy.

Dermojet delivery of bleomycin for the treatment of recalcitrant plantar warts

BACKGROUND

Plantar warts may cause significant morbidity. Intralesional bleomycin is effective. When bleomycin is injected with a needle and syringe, it is difficult to prevent the bleomycin from infiltrating the dermis adjacent to the wart, producing unnecessary acute pain, persistent pain, and potential sloughing of normal adjacent skin. Efficacy of delivery by dermojet is not yet established.

OBJECTIVES

To assess the response of recalcitrant plantar warts to bleomycin delivered by dermojet.

METHODS

A total of 47 patients with 138 plantar warts present for more than 2 years and resistant to 10 cycles of cryosurgery, were recruited. Bleomycin (1 U/ml) was delivered intralesionally by dermojet at 5-week intervals for 25 weeks.

RESULTS

Out of 138, 124 (89.9%) plantar warts showed complete or partial clearance after one to five sets of bleomycin injections. The recurrence rate was 6/138 (4.4%), and 8/138 (5.8%) warts failed to clear. The reduction in mean surface area of the plantar warts after each set of bleomycin injections compared to baseline surface area was statistically significant. Local side effects were similar to other methods of delivery. No systemic side effects were reported.

CONCLUSIONS

This study assesses therapeutic efficacy of bleomycin delivered by dermojet in solely recalcitrant plantar warts. It provides preliminary evidence that this method of delivery may benefit a group of patients with particularly recalcitrant plantar warts and is safe and easy to use in routine dermatology practice.

Bleomycin in dermatology: a review of intralesional applications

Intralesional bleomycin has been favorably used off-label to treat various skin conditions. These include warts, hemangiomas, vascular malformations, telangiectasias, several types of cutaneous malignancies, condyloma acuminata, and the lesions of leishmaniasis cutis. Currently, there is a limited amount of evidence from randomized placebo-controlled trials comparing intralesional bleomycin with other local treatments for these disorders. In this article, we review the pharmacodynamics, mechanism of action, safety profile, and clinical applications of intralesional bleomycin. Dosages, techniques for administration, and efficacy of intralesional bleomycin for each aforementioned clinical entity are also provided. Given its ease and safety in administration, efficacy, and availability, off-label use of intralesional bleomycin can be considered another primary and/or adjunctive therapy for various common cutaneous conditions by practitioners in dermatology today.

Bleomycin and the skin

Bleomycin is frequently used as a chemotherapeutic agent to treat various kinds of malignancy. However, the cytotoxic effects of bleomycin cause a number of adverse responses, in particular in the lung and the skin. Bleomycin is used by dermatologists as a treatment for various skin cancers, recalcitrant warts, keloid and hypertrophic scars. This article discusses the use of bleomycin for various skin disorders, as well as the risk factors and cutaneous side-effects resulting from its use.

Topical treatments for cutaneous warts

BACKGROUND

Viral warts are common and usually harmless but very troublesome. A very wide range of local treatments are used.

OBJECTIVES

To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (March 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to March 2005), EMBASE (1980 to March 2005) and a number of other biomedical databases. The references of all trials and selected review articles were also searched. In addition, we contacted pharmaceutical companies involved in local treatments for warts and experts in the field

SELECTION CRITERIA

Randomised controlled trials of local treatments for cutaneous non-genital viral warts in immunocompetent (healthy) people.

DATA COLLECTION AND ANALYSIS

Data was extracted and two authors independently selected the trials and assessed methodological quality.

MAIN RESULTS

Sixty trials were identified that fulfilled the criteria for inclusion. The evidence provided by these studies was generally weak due to poor methodology and reporting. In 21 trials with placebo groups that used participants as the unit of analysis, the average cure rate of placebo preparations was 27% (range 0 to 73%) after an average period of 15 weeks (range 4 to 24 weeks). The best available evidence was for simple topical treatments containing salicylic acid, which were clearly better than placebo. Data pooled from five placebo-controlled trials showed a cure rate of 117/160 (73%) compared with 78/162 (48%) in controls, which translates to a risk ratio of 1.60 (95% confidence interval 1.16 to 2.23), using a random effects model. Evidence for the absolute efficacy of cryotherapy was surprisingly lacking. Two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy showed no significant difference in efficacy. Evidence for the efficacy of the remaining treatments reviewed was limited.

AUTHORS' CONCLUSIONS

There is a considerable lack of evidence on which to base the rational use of topical treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy, but reasonable evidence that it is only of equivalent efficacy to simpler and safer treatments. The benefits and risks of topical dinitrochlorobenzene and 5-fluorouracil, intralesional bleomycin and interferons, photodynamic therapy and other miscellaneous treatments remain to be determined.

Human papillomavirus: burden of illness and treatment cost considerations

The monetary and personal costs to society of human papillomavirus (HPV) infection are enormous. In order to make a comparison of different treatment methods we reviewed the entire literature on HPV treatment from January 1966 to December 2003 using MEDLINE, with particular reference to published meta-analyses, randomized controlled and comparative studies. Patient-applied therapies offer patients the possibility of convenient and, on the whole, pain-free treatment. Podofilox (podophyllotoxin) and salicylic acid for genital and extragenital warts, respectively, have the additional advantage of being the most cost-effective treatments and, on this basis, they are to be commended as appropriate first-line agents. The second-line treatment of choice for common warts is cryotherapy. For recalcitrant common warts possible options include inosine pranobex with cryotherapy or electrosurgery, imiquimod with paring and occlusion, intralesional bleomycin, or diphencyprone. Alternative first-line and second-line treatments for genital warts would be either some form of surgical removal or imiquimod. The first option may be the cheapest but this has to be balanced against a degree of post-operative morbidity. Limited data from comparative studies do not show any clear difference in efficacy between cryotherapy, trichloroacetic acid, scissor excision, electrosurgery, and laser surgery in the treatment of genital warts, and the cost effectiveness of these therapies is probably similar to that of imiquimod. Cryotherapy and trichloroacetic acid are relatively expensive and inconvenient for patients and should be reserved as third-line treatments with certain exceptions, such as cryotherapy for meatal warts. The duration of treatment is significantly related to the number of warts present, the area covered by the warts, and the length of time the warts have been present. For recalcitrant anogenital warts third-line treatment options that show promise include surgery in combination with imiquimod or cidofovir cream. For squamous intraepithelial lesions that cannot easily be excised or physically ablated current treatment options include imiquimod and fluorouracil cream. The latter is an inexpensive option but causes the greatest morbidity. It is hoped that cidofovir may be added to this list if it becomes commercially available, and that protective and therapeutic HPV vaccines will transform the management of HPV in the future.

Treatment of keloids and hypertrophic scars with dermojet injections of bleomycin: a preliminary study

BACKGROUND

Numerous treatment modalities have been used to treat keloids and hypertrophic scars, but the optimal treatment has not been established.

OBJECTIVE

The aim of this study was to determine the efficacy and safety of intralesional jet injection of bleomycin as therapy for keloids and hypertrophic scars that are unresponsive to intralesional steroid injection.

METHODS

The study included 14 patients with 15 keloids or hypertrophic scars that had not responded to a minimum of three intralesional injections of triamcinolone acetonide. Multiple jet injections of 0.1 ml of bleomycin (1.5 IU/ml) were administered to each lesion, with injection sites spaced 0.5 mm apart. Injections were repeated each month. Scar height was measured, and scar pliability and erythema were scored at baseline and then monthly during the treatment and follow-up periods. Patients' self-assessments of subjective symptoms (pruritus and pain) were also scored. Clinical improvement was defined primarily on the basis of scar height reduction (percentage reduction from baseline), and was classified using the following scale: complete flattening (100%), highly significant flattening (> 90%), significant flattening (75-90%), moderate flattening (50-75%), and minimal flattening (< 50%). Pre- and post-treatment mean values for scar height, scar pliability, erythema, pruritus and pain were statistically compared.

RESULTS

The number of sessions required to successfully treat the lesions ranged from two to six. Eleven lesions (73.3%) showed complete flattening, one (6.7%) showed highly significant flattening, two (13.3%) showed significant flattening, and one scar (6.7%) showed moderate flattening. The mean scar height was significantly lower, and the mean scores for scar pliability and erythema were significantly better at the end of treatment (P < 0.001, P < 0.001 and P < 0.001, respectively). The mean scores for pruritus and pain also improved significantly (P < 0.001 and P = 0.01, respectively). The observed side-effects were hyperpigmentation (four lesions) and skin atrophy (three lesions). No recurrences were noted during follow up (mean duration of 19 months).

CONCLUSIONS

Intralesional jet injection of bleomycin is an effective and safe method of treating keloids and hypertrophic scars that are unresponsive to intralesional steroid therapy.

How and when to treat molluscum contagiosum and warts in children

Warts and molluscum contagiosum are common skin diseases in children and are usually self-limiting. The decision of whether to treat children with molluscum or warts should be individualized to the patient and his or her family. Considerations include how symptomatic the lesions are, the extent and duration of disease, the ability of the child and the parents to tolerate and comply with treatment recommendations, and any underlying medical conditions (Table, see page 219). Recurrences of molluscum contagiosum and especially warts are common, and realistic expectations regarding the potential for treatment failure and recurrence should be discussed with the child and his or her family prior to initiating any therapy. As pediatric practitioners, we all remain acutely aware of our patients' physical and psychological development and the potential for any intervention to influence this development. Although various treatment modalities now exist for the treatment of these viral diseases, any intervention should be balanced against these considerations.

Local treatments for cutaneous warts

BACKGROUND

Viral warts caused by the human papilloma virus represent one of the most common diseases of the skin. Any area of skin can be affected although the hands and feet are by far the commonest sites. A very wide range of local treatments are available.

OBJECTIVES

To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (January 2003), the Skin Group trials register (January 2003), MEDLINE (1966 to January 2003), EMBASE (1980 to January 2003) and a number of other key biomedical and health economics databases. In addition the cited references of all trials identified and key review articles were searched. Pharmaceutical companies involved in local treatments for warts and experts in the field were contacted. The most recent searches were carried

SELECTION CRITERIA

Randomised controlled trials of local treatments for cutaneous non-genital viral warts in immunocompetent human hosts were included.

DATA COLLECTION AND ANALYSIS

Study selection and assessment of methodological quality were carried out by two independent reviewers.

MAIN RESULTS

Fifty two trials were identified which fulfilled the criteria for inclusion in the review. The evidence provided by these studies was generally weak because of poor methodology and reporting. In 17 trials with placebo groups that used participants as the unit of analysis the average cure rate of placebo preparations was 30% (range 0 to 73%) after an average period of 10 weeks (range 4 to 24 weeks). The best available evidence was for simple topical treatments containing salicylic acid, which are clearly better than placebo. Data pooled from six placebo-controlled trials show a cure rate of 144/191 (75%) compared with 89/185 (48%) in controls, odds ratio 3.91 (95% confidence interval 2.40 to 6.36), random effects model. Most of the bigger trials of cryotherapy studied different regimens rather than comparing cryotherapy with other treatments or placebo. Pooled data from two small trials that included cryotherapy and placebo or no treatment, showed no significant difference in cure rates. In two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy no significant difference in efficacy was demonstrated. There was no consistent evidence for the effectiveness of intralesional bleomycin. Four studies, using warts rather than individuals as the unit of analysis, had widely varying results which could not be meaningfully pooled. There was some evidence for the efficacy of dinitrochlorobenzene, a potent contact sensitizer. Pooled data from two small studies comparing dinitrochlorobenzene with placebo showed cure rates of 32/40 (80%) and 15/40 (38%) respectively, odds ratio 6.67 (95% confidence interval 2.44 to 18.23), random effects model. Only limited evidence was found for the efficacy of topical 5-fluorouracil, intralesional interferons and photodynamic therapy.Bleomycin, dinitrochlorobenzene, 5-fluorouracil, interferons and photodynamic therapy are potentially hazardous or toxic treatments.

REVIEWER'S CONCLUSIONS

There is a considerable lack of evidence on which to base the rational use of the local treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy and some evidence that it is only of equivalent efficacy to simpler, safer treatments. Dinitrochlorobenzene appears to be effective but there were no statistically significant differences when compared with the safer, simpler and cheaper topical treatments containing salicylic acid. The benefits and risks of 5-fluorouracil, bleomycin, interferons and photodynamic therapy remain to be determined.

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.

Treatment of viral warts by intralesional injection of zinc sulphate

BACKGROUND

The aim of this study was to verify the efficacy of the intralesional injection of 2% zinc sulphate as compared to an injection of 7% hypertonic sodium chloride solution in the treatment of viral warts.

PATIENTS AND METHODS

One hundred patients (53 females and 47 males) aged 4-45 years (mean+/-SD 19.93+/-7.92) and diagnosed with multiple verruca vulgaris (common warts) were the subject of the study. The duration of the viral warts ranged from 0.1-17 years (mean+/- SD 1.87+/-2.73). A total of 623 lesions were included in the study (mean+/- SD of lesions, 10.8+/-8.05). The treated number of lesions were 316 (mean+/- SD 4.78+/-5.09), with the untreated 307 lesions left as control.

RESULTS

In 53 patients (30 females, 23 males), 173 lesions were treated with 2% zinc sulphate intralesionally, while 176 lesion were left untreated as control. The total clearance rate of the treated lesions were 98.2% within 6 weeks of follow-up (80.92% of lesions needed a single injection and showed total clearance within 2 weeks), while none of the control lesions showed any spontaneous clearance within the same period. In 47 patients (27 females, 20 males), 143 lesions were treated with 7% hypertonic sodium chloride solution intralesinally, with the remaining 131 lesions left untreated as control. Only 8.3% of treated lesions showed total clearance within 10 weeks of follow-up.

CONCLUSION

Two percent zinc sulphate can be recommended as a new and effective local mode of therapy of viral warts, especially for the recalcitrant form.

Treatment of refractory hand warts by isolated limb infusion with melphalan and actinomycin D

We present an immunocompetent man with extensive warts on the hands, refractory to a number of conventional treatment modalities and causing substantial morbidity and impairment of normal function. Isolated limb infusion (regional intra-arterial chemotherapy) with melphalan and actinomycin D was performed, with substantial clearing of the warts within 2 months. Treatment-induced morbidity was limited to mild local erythema and oedema which resolved within 3 weeks. After 9 months' follow up, the patient had only a few residual warts and was able to resume normal activities.

Pulsed dye laser treatment of warts: an update

BACKGROUND

Warts are a therapeutic challenge. New studies indicate that pulsed dye laser therapy may be effective, with clearance rates of 72 to 93%.

OBJECTIVE

To determine clearance rate in pulsed dye laser treatment of warts and compare our rate to those of other published studies.

METHODS

Thirty-three patients with 96 warts received pulsed dye laser treatment for recalcitrant plantar, digital, peri- and subungual, and body warts.

RESULTS

Forty-eight percent of patients had complete wart clearance; 45% partially cleared. Sixty-nine percent of those who cleared remained wart-free for an average of 11 months. Mean fluence was 9.4 J/cm2, with an average of 3.4 treatments. Body and palmar warts responded best, digital and peri- and subungual next, and plantar lesions worst. No significant side effects were observed.

CONCLUSION

Pulsed dye laser is an effective treatment option for recalcitrant warts with an excellent side effect profile. However, our response rates were not as high as those previously reported, and we feel that further studies would be useful.

Warts and molluscum contagiosum: beware of treatments worse than the disease

To treat or not to treat, that is the question. Two cutaneous infections, warts and molluscum contagiosum, have evaded eradication for centuries, and the viruses continue to thrive and to expand in number despite all attempts at destruction. Meanwhile, many cases regress spontaneously. In this article, the authors review the characteristics of the viruses involved; discuss their transmission, epidemiology, and clinical manifestations; and assess the effectiveness of available therapies.

Bleomycin sulfate in the treatment of mosaic plantar verrucae: a follow-up study

In this report, the authors will supplement research performed in 1989 by Sollitto, Napoli, and Gazivoda on the use of intralesional bleomycin for the treatment of verrucae. With various alterations of technique, their original success rate of 32.2% was improved to 65.4%. Thus, bleomycin is a very effective first line treatment for multiple verrucae, particularly of the mosaic variety. An association is also made between patients with pedal hyperhidrosis and the occurrence of multiple verrucae, notably lesions that prove recalcitrant to initial therapy.

The treatment of palmar and plantar warts using natural alpha interferon and a needleless injector

BACKGROUND

The treatment of palmar and plantar warts is difficult and often frustrating. The need for multiple destructive treatments and recurrences after apparent cure are common.

OBJECTIVE

The purpose of this study was to determine if intralesional natural alpha interferon might offer an effective alternative therapy for common plantar and palmar warts.

METHODS

A series of 22 private office patients with palmar and plantar warts were treated with intralesional natural alpha interferon using a needless injector. We treated twice weekly for a minimum of 8 weeks or until clear.

RESULTS

Sixteen patients (73%) showed complete clearing of their warts in a mean of 11 weeks of twice weekly treatment. Upon follow-up, which averaged 9.5 months, 17 of 21 patients (81%) remained clear of their warts.

CONCLUSION

Natural alpha interferon by needless injector appears to represent an effective alternative treatment for palmar and plantar human papillomavirus lesions. Further study of this modality is indicated.

Topical treatment of resistant warts with glutaraldehyde

Therapy with glutaraldehyde (GA) was used to treat twenty-five patients with selectively resistant warts. The patients were categorized as having one or more of the following conditions: 1) the location of the warts was either periungual, palmar or plantar, 2) the age of the patient was five years or younger, 3) the number of warts was two or more.

RESULTS

Eighteen (72%) out of twenty-five cases were cured, and the other seven (28%) were not. The individual cure rates of the three conditions above were 80%, 60%, and 68.5% respectively. Pigmentary changes occurred immediately after the initial topical application of glutaraldehyde, and the surface of the verruca hardened. Soon afterwards some debris began to drop off of the verruca tissue little by little, and final healing was completed by less than twelve weeks without disagreeable marks. This therapy was found to be extremely useful, not only because the cure rate was high, but the following advantages were also noted: 1) no pain or pruritus, 2) no evidence of scarring or permanent pigmentary change, 3) good penetration in any location, 4) no need for special instruments or reagents except the solution, and 5) no special technique required (possible home treatment). This therapy is superior to cryotherapy (CT) in that it is useful for warts on any location, regardless of the number of lesions, and it is good for young children, although the cure rates for CT and GA are almost equal.

Histologic, pharmacologic, and immunocytochemical effects of injection of bleomycin into viral warts

BACKGROUND

The plasma concentration of bleomycin after injection of bleomycin into warts is unknown, as is the long-term stability of bleomycin solution.

OBJECTIVE

Our purpose was to measure plasma bleomycin concentration after injection of bleomycin into warts, to relate histologic and immunocytochemical changes in warts to possible mechanisms of action of bleomycin, and to asses the long-term stability of stored frozen bleomycin solution.

METHODS

One milligram of bleomycin was injected into warts on the hands of seven men. Blood samples were taken 15 to 120 minutes after injection, and plasma bleomycin was measured by radioimmunoassay. Warts were removed 2 hours and 48 hours after treatment and studied histologically by light microscopy and for the presence of bleomycin by immunocytochemistry. The bleomycin concentration in 8 aliquots of solution stored at -20 degrees C for varying periods was measured by radioimmunoassay.

RESULTS

Peak levels of bleomycin of 7 to 113 ng/ml were reached by 45 minutes after injection. Plasma bleomycin exposure ranged from 515 to 5137 ng/ml/min between 15 and 120 minutes after injection. The most pronounced histologic changes at 48 hours were individual keratinocyte apoptosis throughout the epidermis merging into areas of complete epidermal necrosis, diffuse neutrophil accumulation, and microabscess formation at the granular layer. Immunocytochemistry demonstrated tissue-fixed bleomycin in all levels of the epidermis except the basal layer and most prominently in the granular layer. Bleomycin in solution stored for up to 27 months at -20 degrees C in glass showed no significant loss of immunoreactivity.

CONCLUSION

The use of bleomycin for the treatment of warts results in significant systemic drug exposure; thus it would be prudent to exclude pregnancy before treating women of child-bearing age. Bleomycin probably has a direct toxic effect on keratinocytes. Dilute bleomycin solution stored at -20 degrees C in glass is stable.

ABC of antenatal care. Multiple pregnancy

Images

Dermatologic therapy: December 1987 to December 1988

In this article I have reviewed the significant therapeutic advances that have been reported in the English-language literature from December 1987 to December 1988. Clinicians should read the original articles in toto before attempting any new experimental or controversial therapy.