Title : Novel immuno-keratolytic therapy for recalcitrant verruca plana using BCG, needling, and tretinoin
Abstract:
Verruca plana, caused primarily by human papillomavirus (HPV) types 3 and 10, remains a therapeutic challenge owing to its chronicity, cosmetic implications, and resistance to conventional modalities such as cryotherapy, cauterization, and keratolytics. Recurrence and post-inflammatory dyschromia are frequent, particularly in darker skin types. With growing evidence supporting immune-based interventions, this study introduces a novel triple synergistic regimen combining topical Bacillus Calmette–Guérin (BCG), Falkner’s needling, and topical tretinoin to achieve rapid, scar-free clearance in recalcitrant verruca plana.
Objectives: To evaluate the clinical efficacy, immune-modulating response, and tolerability of a combined protocol involving topical BCG, Falkner’s needling, and topical tretinoin in patients with resistant verruca plana.
Methods: Fifteen patients (aged 17–42 years) with biopsy-confirmed verruca plana unresponsive to standard therapies (cryotherapy, salicylic acid, or imiquimod) were included. Under aseptic precautions, Falkner’s needling was performed to fragment lesions and facilitate intradermal exposure of viral antigens. Immediately post-needling, reconstituted topical BCG (derived from an intradermal vial) was applied over lesions and occluded for six hours. From the following day, patients initiated nightly topical tretinoin 0.05% for six to eight weeks to promote epidermal turnover and enhance antigen presentation. The procedure was repeated every three weeks for up to three cycles. Clinical response, dermoscopic evolution, and side effects were recorded at each visit, with follow-up for three months post-treatment to assess recurrence.
Results: Thirteen of fifteen patients (86.6%) achieved complete clearance within 8–10 weeks, while the remaining two demonstrated >75% improvement. Lesions showed progressive flattening, surface normalization, and pigment restoration. Notably, distant untreated lesions regressed concurrently, signifying systemic immune activation. Adverse effects were limited to transient erythema, mild scaling, and burning, resolving spontaneously without pigmentary sequelae. No recurrence or scarring was observed during follow-up. The therapeutic synergy of needling-induced antigen exposure, BCG-driven immune activation, and tretinoin-mediated keratolysis facilitated robust viral clearance and epidermal remodelling.
Conclusions: This triple synergistic regimen represents a ground breaking immuno-keratolytic approach in the management of recalcitrant verruca plana. It combines simplicity, safety, and cost-effectiveness with exceptional clinical outcomes and minimal downtime. The protocol’s ability to trigger both local and systemic antiviral immunity while preserving cosmetic integrity positions it as a promising alternative to conventional destructive modalities. Larger controlled studies are warranted to further substantiate its efficacy and define optimal treatment parameters.
