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- Presentation
Management of Subungual Warts: Treatment Options, PPD Technique, and Case Experiences
Description
The speaker discussed the difficult management of subungual warts, which are often recalcitrant because of limited drug penetration and the risk of permanent nail damage. Treatment choices differ by age and severity: in children, small or early lesions may resolve spontaneously, while larger or long-standing warts may be treated with topical salicylic acid, topical immunotherapy, or, for refractory cases, intralesional agents such as PPD, MMR, vitamin D, bleomycin, or cidofovir, as well as hyperthermia or photodynamic therapy. In adults, intralesional bleomycin is presented as a first-line option, with topical 5-FU/salicylic acid, imiquimod, cryotherapy, and intralesional PPD, candida, or MMR as alternatives, though destructive methods can be painful and scar. The speaker emphasized intralesional PPD as a tissue-sparing, less painful option for refractory cases, explained that it works via delayed hypersensitivity and immune activation against HPV, and showed several cases with good responses after repeated injections. The technique involves injecting into the nail bed if the nail plate is thick, or directly into the wart if it is accessible, repeating every 2 to 4 weeks, and improving outcomes by debulking hyperkeratosis with paring, clipping, or 40% urea cream. Overall, bleomycin is effective but carries pain and necrosis risk, while PPD is safer but slower to work.
View moreConclusions
- Subungual warts are particularly difficult to treat because thick nail tissue limits drug penetration and treatment can risk permanent nail damage.
- For adults, intralesional bleomycin is presented as the usual first-line treatment, but it can be painful and may cause necrosis or other local adverse effects.
- For children, topical salicylic acid or other conservative keratolytic approaches are preferred first because many lesions may resolve spontaneously.
- Intralesional PPD appears to be an effective tissue-sparing option for refractory subungual warts, especially when other treatments have failed.
- PPD is generally less painful and safer than destructive therapies, but it tends to work more slowly and may require repeated sessions over months.
- Reducing hyperkeratosis with paring, clipping, or 40% urea cream can improve the effectiveness of intralesional treatment.
- Direct injection into the wart or nail bed every 2 to 4 weeks is an important practical technique for PPD therapy.
- Overall, the presentation suggests a treatment strategy that balances efficacy against the risk of pain, necrosis, and nail-unit scarring, with PPD favored when tissue preservation is especially important.
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