INTRODUCTION
Verruca vulgaris is a common cutaneous manifestation of human papillomavirus (HPV) infection that presents as hyperkeratotic, cauliflower-like papules with central black petechiae; it is most often found on the digits, palmoplantar, and periungual regions. These lesions may be associated with pain, social stigma, and limitations on activities of daily life. Current therapies include salicylic acid, cryotherapy, surgical removal, chemotherapeutics (eg, 5-fluorouracil, bleomycin), immunotherapies (eg, candida antigen, MMR, and HPV vaccines), photodynamic therapy, and laser treatments (eg, pulsed-dye, carbon dioxide, erbium, neodymium).1 However, lesions may be resistant to conventional methods, posing a significant therapeutic challenge. Here we present the case of a patient with recalcitrant warts unresponsive to six unique treatment modalities who exhibited complete resolution with intralesional bleomycin and cryotherapy.
CASE REPORT
A 64-year-old man presented with a three-month history of untreated warts. On exam, verrucous keratotic papules with capillary thrombosis under dermoscopy were appreciated on the left second (Figure 1A) and fifth digits. Initial attempts at cryotherapy destruction paired with daily salicylic acid 17% under occlusion were unsuccessful. Following 14 months of five treatments with cryotherapy and daily over-the-counter salicylic acid 17% with minimal response and the development of new lesions, a decision was made to administer a single treatment of cantharone and continue with salicylic acid 17%. Temporary regression of the lesions was followed by significant regrowth in the previously affected areas. Further approaches with intralesional candida antigen (0.6 ml) were determined ineffective after the third injection without response. Due to continued lack of improvement, squaric acid sensitization began with a 2% solution applied topically to the right upper
