JRSM >
Volume 97, Number 4 >
Pp. 180
Department of Orthopaedics, Guy's & St Thomas' Hospitals, London, UK
Correspondence to: Mr A Tavakkolizadeh, 44 Shooters Hill Road, London SE3 7BG,
UK
E-mail:
tavak{at}globalnet.co.uk
Warts are commonly treated with topical salicyclic acid—a safe and effective method in adults.1,2 But the instructions must be followed with some care.
CASE HISTORY
A man of 45 sought advice after two weeks of increasing pain and swelling in the left hand. The symptoms had begun after use of a topical 12% salicylic acid preparation (Bazuka, Dendron Ltd, UK) to treat a wart on the palm of his left hand. Before starting the treatment he had shaved the wart, originally about 0.5 cm in diameter and a few millimetres thick, down to its base with a scalpel, without causing any bleeding. For a week he had then applied Bazuka in large quantities two or three times daily—effectively in twice the recommended dosage—without a covering dressing. When the area around the wart became painful and swollen, his general practitioner prescribed antibiotics. After ten days of taking these without benefit he attended the accident and emergency department.
On examination he had a healed wart on the ulnar border of the palm with an associated collection mostly on the lateral aspect, fluctuant and non-tender without surrounding cellulitis (Figure 1). The white cell count was normal but C-reactive protein was raised at 10 mg/L. Intravenous antibiotics (benzylpenicillin, flucloxacillin, metronidazole) were started and the next day the lesion was incised and drained (yielding about 15 mL), with muscle debridement to remove the superficial necrotic layer. The wound was dressed with betadine-soaked cotton gauze twice daily over the next seven days. Histological and microbiological analyses showed chronic inflammation without infection. Within 48 hours after the debridement the C-reactive protein was normal. When the wound was confirmed to be clean, a split skin graft was applied to the defect, which measured 50 x 35 mm. The patient was in hospital for a total of two weeks and returned to normal work six weeks after admission.
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COMMENT
We have not found any report of such a severe reaction to a salicylic acid preparation used for treatment of warts. Heng et al.,3 however, recorded an episode of deep-seated inflammation in the hypothenar eminence in a patient who had used a topical methylsalicylate/menthol product for muscular pain. Salicylates can be absorbed percutaneously from such preparations,4 and damage to skin can increase local and systemic concentrations.5,6 In the present case the severe chemical reaction seems to have been due to overzealous application, contrary to the manufacturer's instructions.
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