Dear Editor,

Periungual warts (PW) are very common and frequently encountered in the clinical setting. A variety of treatment modalities have been reported, including topical, intralesional, systemic, and surgical approaches.1 Despite the existence of several treatment approaches, PW are still characterized by their therapeutic resistance.

We report a case of a 37-year-old female patient presenting a recalcitrant PW on her left thumb (Figure 1). Previous treatments included cryotherapy (15 treatments) and imiquimod 5% cream (3 times a week for 8 weeks), without improvement.

Figure 1.

Periungual wart. Verrucous lesion on the left thumb with subungual impairment and black dots

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We applied ingenol mebutate (IM) gel (Picato®, 0.05%, LeoPharma, Balerup, Denmark) using a multipuncture technique. After skin antisepsis with clorexidine 0.2% solution, IM 0.05% gel was applied over the lesional area (4 x 4mm) and 150 superficial punctures per treatment were made with a 31G needle. The treatments were repeated 3 times at 15-day intervals. Fifteen days after the third procedure, complete resolution was observed (Figure 2). Regarding to adverse effects, only mild desquamation occurred after each application.

Figure 2.

Clinical clearance of the lesions 15 days after the third procedure

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IM gel has been effective against human papilloma virus (HPV) lesions, as shown previously in two case series of genital warts, with total lesional clearance in 18 of 19 patients.2,3 The therapeutic response observed in our case suggests that IM can also be a therapeutic modality in more keratotic HPV-related lesions, such as PW, since drug penetration can be improved by multipuncture technique.

Financial support: None.

Conflict of interest: None.