Diagnosis and Individualized Treatment of Periungual Warts

Conclusions

• Periungual warts are usually diagnosed clinically with dermoscopy, but biopsy is important when the appearance is atypical or when squamous cell carcinoma and other mimickers are possible.
• There is no single gold-standard treatment for periungual warts, because available therapies have variable effectiveness and the evidence base is often limited.
• Treatment should be individualized according to the patient, lesion size, lesion number, and nail-unit location, rather than escalated aggressively by default.
• A good doctor-patient relationship and adherence to treatment are key determinants of success, and keratolytics can be useful as an initial step to prepare lesions for further therapy.
• Some periungual warts may improve or even resolve over time, especially in children, so asymptomatic lesions do not always require immediate aggressive treatment.
• Bleomycin appears to be an effective first-line option with high cure rates and generally acceptable safety, but it can cause important adverse effects such as pain, necrosis, Raynaud-like changes, and nail dystrophy or loss.
• Multiple bleomycin sessions often improve cure rates compared with a single session, but outcomes depend on follow-up duration and treatment protocol.
• Combining bleomycin with electroporation/electrochemotherapy may increase efficacy compared with bleomycin alone, though it may also intensify side effects.
• Newer or adjunctive approaches such as topical fluorouracil-salicylic acid, HPV vaccination, hyperthermia, vitamin D3, and immunologic or intralesional therapies show promise but need stronger evidence before they can replace established approaches.