Adverse reaction to intralesional bleomycin therapy for periungual warts: A case report

Periungual warts pose a therapeutic challenge due to their persistence and proximity to the nail unit, which increases the risk of complications. Although conventional treatments exist, their efficacy is limited in this area. Intralesional bleomycin has emerged as an effective alternative, offering targeted cytotoxic effects. However, its use may be associated with potential adverse effects. This report presents an 18-year-old female with a verrucous plaque (2×3 cm) on the hyponychium and lateral nail folds. Intralesional bleomycin (0.1 mL of 3 U/mL) was administered after superficial paring. Post-injection, she developed severe pain, bluish-black discolouration, tense bullae and difficulty flexing the distal phalanx. Dermoscopy revealed pigment network, blue-grey clods and splinter haemorrhages. Arterial Doppler ruled out vascular compromise, and she was treated with nifedipine to enhance blood flow. The patient showed gradual improvement. Intralesional bleomycin is effective for periungual warts but requires a precise injection technique to avoid severe complications. Early recognition and management of adverse effects are critical to ensuring patient safety and treatment success.