07/20/2020    David Secord, DPM

Panacos Procedure for Warts

I’ve been using the Panacos graft and the
bleomycin treatments ever since I first started
practicing. I list these two together because
they attempt to accomplish the exact same thing
with somewhat different techniques.

Bleomycin technique:

The bleomycin treatment is my primary treatment
for verrucae vulgaris lesions and I currently
have a 99.7% success rate over 8 years and
hundreds of cases with the added benefit that if
the person has multiple verrucae, treating just
the one lesion will allow resolution of all of
them in the course of 5-6 weeks.

The procedure entails using the body’s own immune
system to kill the wart and follows the path of
driving some of the warty material into the
dermis, where the body will identify it and raise
killer T-cells to the HPV. As these circulate
throughout the body, any place with a wart will
be affected and the lesions will shrink and
disappear. First off, I don’t do this on a lesion
that is larger than 0.6cm (about the diameter of
a pencil eraser) as the wound left when it is
deroofed seems too large to heal quickly.

For lesions larger than 0.6cm, I use Aldara cream
(which, in the case of plantar warts—as opposed
to genital warts, is applied QD under occlusion—I
like duct tape, for an application time of 8
hours, after which you completely wash it off,
with total application time consisting of 3
months, with weekly debridement of the
hyperkeratotic skin).

You see the patient and debride the lesion of
hyperkeratotic skin to thin it out without going
to the level of pinpoint bleeding and thrombosed
capillaries. The area is anaesthetized under the
lesion (I’ll use about 1.5cc of 1% lidocaine with
epinephrine and 0.5% Marcaine) and prep the area
with EtOH. Using a 12 gauge needle, I use the
bevel of the needle to go around the periphery of
the wart, 1-2mm beyond the visible lesion,
remembering that the virus is 1-2mm beyond the
visible lesion, and use the bevel to
circumferentially outline the lesion. This makes
the deroofing procedure much easier.

I then break up the capsule of the lesion by
piercing it over and over (maybe an average of
35-40 times) and once it is broken up (with the
needle only passing to the dermis and not the
sub-Q fat, as it is not necessary to go deeper
than this as the cellular immune system resides
at the dermis and if you penetrate to sub-Q fat,
you will cause scarring), I inject the Bleomycin.

I’ve read of other people injecting a cc or two
into a lesion and I can’t imagine what they do
with that much volume, as it has nowhere to go.
You also can’t inject between the dermis and
epidermis as the rete ridges hold the two layers
together tightly and you only see this violated
in infections such as scalded skin syndrome. If
you are “injecting under the lesion” you are
injecting into sub-Q fat and that is too deep.
The cellular immune system resides at the dermal
level and both the wart and Bleomycin need to
reach this level to stimulate that immune system.

Violation of the sub-dermal layer will only
accomplish scarring by going through the deep
fascia to pass to the sub-Q fat and that is poor
technique. The bleomycin serves only one purpose,
which is to halt the division of the virus as you
wait for the immune response. That’s all it does.
The most I’ve ever injected into the lesion (and
it is into the pulverized wart and not under it,
as ‘under it’ would be below the dermis) is about
0.10cc with the 12 gauge needle on a tuberculin
syringe. That is correct. You inject one tenth of
a cc and that’s it.

Once injected, I then puncture the lesion over
and over again to drive both the warty material
and the bleomycin to the dermal level. I wipe the
area with EtOH and place a Band-Aid™ over the
site with topical antibiotic on the lesion. I
tell them to take it easy the rest of the day and
wash it with soap and water every day when they
bathe and cover it with a Band-Aid™ and topical
antibiotic.

I see them in 3-4 days to deroof the lesion. This
is done with a forceps and 15 blade on a #3
handle. You go around the lesion and retract with
the forceps and the visible wart will come out in
pieces and leave an impressive hole in the foot.
This is just dead tissue and so the patient is
relatively anesthetic to the procedure. I cover
it with antibiotic and a Band-Aid and see them in
a week, letting them know that in a day or so the
hole will fill in and to wash it normally with
soap and water and keep it covered.

I see them in a week to make sure it doesn’t get
infected (I’ve never had an infection yet) and
then back again in a month and it either worked
or didn’t. If they adequately sero-convert, the
other warts they possess will disappear as well,
taking about a month. I've read of other folks
saying that the peripheral warts resolve in 3
months, but I've never seen it take that long.

It is usually a process of 5 weeks to seroconvert
and once that's done, the wart slowly thins out
and decreases in diameter and its gone, taking
about a month or so. In only rare occurrences do
I see failure of this and would attribute it to
failure of the immune system, as a repeat of the
procedure usually fails as well. The Bleomycin
comes desiccated and is good for about a month
once hydrated, so you have to do a few to justify
the cost of the material.

Panacos Graft technique:

I’ve done 24 Panacos graft procedures and only
use it for mosaic warts and have a 100% success
rate over those 24 cases, with the entire warty
material sloughing off like a scab in about 4-6
weeks, rather like the seroconversion time for
the bleomycin treatment. Rather than being a
radical procedure to use, it seems pretty
straight forward to me. I can’t imagine why it
isn’t everyone’s choice with the astonishing
success rate I’ve seen with these two procedures.

It won’t work in the immunocompromised patient.
The procedure involves taking a small amount of
the warty material from the mosaic (I usually use
a 5mm biopsy punch) and trimming off the horny
epithelial layer. You should be able to easily
distinguish this keratinized layer from the
epidermal/dermal junction from the more firm
texture of the horny, keratinized skin. If this
is not done, you will very likely implant this as
part of the procedure and end up with resolution
of the mosaic wart on one foot and an epidermoid
inclusion cyst on the recipient foot.

I follow the description of the procedure via Dr.
Panacos and make an incision on the recipient
foot—usually around the arch area as a stab
incision and implant the epidermis of the graft
from the donor foot. It needs to be implanted to
the dermis and not below the fascia, so this is a
small amount of tissue being implanted
superficially to the skin. A single stitch over
the recipient site is done and the stitch is
removed in 3 days. Seroconversion will occur in
around 5 weeks—just like the bleomycin procedure—
and the patient should see the mosaic become
thinner and thinner and slough off at about a
month or a month and a half after the procedure.

David Secord, DPM, McAllen, TX

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