Journal of Dermatological Treatment

ISSN: 0954-6634 (Print) 1471-1753 (Online) Journal homepage: https://www.tandfonline.com/loi/ijdt20

Combined therapy of plantar warts with topical

bleomycin and microneedling: a comparative
controlled study‫‏‬

Hend D. Gamil, Mohamed M. Nasr, Fathia M. Khattab & Amira M. Ibrahim

To cite this article: Hend D. Gamil, Mohamed M. Nasr, Fathia M. Khattab & Amira M. Ibrahim
(2019): Combined therapy of plantar warts with topical bleomycin and microneedling: a comparative
controlled study‫‏‬, Journal of Dermatological Treatment, DOI: 10.1080/09546634.2019.1612837

To link to this article: https://doi.org/10.1080/09546634.2019.1612837

Published online: 17 May 2019.

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JOURNAL OF DERMATOLOGICAL TREATMENT
https://doi.org/10.1080/09546634.2019.1612837

ARTICLE

Combined therapy of plantar warts with topical bleomycin and microneedling: a

comparative controlled study
Hend D. Gamila, Mohamed M. Nasra, Fathia M. Khattaba and Amira M. Ibrahimb
a
Dermatology Dermatology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt; bFaculty of Medicine, Zagazig University,
Zagazig, Egypt

ABSTRACT ARTICLE HISTORY

Background: The aim of this study was to assess the efficacy of combination between microneedling Received 8 April 2019
with dermapen and topical bleomycin in the treatment of plantar warts in comparison with intralesional Accepted 10 May 2019
bleomycin and intralesional saline (placebo).
KEYWORDS
Methods: Fifty-four patients were assigned into three groups, each containing 18 patients. The first group
Bleomycin; human
treated by micro-needling phenotype with topical bleomycin at 2 weeks interval, the second group papillomavirus; verru-
received intralesional bleomycin at 3 weeks interval and the control group was intralesional saline for a cae; warts
maximum of four weeks.
Results: Complete clearance of warts in 16 patients in the micro-needling group (88.9%) versus 15
patients (83.3%) in the intralesional bleomycin group versus one patient (5.6%) in the control group.
Conclusions: Microneedling assisted topical bleomycin spraying seems to be a promising effective and
noninvasive therapeutic modality for recalcitrant plantar warts that facilitates delivery and absorption of
bleomycin into the lesion.

Introduction dermapen becomes important, as bleeding induced by longer

Plantar wart (Verruca plantaris) is a wart occurring on the sole or
toes of the foot. Plantar warts can be painful due to their cal-
lused, endophytic papules that have deeply penetrating sloping
sides and a central depression (1). The types of human papilloma-
virus (HPV) that have been isolated from plantar warts include
HPV-1, -2, -3, -4, -27, -29, -57, -60, -63, -65, -66, and -69. In one
randomized controlled trial, 88% of plantar warts were caused by
HPV-1, -2, -27, or -57. Most plantar warts are attributed to HPV-1
(2). Plantar warts exhibit an annual incidence of 14% in the gen-
eral population. Transmission of warts occurs from direct person
to person contact or indirectly by fomites (3). Treatment of plan-
tar warts is a therapeutic challenge regarding both tolerability
and efficacy. An innovative approach of combining microneedling
with topical bleomycin for the treatment of recalcitrant plantar
warts was first reported by Konicke and Olasz (4).
Bleomycin is a glycopeptide antibiotic produced by the bacter-
ium Streptomyces verticillus. It acts by inhibiting the deoxyribo-
nucleic acid (DNA) synthesis in cells and viruses; it induces strand
cleavage of the DNA molecule (5). Microneedling is a minimally
invasive procedure; dermapen designed in a special form to con-
trol depth penetration of the skin (6). The microneedles penetrate
through the epidermis but do not remove it; so, the epidermis is
only punctured and rapidly heals based on the controlled mech-
anical stimulation of the wound-healing process by the needle
(6,7). It has also been shown to augment transdermal drug deliv-
ery. By creating micropores through the stratum corneum and
into the underlying epidermis, microneedling bypasses the barrier
function of the stratum corneum to rapidly deliver topical medica-
tions into the dermal microcirculation without penetrating deep
enough to stimulate nerves within the dermis. Choice of
needles has been hypothesized to inhibit drug absorption (8). The
aim of this study was to assess the efficacy of combination
between microneedling with dermapen and topical bleomycin in
the treatment of plantar warts in comparison with intralesional
bleomycin and intralesional saline.
Materials and methods
This study was carried out in the Dermatology and Venereology
Outpatient Clinic at Zagazig University Hospitals from January
2018 to August 2018. The study included 54 patients who had
plantar warts. Written informed consent was taken from all
patients before the start of the study. Inclusion criteria include
plantar warts of different sites, sizes and durations, recalcitrant or
non-recalcitrant warts, and patients with no concurrent systemic
or topical treatment of warts.
While exclusion criteria are patients with prior allergic response
to bleomycin, pregnant and lactating women, who received any
other treatments for their warts in the last month before enroll-
ment, Raynaud’s phenomena, and peripheral vascular diseases.
The diagnosis was made on the basis of history and typical
clinical features. Patients were categorized into three groups (A, B,
and C), each containing 18 patients. The first group (A) treated by
micro-needling phenotype with topical bleomycin at 2 weeks
interval, the second group (B) received intralesional bleomycin at
3 weeks interval and the control group (C) was intralesional saline
for a maximum of four weeks.
Group A included 18 patients treated by dermapen with top-
ical bleomycin. Bleomycin is available in a vial containing (15 mg)
powder. It was diluted by 15 mL saline, so the concentration
became (1 mg/1 mL). The wart was first wiped with alcohol and

CONTACT Fathia M. Khattab fathiakhattab@yahoo.com Department of Dermatology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
ß 2019 Taylor & Francis Group, LLC
2 H. D. GAMIL ET AL.

then superficially pared with a scalpel (blade no. 22) to remove
the associated callus without reaching the bleeding points.
Microneedling (pen-type) was performed on each lesion using a
36 pins needle cartridge with a 1-cm tip diameter at a 2-mm
depth setting for 2–3 min, with intermittent topical application of
bleomycin. In a single visit, a total of 0.2–0.5 mL of 0.1% of bleo-
mycin solution was applied depending on the size of the single
wart with a maximum of 2 mL for multiple warts in each patient
and occlusion for 12 h. Treatment was done for a maximum of
four sessions at 2 weeks intervals (4).
As regards group B, it included 18 patients subjected to intra-
lesional bleomycin injection. The bleomycin vial containing 15 mg
powder was first diluted by 5 mL saline (3 mg/1 mL). Before injec-
tion, further dilution with 2% lidocaine was done using double
the amount taken from the bleomycin vial, so their concentration
becomes 1 mg/1 mL (1 unit/mL). This was injected into the base
of the wart, using a 100-unit insulin syringe that also provides
concurrent acceptable anesthesia. The injection was continued
until each wart had blanched.
In a single visit, less than 2 mL of 0.1% bleomycin solution was
given to avoid any systemic side effects in a given patient.
Treatment was done for a maximum of four sessions at 3 weeks
intervals (9). Intralesional injection of normal saline was done in
group C into warts for up to four sessions.
The response was evaluated by a decrease in the size of warts
and photographic comparison at baseline and at each visit.
Immediate and late adverse effects of microneedling with topical
bleomycin and intralesional bleomycin (including local pain dur-
ing and after treatment, pigment changes, scarring, tissue dam-
age, itching) were recorded at each treatment session.
A pain scale of 0 (no pain) to 10 (the worst pain the patient
has ever felt) was used to measure the injection pain as (1–3)
mild, (4–6) moderate, and (7–10) severe.
Evaluation of response was done as, complete response (CR):
disappearance of the wart(s) and a return of the normal skin mark-
ings with no recurrences, partial response (PR): 50–99% reduction
in wart size, and no response (NR): 0–49% decrease in wart size.
Follow up was done for 6 months after completion of the
treatment for detection of any wart recurrence.
A chi-square (v2), t-test or Fisher’s exact test and ANOVA (f test)
were applied for statistical analysis. In all tests, statistical signifi-
cance was set at p
.05.
Results
A total of 54 patients with plantar warts of different sizes, sites,
and numbers were enrolled in this study. Baseline parameters
(age, sex, number, size, sites of warts, and wart duration) of the
studied patients in the three groups are presented in Table 1.
As regards clinical response after the end of therapy among
three groups showed a highly statistically significant difference of
groups A and B as compared to the control group. In group A, CR
was detected in 16 patients (88.9%) and PR in two patients
(11.1%). In group B, complete clearance was observed in 15
patients (83.3%) and PR in three patients (16.7%). In group C,
complete clearance of the treated warts was observed only in one
patient (5.6%) and PR in two patients (11.1%) (Table 2).
Comparison of clinical response after the end of therapy
according to the number of warts among group A and group B
showed a statistically significant difference of group A as com-
pared to group B in the fourth session (p ¼ .0017) and the overall
response (p ¼ .02).
No statistically significant relation was detected between the
size of warts and clinical response in group A and group B.
In group A, a highly statistically significant relation was detected
between age (mean age 25.6 ± 7.8 and range 13–40) and CR to
therapy (p < .001) while a non-significant relation was detected in

Table 1. Demographic data of the three studied groups.

Variable Dermapen with topical bleomycin (A) (n ¼ 18) Intralesional bleomycin (B) (n ¼ 18) Control group (C) (n ¼ 18) p Value KW v2
Age (years) .9 –
Mean ± SD 28.1 ± 10.7 29.6 ± 11.3 28.5 ± 14 (NS)
Range 13–55 15–56 9–64
Gender 1.0 –
Male 12 (66.7%) 12 (66.7%) 12 (66.7%) (NS)
Female 6 (33.3%) 6 (33.3%) 6 (33.3%)
Number
Mean ± SD 4.5 ± 7.1 3.5 ± 2.0 2.3 ± 1.9 .3 2.2
Median 2 2.5 2 (NS)
Range (1–30) (1–10) (1–8)
Size .9 – 0.16
<1 cm 11 (61.1%) 12 (66.7%) 11 (61.1%) (NS)
>1 cm 7 (38.9%) 6 (33.3%) 7 (38.9%)
Site .3 – 2.2
Unilateral 13 (72.2%) 10 (55.6%) 14 (77.8%) (NS)
Bilateral 5 (27.8%) 8 (44.4%) 4 (22.2%)
Duration .1 3.5
Mean ± SD 12.3 ± 10.6 19.5 ± 18.6 11.2 ± 13 (NS)
Median 7 5 6
Range (1–36) (2–60) (1–48)
Previous TTT
No treatment 5 (27.8%) 8 (44.4%) 13 (72.2%) .06 – 17.6
Cryocautery 5 (27.8%) 4 (22.2%) 0 (0.0%) (NS)
Chemical TTT 6 (33.3%) 2 (11.1%) 2 (11.1%)
Surgery 0 (0%) 3 (16.7%) 1 (5.6%)
Electrocautery 1 (5.6%) 0 (0.0%) 0 (0.0%)
Combined 1 (5.6%) 1 (5.6%) 2 (11.1%)
KW: Kruskal–Wallis test, one-way ANOVA on ranks; v2: chi-squared test.
p
.05 ¼ significant (Sig.).
p < .001 ¼ highly significant (HS).
p>.05 (NS).
 JOURNAL OF DERMATOLOGICAL TREATMENT 3

Table 2. Comparison of overall response according to number of warts in the three studied groups.
Group A Group B Group C
(81 warts) (63 warts) (41 warts)
Overall response No. % No. % No. % v2 p Value
CR 77 95.06 53 84.12 1 2.44 174.6 <.001
PR 4 4.9 10 15.87 2 4.8 (HS)
NR 0 0.0 0 0.0 38 68
v2 ¼ chi-squared test.
p < 0.001 ¼ highly significant (HS).

Table 3. Side effects of treatment among group A and group B. In this study, comparison of clinical response in the three
Group A Group B groups showed a highly statistically significant difference of
microneedling group (group A) and intralesional group (group B)
Side effects No. % No. % v2 p Value
as compared to the control group. Complete clearance was
Local pain 18 100.0 18 100.0 0.0 1.0 (NS)
Mild hyperpigmentation 2 11.1 3 16.67 0.23 .62 (NS) detected in 88.9% of patients in group A and 83.3% of patients in
Erythema, edema 0 0.0 10 55.5 13.05 <.001 (HS) group B compared to 5.6% in the control group, with no recur-
Hemorrhagic blister 0 0.0 6 33.3 5.0 .025 (Sig.) rence during the 6 months follow up. Also, comparison of clinical
Infection 0 0.0 1 5.5 0.0 1.0 (NS) response according to the number of warts showed a statistically
Local itching 0 0.0 1 5.5 0.0 1.0 (NS)
significant difference in group A (95.06%) as compared to group
means significant (Sig.).
means highly significant B (84.12%) and control group (2.44%).
(HS).
The results of this study in group A, with complete clearance
in 88.9% of patients using dermapen with topical 1 U/mL bleo-
Table 4. Comparison of pain scale degree among group A and group B. mycin coincides with that reported by Al-Naggar et al. (10) of
Pain scale Group A (n¼ 18) Group B (n¼ 18) t p Value 83.3% clearance in their non-controlled study, using the same
Mild (1–3) 18 0 14.75 <.001 technique with no recurrence during 3 months follow up.
Moderate (4–6) 0 18 (HS) In contrast, it reported 100% clearance of recalcitrant warts
Severe (7–10) 0 0
using the same technique, which may be attributed to the low
Mean ± SD 1.1 ± 0.3 4.7 ± 0.9
Range (1–2) (4–6) number of treated cases (three cases only) in their study (4); also,
t-test or Fisher Exact test. reported complete clearance in 74% of patients with plantar warts
p < 0.001 ¼ highly significant (HS). using the translesional multipuncture technique (11). This
decrease in clearance rate may be attributed to the very low con-
centration (0.1 U/mL) of bleomycin used compared to 1 U/mL of
group B. In group A, a statistically significant association was bleomycin concentration in this study.
detected between unilateral lesions and CR to therapy (p ¼ .018) In the present work, CR was detected in 95.06% of treated
while a non-significant relation was detected in group B. warts in group A. Similarly, Shelley and Shelley (12), who were the
In group A, there was a highly statistically significant associ- first to use the multipuncture technique for warts via a bifurcated
ation between the clinical response of patients to therapy and vaccination needle, reported 92% clearance rate of treated warts
disease duration (p < .001) with increase mean duration among after a single treatment with no recurrence for 6 months. A non-
partially responder cases (24 ± 0.0 months) compared to com- controlled early multipuncture technique reported using a
pletely responded (10.8 ± 10.4 months). Monolet needle in plantar, palmar and periungual warts showed
The relation between previous therapy and clinical response 92% clearance rate with 11% recurrence after 1–4 years follow up
among group A and group B showed no statistically significant (13). Also, a case with a recalcitrant plantar wart that responded
association among partially responded cases compared to com- completely to multipuncture administration of higher concentra-
pletely responded. tion of bleomycin (3 U/mL) with no side effects was reported (14).
The adverse effects in group A revealed that mild hyperpig- Superficial paring was done with a scalpel before micronee-
mentation was observed in two patients (11.11%); as regards dling with dermapen in group A. The abrupt separation between
group B, erythema and edema at injection site in 10 patients the wart tissue and the protective horny ring becomes more obvi-
(55.5%), Hemorrhagic blister in six patients (33.3%), mild hyperpig- ous, as the epithelial ridges of the plantar skin are not continued
mentation in three patients (16.67), local infection in one patient over the surface of the wart. If the paring is continued, small
(5.5%), and local plantar itching in one patient (5.5%) (Table 3). bleeding points, the tips of the elongated dermal papillae, are evi-
A high statistically significant difference in the pain scale dent (15).
degree was recorded in group A compared to group B (p < .001) The results of this study in group B, with complete clearance
(Table 4). The photomicrographic documentations are shown in in 83.3% of patients treated by intralesional injection of 1 U/mL
Figures 1–4. bleomycin, higher than that reported by Al-Naggar et al. (10) in
In the present study, no recurrence was observed in any of the their non-controlled and that reported by Barkat et al. (16) in their
studied patients after the 6-month follow-up period. dermoscopic assisted placebo-controlled of 70% clearance using
the same technique (paring before injection at 2 weeks interval)
with no recurrence during 3 months follow up. This decrease in
Discussion
clearance rate may be attributed to debridement of the lesions
Treatment of plantar warts is a therapeutic challenge regarding prior to injection allows leakage of the solution and reduces the
both tolerability and efficacy. An innovative approach to combin- effectiveness of intralesional bleomycin.
ing microneedle with topical bleomycin for the treatment of recal- Similarly, reported 94.9% clearance in their noncontrolled
citrant plantar warts was reported (4). study, using the same technique with 13% recurrence rate. This
4 H. D. GAMIL ET AL.

Figure 1. A 25 years old male with multiple warts on right big toe and 4th metatarsal head showed a complete response after two sessions of dermapen with topical
bleomycin.

Figure 2. A 42 years old male with a wart lesion on right sole showed partial response after four sessions of dermapen with topical bleomycin.

may be attributed to more bleomycin solution remained within
warts during the high-pressure injections and through one punc-
ture site (9).
In the present work, CR was detected in 84.12% of injected
warts in group B that coincides with that reported to use the
intralesional technique of 1 U/mL bleomycin for plantar warts via
the dermojet for a maximum of five sessions with 5 weeks inter-
val, reported 89.9% clearance of treated warts with 4.4% recur-
rence rate (17).
In contrast, 23% clearance of recalcitrant plantar warts with
perilesional bleomycin injection after paring was reported. In their
subsequent study, they reported 65% clearance with intralesional
single-injection bleomycin without paring suggesting that the suc-
cess of bleomycin treatment can be technique dependent (18).
In the current study, a statistically significant difference was
found between groups A and B in therapy duration where a more
rapid response was observed in group A (p ¼ .0012). Therapy dur-
ation was 6.4 ± 1.8 weeks for microneedling and 9 ± 2.3 weeks for
 JOURNAL OF DERMATOLOGICAL TREATMENT 5

Figure 3. A case of 53 years old male with wart lesions on left sole showed complete response after two sessions of intralesional bleomycin.

Figure 4. A case of 32 years old male with a recalcitrant wart on right sole showed partial response after four sessions of intralesional saline.

intralesional bleomycin. The mean number of sessions for CR was Also, in this study, a highly statistically significant correlation
3.18 ± 0.8 in group A at 2-week intervals and 3.2 ± 0.7 in group B was only detected in group A, between the CR and both the age
at 3-week intervals. These results coincide with that reported by of patients (p < .001) and duration of warts (p < .001). Warts with
Al-Naggar et al. (10). shorter duration were more likely to respond to microneedling
6 H. D. GAMIL ET AL.
with topical bleomycin. A retrospective study which investigated
the safety and efficacy of combining intralesional bleomycin with
PDL reported that younger patients had a better outcome (19).
A statistically significant relationship was detected in this study
between the site and CR of patients in group A. Patients that
have unilateral wart(s) were more likely to respond to micronee-
dling with topical bleomycin. This may be attributed to decrease
sensitivity degree to bleomycin in patients with bilateral lesions in
group A due to previous destructive therapy scarring.
In this study, adverse effects were mild, transient, and less sig-
nificant in the micro-needling group. The pain was a constant
finding in all groups but its degree differed on a pain scale of
1–10. A very mild pain grade or discomfort during pricking (1–2)
was recorded in group A. In group B, moderate pain that varies
from 4 to 6 degrees on pain scale started 12–24 h after the ses-
sion and persisted for 7–10 days.
Also, the pain was reported by a constant side effect for bleo-
mycin injection (9,16–18). Similarly, the pain was reported by Al-
Naggar et al. (10) in 100% with intralesional bleomycin versus
20% of patients with microneedling and topical bleomycin.
Transient mild hyperpigmentation around the wart was observed
in this study, in two patients in group A and three patients in
group B. This observation comes in agreement with study who
reported dyspigmentation with intralesional bleomycin in a sig-
nificant number of patients which may be attributed to the asso-
ciated inflammation (9). Other side effects as erythema, edema,
hemorrhagic blister, infection, and itching were observed in group
B only. Similar side effects of intralesional bleomycin were fre-
quently reported (10,18). The absence of these side effects in
group A most likely due to the utilization of a minimal concentra-
tion and the essential restriction of the drug to the wart tissue
through the use of the multipuncture technique minimizes local-
ized high concentrations of bleomycin on the wart and distributes
the drug throughout the wart tissue. Similarly, it reported that
microneedling-assisted multipuncture technique has an advantage
of reducing the deep injection of higher concentrations of bleo-
mycin, providing a more homogenous distribution of the bleo-
mycin throughout the entire wart and producing less pain as well
as fewer tendencies to any adverse events (10).
Conclusions
In conclusion, microneedling assisted topical bleomycin spraying
seems to be a promising effective and noninvasive therapeutic
modality for recalcitrant plantar warts that facilitates delivery and
absorption of bleomycin into the lesion. It is well tolerated with
minimal pain and a high cure rate as compared to intralesional
bleomycin therapy. Further large randomized controlled studies
are recommended with a long follow-up to assess possible recur-
rences and confirm long-term efficacy.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Fathia M. Khattab http://orcid.org/0000-0002-2600-4021
References
1. Witchey DJ, Witchey NB, Roth-Kauffman MM, et al. Plantar
warts: epidemiology, pathophysiology, and clinical manage-
ment. J Am Osteopath Assoc. 2018;118:92–105.
2. Doorbar J. Host control of human papillomavirus infection
and disease. Best Pract Res Clin Obstet Gynaecol. 2018;47:
27–41.
3. Stulberg DL, Hutchinson AG. Molluscum contagiosum and
warts. Am Fam Physician. 2003;67:1233–1240.
4. Konicke K, Olasz E. Successful treatment of recalcitrant plan-
tar warts with bleomycin and microneedling. Dermatol
Surg. 2016;42:1007–1008.
5. Kruter L, Saggar V, Akhavan A, et al. Intralesional bleomycin
for warts: patient satisfaction and treatment outcomes. J
Cutan Med Surg. 2015;19:470–476.
6. Iriarte C, Awosika O, Rengifo-Pardo M, et al. Review of appli-
cations of microneedling in dermatology. Clin Cosmet
Investig Dermatol. 2017;10:289–298.
7. McCrudden MTC, McAlister E, Courtenay AJ, et al.
Microneedle applications in improving skin appearance. Exp
Dermatol. 2015;24:561–566.
8. Larran~eta E, McCrudden MTC, Courtenay AJ, et al.
Microneedles: a new frontier in nanomedicine delivery.
Pharm Res. 2016;33:1055–1073.
9. Dhar SB, Rashid MM, Islam A, et al. Intralesional bleomycin
in the treatment of cutaneous warts: a randomized clinical
trial comparing it with cryotherapy. Indian J Dermatol
Venereol Leprol. 2009;75:262–267.
10. Al-Naggar M, Al-Adl A, Rabie A, et al. Intralesional bleomycin
injection vs microneedling-assisted topical bleomycin spray-
ing in treatment of plantar warts. J Cosmet Dermatol. 2019;
18(1):124–128.
11. Al-Ghamdi KM, Khurram H. Successful treatment of periun-
gual warts with diluted bleomycin using translesional multi-
puncture technique: a pilot prospective study. Dermatol
Surg. 2011;37:486–492.
12. Shelley WB, Shelley ED. Intralesional bleomycin sulfate ther-
apy for warts: a novel bifurcated needle puncture tech-
nique. Arch Dermatol. 1991;127:234–236.
13. Munn SE, Higgins E, Marshall M, et al. A new method of
intralesional bleomycin therapy in the treatment of recalci-
trant warts. Br J Dermatol. 1996;135:969–971.
14. Temel A. Successful treatment of plantar warts with bleo-
mycin using multi- puncture technique and review of multi-
puncture applications. J Res Dev. 2016;4:137–139.
15. Plasencia JM. Cutaneous warts: diagnosis and treatment.
Prim Care. 2000;27:423–434.
16. Barkat MT, Abdel-Aziz RTA, Mohamed MS. Evaluation of
intralesional injection of bleomycin in the treatment of
plantar warts: clinical and dermoscopic evaluation. Int J
Dermatol. 2018;57:1533–1537.
17. Agius E, Mooney JM, Bezzina AC, et al. Dermojet delivery of
bleomycin for the treatment of recalcitrant plantar warts. J
Dermatolog Treat. 2006;17:112–116.
18. Sollitto RJ, Pizzano DM. Bleomycin sulfate in the treatment
of mosaic plantar verrucae: a follow-up study. J Foot Ankle
Surg. 1996;35:169–172.
19. Dobson JS, Harland CC. Pulsed dye laser and intralesional
bleomycin for the treatment of recalcitrant cutaneous warts.
Lasers Surg Med. 2014;46:112–116.