Ungual warts: comparison of treatment with intralesional bleomycin and electroporation in terms of efficacy and safety

Abstract

Background Ungual warts are considered the most common benign nail tumour, and they are caused by the human papillomavirus. Despite the numerous treatments reported in the medical literature, ungual warts are considered frustrating, with high relapse rates and a potential risk of nail dystrophy. Bleomycin is a therapeutic option showing a good safety profile and high cure rates. Objective To evaluate the efficacy of electrochemotherapy using intralesional bleomycin for the treatment of ungual warts in comparison with intralesional bleomycin alone and describe the side‐effects related to the use of both techniques. Methods This was a prospective, randomized, double‐blind, controlled clinical trial. Forty‐four 18‐ to 60‐year‐old female and male patients with ungual warts of only one finger were included. The patients were divided into two treatment groups: GA – intralesional bleomycin; and GB – electroporation and intralesional bleomycin. Following a single application, the patients were followed up for 180 days. Results The patients’ mean age was 36 years for GA and 37 years for GB. Most patients were female (68%). Of 22 patients in GA completing the study, 11 (50%) achieved the cure, while 18 (85.7%) of 21 patients completing the study in GB showed cure. A significant association of patients with or without cure after the GA and GB treatments (P = 0.022) was observed. None of the patients in either group had systemic side‐effects. Independent of the technique used, all the participants considered the adverse effects tolerable. Conclusion The intralesional use of bleomycin associated with electroporation for the treatment of ungual warts (both periungual and subungual) showed a statistically superior cure when compared with intralesional bleomycin alone. Side‐effects were more frequently observed in the electrochemotherapy with bleomycin group than in the bleomycin monotherapy group.

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

“…Varying concentrations of bleomycin solution have been used in different studies due to lack of standardization. Table 1 treatment results with varying strength of bleomycin solution [12][13][14][15][16]. The side effects reported with the use of injection bleomycin are tabulated in Table 2 [17,18].…”

“…Varying concentrations of bleomycin solution have been used in different studies due to lack of standardization. Table 1 summarizes the treatment results with varying strength of bleomycin solution [12-16].…”

“…Bleomycin is a cytotoxic agent that inhibits DNA and protein synthesis and has been used in the treatment of viral warts for >5 decades [3]. Many recent reports have shown encouraging results with intralesional bleomycin in ungual warts [4]. Two techniques have been used: multi-puncture technique and intralesional injection of bleomycin.…”

The diverse methods of bleomycin delivery in cutaneous warts: A literature review

“…Both hypertrophic and atrophic scarring were reported in the PDL trials 11,14 . With electroporation, onycholysis in 13% and reflex sympathetic dystrophy in 4% (one patient) were reported 12 …”

“…Although, traditionally used by intralesional injection, other methods of intralesional administration have been described with varying results. Topical instillation of bleomycin with either microneedling, multiple puncture techniques and microneedle patches to enhance intralesional drug delivery are described 10‐12 . Additionally, intralesional injection has also been combined with electroporation and pulsed dye laser (PDL) 13,14 .…”