BLEOMYCIN ------------------------------------------------- I am interested in experiences with the poking technique using bleomycin for warts. Specifically (1) What concentration of bleo has been used (2) How successfu is this treatment (as best anyone can guess about results in wart therapy)? Compared with intralesional bleo? Also, any experience to compare its use as a first (or second) line rather than last ditch treatment in an effort to achieve more rapid resolution? Finally, how long have you kept the bleo after it has been diluted (especially in light of its significant expense)? Thank you. Thomas A. Sattler, M.D ------------------------ 1. Bleomycin concentration: 1 unit per ml (reconstitute 15 U vial with 15cc saline. 2. My experience is purely subjective thus far, but in general I do not use Bleo+BCA unless BCA and 96% pyruvate and LN2 have all failed. I find that the depth of wart destruction per treatment is greater than with BCA alone (i.e. I can debride more of it in the scab at 2 weeks), and with minimally more discomfort than BCA alone. BCA + Bleo also seem much better than trying to "tattoo" Bleo alone as described by Spiro. 3. Compared to I.L. Bleo at the same concentration, there is markedly less hemorrhagic necrosis and less pain, but it also takes many more treatments to clear the wart than by I.L. injection. On the other hand, one can safely treat periungual warts by this method - a big advantage! 4. The bleo solution is stored at refrigerator temperature for up to 4 months, withdrawing small aliquots of tenths of an ml. at a time for pt. treatments. For research on storage and the only good paper on serum levels see James et. al. JAAD 1993 28(6): 933-7. I don't freeze it to -20 degrees C. Finally: I use a sharp "BCA toothpick" to apply it. When I asked Dr. W. Shelley in person about the bifurcated needle technique he described in Arch Derm 1991, 127(2): 234-6, he told me that he used local anesthesia, then macerated the wart with the bleo solution "until it was a bloody mess" to obtain the cure rates he reported. My patients wouldn'to go for this. I would sooner use my CO2 laser once I had the xylocaine in. Gene Sienkiewicz, M. D. ----------------------- I've used bleomycin for plantar warts for several years routinely and with no problems. Today a patient stated that she was allergic to "mycins." She had an allergic contact dermatitis to neomycin and an urticarial eruption from erythromycin within an hour after taking a tablet. I was uncertain enough regarding the risk of an allergic reaction to bleomycin that I treated her with mediplast pads. Can anyone shed any light regarding the risk of bleo in this patient? James G. Rothschild ------------------- Why not use her natural allergy to neomycin in treatment of the wart? Let her apply neomycin in small amounts daily to the wart to develop a brisk conatct dermatitis. Its easier than using DNCB. Haines ELy ----------- Erythromycin and bleomycin both share the distinction of being derived from streptomyces species (soil fungi), and both have a complex carbon backbone to which two deoxy-sugars are attached. While there are certain general similarities in structure between the two drugs, I would not necessarily assume that they would cross react. Erythromycin has a many carbon lactone ring to which the sugars are attached, and bleo has a somewhat aromatized non-ring pseudopeptide backbone which includes a number of nitrogen resides. Unless someone else says that there is a high percentage of cross-reaction, I would use it, but monitor her closely in the office for an hour to be sure she doesn't have her typical erythromycin reaction. Mark Naylor, M.D. ----------------- I was using a lot of bleo for warts until a few years ago when I injected a plantar wart once in a healthy adult male and he developed a leukocytoclastic vasculitis with arthralgias, fever, andbilateral pedal edema 48 hours later. I have the photos and biopsies to prove it. He required prednisone to quiet the reaction, which continued for two weeks. A workup for other causes was negative. The wart went away. I reported the reaction to the manufacturer and submitted a case report to Cutis, but it was never published. A little later a JAAD article appeared re: significant systemic blood levels of bleo from typical intralesional verruca injections. Since then I use it a lot less, and never in kids under 16. Now I never inject it, but poke it in topically together with bichloracetic acid and occlude for 24 hrs. This combination works better than either one alone for me, and seems safer. Gene Sienkiewicz, M. D. ----------------------- I have tried the vaccination technique for warts for a year or so and did not find it nearly as useful as local injection. I have had one severe adverse response to injected bleomycin which I published in the archives several years ago but for the most part it remains my most reliable plantar war therapy. L.J. Gregg, MD -------------- I have no idea if there is any structural similarity or antigenic cross reactivity between the aminoglycoside antibiotics and bleomycin. However, I have seen two patients with apparent delayed hypersensitivity reactions to intralesional bleo. These took the form of swollen, erythematous areas extending several centimeters around the treated wart, and persisted for about a week. The problem resolved uneventfully and the warts were gone! Mark Valentine --------------