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Anais Brasileiros de Dermatologia

Print version ISSN 0365-0596On-line version ISSN 1806-4841

An. Bras. Dermatol. vol.93 no.5 Rio de Janeiro Sept./Oct. 2018 


Multipuncture technique with ingenol mebutate in the treatment of a periungual wart*

Gerson Dellatorre1

Anarosa Barbosa Sprenger1

1Department of Dermatology, Hospital Santa Casa de Curitiba, Curitiba (PR), Brazil.

Dear Editor,

Periungual warts (PW) are very common and frequently encountered in the clinical setting. A variety of treatment modalities have been reported, including topical, intralesional, systemic, and surgical approaches.1 Despite the existence of several treatment approaches, PW are still characterized by their therapeutic resistance.

We report a case of a 37-year-old female patient presenting a recalcitrant PW on her left thumb (Figure 1). Previous treatments included cryotherapy (15 treatments) and imiquimod 5% cream (3 times a week for 8 weeks), without improvement.

Figure 1 Periungual wart. Verrucous lesion on the left thumb with subungual impairment and black dots 

We applied ingenol mebutate (IM) gel (Picato®, 0.05%, LeoPharma, Balerup, Denmark) using a multipuncture technique. After skin antisepsis with clorexidine 0.2% solution, IM 0.05% gel was applied over the lesional area (4 x 4mm) and 150 superficial punctures per treatment were made with a 31G needle. The treatments were repeated 3 times at 15-day intervals. Fifteen days after the third procedure, complete resolution was observed (Figure 2). Regarding to adverse effects, only mild desquamation occurred after each application.

Figure 2 Clinical clearance of the lesions 15 days after the third procedure 

IM gel has been effective against human papilloma virus (HPV) lesions, as shown previously in two case series of genital warts, with total lesional clearance in 18 of 19 patients.2,3 The therapeutic response observed in our case suggests that IM can also be a therapeutic modality in more keratotic HPV-related lesions, such as PW, since drug penetration can be improved by multipuncture technique.

*Work conducted at the Hospital Santa Casa de Curitiba, Curitiba (PR), Brazil.

Financial support: None.


1 Herschthal J, McLeod MP, Zaiac M. Management of ungual warts. Dermatol Ther. 2012;25:545-50. [ Links ]

2 Schopf RE. Ingenol mebutate gel is effective against anogenital warts - a case series in 17 patients. J Eur Acad Dermatol Venereol. 2016;30:1041-3. [ Links ]

3 Braun SA, Gerber PA. Ingenol mebutate for the management of genital warts in sensitive anatomic locations. J Am Acad Dermatol. 2017;77:e9-e10. [ Links ]

Received: November 05, 2017; Accepted: January 20, 2018

Mailing Address: Gerson Dellatorre. E-mail:

Conflict of interest: None.


Gerson Dellatorre


Approval of the final version of the manuscript, Design and planning of the study, Preparation and writing of the manuscript, Intellectual participation in propaedeutic and/or therapeutic conduct of studied cases, Critical review of the literature

Anarosa Barbosa Sprenger


Approval of the final version of the manuscript, Collecting, analysis and interpretation of data, Effective participation in research orientation, Intellectual participation in propaedeutic and/or therapeutic conduct of studied cases, Critical review of the literature, Critical review of the manuscript

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial License which permits unrestricted noncommercial use, distribution, and reproduction in any medium provided the original work is properly cited.