03/17/2026 David Secord, DPM
Bleomycin Injections for Verrucae (Brian Kiel, DPM)
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 anaesthetic 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 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. Y
ou 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 $350and usual
reimbursement is $280.The cost of a desiccated
bottle of this (5ml) is around $70.00 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, McAllen, TX
