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.

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Methotrexate is a versatile antineoplastic and immunosuppressive agent. We report a case of a young adult on the Cancer and Leukaemia Group B 10403 treatment protocol for B-cell acute lymphoblastic leukaemia. She has previously completed the induction and consolidation phases with good tolerance then started on Capizzi methotrexate during the interim maintenance phase. Few days after receiving one intermediate dose of methotrexate, she developed severe multiorgan toxicities including pancytopaenia and several dermatologic toxicities. The patient underwent extensive diagnostic workup, with all results negative, pointing eventually towards severe methotrexate toxicity. This case highlights the broad spectrum of toxicities that can occur even with low doses of methotrexate. Capizzi methotrexate therapy implies no leucovorin therapy, hence putting patients at risk for multiorgan toxicity. Our experience reinforces the importance of close monitoring for patients receiving methotrexate, regardless of dose, and the prompt administration of high-dose leucovorin once toxicity suspected.