A patient applied bleach to her verrucas after they had not responded to treatment carried out by a hospital’s dermatology team. The outcomes are discussed

Keywords Verrucae vulgaris, Dermatology, Skin sensitisation

Introduction

Plantar warts, also known as verrucae vulgaris, are a cutaneous presentation of the human papilloma virus (HPV)It is estimated that the prevalence is around 3.9 to 4.9% in children and adolescents (Cooper, 2005).

Plantar warts appear as round lesions, with defined limits and a keratotic surface, sometimes with induration and adjacent deep extension. An area of skin can become infected if it is in direct contact with a wart. (Lipke, 2006).

Several treatments are available, with an emphasis on topical agents such as salicylic acid (a keratolytic agent)trichloroacetic acid and podophyllin.

Imiquimod, an immunomodulating agent, and 5-fluorouracil, a topical cytostatic, can be applied to plantar warts. Surgical treatment, by cryosurgery, curettage or excision, is also an option.

The treatment of plantar warts is complex and uncertain, as it is often necessary to try a number of treatments by themselves or in combination.

Background

Emma (not her real name) suffered from 16 plantar warts and treated them with sanitary bleach. Within three months, almost all the lesions had disappeared. After four months, she was totally healed.

We found only sporadic and unscientific use of bleach as an alternative therapy for warts through reports of lay people in some health forums on the Internet, and this case may suggest further investigation is needed into this.

Emma, 28, suffers from chronic reactive depression and had heart surgery in infancy because of congenital heart disease.

The warts had started appearing three years previously. Sixteen plantar warts had appeared mainly on loadbearing areas of her left foot. The warts had a slightly brown, rough surface and caused pain when walking.

Treatment

The warts had not responded to treatment carried out by the hospital clinical dermatology team.

The treatments carried out were:

Salicylic acid;

Fluorouracil plus lactic acid plus salicylic acid;

Cryotherapy with liquid nitrogen;

Superficial excisional approach using minor surgery under local anesthesia in hospital environment;

Topical and systemic retinoids;

Imiquimod.

None of these treatments were successful, so the nextstage would have been surgical excision. However, the high number of warts meant that this would require extensive surgery with a prolonged recovery period.

On her own initiative, and without valid and credible scientific support, the woman began implementing topical applications of pure bleach on the lesions. Using a small brush, she applied a thin layer of bleach on the warts, as the exclusive therapy. The skin surrounding the lesions was protected with a barrier cream.

Notified in advance, our nursing department in the social center monitored this for severe skin adverse effects resulting from the use of this product.

Recovery

Under our supervision, the patient applied the bleach for three months twice a day. At the end of this period, we found 13 warts had disappeared, and the remaining three had reduced in size. All warts had disappeared totally after the fourth month.

There were no serious side effects, except mild soreness at the time of application and flushing of the limits in the vicinity of the lesions. The warts did not recur.

Discussion

The treatment of plantar warts presents various problems that make outcomes uncertain.

The treatments have two basic fronts of action: inactivating the replication of HPV; and/or destruction of infected keratinocytes.

It is likely that the use of bleach acts in the same manner as the Dakin`s solution (which is chemically analogous) by combining these two mechanisms, since this compound is active against several viruses and bacteria (Heggers, 1991) and causes debridement of cellular components (Bryant, 2007). Although 67% of warts go into spontaneous remission within two years, spontaneous remission was unlikely in this case because of the short space of time (Cooper, 2005).

The use of bleach can cause problems of skin sensitisation and local irritation. We cannot advocate its use to treat plantar warts for this reason, and because of the absence of evidence on how it can be applied safely.

These matters are particularly important in the case of diabetic patients with circulatory disorders, or when the warts are in places such as feet that are more prone to develop severe skin lesions with the use of bleach.

An alternative is to investigate the use of sodium hypochlorite 0.5% - a safer alternative to sanitary solutions of bleach. Chemically analogous to the sanitary bleach, their mode of action is similar to this product.

Conclusion

This case demonstrates that bleach can be used to treat plantar warts, following scrupulous application and monitoring.

However, the lack of evidence means that the application of bleach to treat plantar warts cannot be recommended as a safe and acceptable method for routine use in clinical practice.

Studies on sodium hypochlorite solution may show it is equally effective without the risks associated with bleach.

Author Nuno Manuel Teles Pinto is licenced in nursing and head nurse of the nursing department at the Social Community Center of São Félix da Marinha, Gaia, Oporto district, Portugal.

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Cooper J (2005) Warts, Plantar. eMedicine, Medscape.



Heggers et al (1991) Bacterial and wound-healing properties of sodium hypochlorite solutions. The 1991 Lindenberg Award. Journal of Burn Care & Rehabilitation. 1991;12, 420-424.



Lipke MM (2006) An armamentarium of warts treatments. Clinical Medicine and Research; 4: 273-293.