08/14/2025 David Secord, DPM
Intralesional Cidofovir Promising for Treating Refractory 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 28
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 as the epidermis grows and
the T-killer cells reach the virus. 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).
With Bleomycin, 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 1 or 2cc 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. 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 the patient 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 seroconvert,
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 34 Panacos
graft procedures and only use it for mosaic warts
and have a 100% success rate over those 34 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.
Between Bleomycin and Aldara, I very infrequently
have failure of treatment. In those rare
instances, I do a primary excision of the lesion.
I’ve used Dockery’s method of curettage and
topical steroid with mixed results for mosaic
warts and primary excision for solitary lesions.
In children I start with Tagamet and have seen
very good results. I seem to see a magic age of 12
as the cutoff for some reason. In my hands,
Tagamet works very well in the 12 and under crowd
and no response in the over 12 age group for
reasons I can't explain.
I follow the exact method outlined by Dr. Panacos
and make sure to trim off the horny epithelia to
prevent inducing an epidermoid inclusion cyst from
the implantation procedure, which appears to be
the only pitfall of the procedure.
Coding the procedure would be through the
destruction of lesion codes, CPT 17000 and CPT
17003 (times the number of units corresponding to
the number of lesions up to 14) for the Panacos,
for which I bill $400. For the Bleomycin
treatment, bill code J9040. I charge $350 and
usual reimbursement is $280. The cost of a
desiccated bottle of this (5ml) is around $70 and
once received, must be refrigerated, whether
hydrated or not and once hydrated, is good for 30
days. I also charge a J code for the injection of
anesthesia, although it is often not reimbursed.
David Secord, DPM, San Juan, TX
