Exploring Alternative Treatment For Resistant Warts

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This otherwise healthy patient inappropriately applied OTC 40% salicylic acid to his warts and presented with substantial pain caused by ulceration of the skin that was well beyond the viral tissue margins.
Here one can see a wart before treatment with 5-fluorouracil.
Here you can see the characteristic superficial ulceration that usually occurs between the fourth and tenth week of treatment with 5-fluorouracil. This ulceration is desirable as it indicates destruction of the lesion.
Here one can see the interruption of skin lines along with acanthosis, hyperkeratosis and small dark pinpoint dots representing thrombosed capillaries.
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Author(s): 
By Robert Salk, DPM, Kirk Grogan, DPM, Thomas Chang, DPM, and Walter D’Costa, DPM

Our standard injection technique utilizes a 27-gauge needle and a 3-ml syringe with a 1.0- to 1.5-U/ml solution of bleomycin. One can prepare this by adding 10 to 15 ml of 0.5% marcaine with epinephrine to 15 units of bleomycin. Doing so produces an activity of 1 to 1.5 units of bleomycin per milliliter of prepared solution. Bleomycin is typically supplied in 15- or 30-unit vials of sterile lyophilized material and must be refrigerated.
In a review of the literature, authors commonly utilized a 1.0-U/ml solution with sterile saline or water.4-6 The authors believe that the increase in strength from 1.0-U/ml to 1.5-U/ml can make a significant difference in cure rates without affecting safety. A 1-cm lesion will usually receive 0.5 to 0.75 ml of this solution.
One should inject the bleomycin strictly into the wart without going deep into subcutaneous tissue. You can accomplish this by turning the needle bevel up away from the skin while inserting the needle at the edge of the wart. Make sure the insertion is as flush to the skin as possible in order to avoid too deep a penetration. Proceed to fan the needle across the wart through one puncture site in order to prevent the medication from seeping from multiple holes. Using the appropriate injection technique will allow you to see the needle through the transparency of the epidermis.
There will be a hemorrhagic blister from the injection. This is normal. You should debride the blister during a return visit from the patient one or two weeks after the injection.
Studies have reported success rates up to 99.23 percent via one to three injections of bleomycin into 1,052 warts at an Australian Air Force Base.4-6 Studies have also shown success with infiltration of bleomycin via a multiple puncture using a vaccination needle.4-6

Other Modalities That May Merit Consideration
Candida antigen. A new and under-studied treatment for warts involves the intralesional injection of Candida skin test antigen.7 With the injection of the wart, 74 percent had complete clearing in the pilot study.7 The remarkable aspect of this study is that 78 percent of those with resolution also had resolution of anatomically distant, untreated warts. This suggests an HPV-directed immunity in some patients.
In using this treatment approach, one would deliver the antigen with a needle and syringe, using the same concentration as with allergy testing, into the base of the wart. Then you would proceed to puncture the wart aggressively to help initiate an immune response. Keep in mind that this process is uncomfortable and may require a prescribed analgesic for the patient. One should follow up with the patient in one to two weeks.
Duct tape. A fitting conclusion to the myriad of non-surgical therapies is the use of duct tape. In one study by Focht, et. al., on warts in children, 85 percent of those treated with duct tape had resolution while 60 percent of those treated with cryotherapy had resolution.8 This study shows the importance of the simple act of occluding the wart, which creates a macerating and keratolytic environment not unlike salicylic acid. This therapy does require the use of a pumice stone at home and clinical debridement in the office. Still, this may be a simple and painless treatment course for the pediatric patient.
Results are not as promising with tape occlusion alone in the adult population. A preliminary result from a study we are conducting shows only 10 percent resolution in adult patients with tape occlusion alone. However, the majority of patients have had substantial reduction in size of their lesions after 12 weeks of treatment. By incorporating combination therapy with tape and a topical medication (i.e. 5-fluorouracil, imiquimod), we expect better results.

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