Introduction
Verruca vulgaris, or the common wart, is a benign epidermal proliferation caused by the human papillomavirus (HPV). While many warts resolve spontaneously, a significant subset becomes recalcitrant, persisting for years and failing multiple therapeutic modalities. Standard treatments are often destructive and invasive, including cryotherapy, salicylic acid, laser ablation, and surgical excision, which can be painful, blistering, cause scarring and have high recurrence rates.1
Dextrose prolotherapy is a regenerative injection therapy involving the administration of a hyperosmolar dextrose solution to stimulate a localized inflammatory response and promote tissue healing. It is well-established in musculoskeletal medicine for treating chronic tendinopathies and osteoarthritis.2 More recently, its ability to initiate a robust inflammatory cascade has been explored in the treatment of chronic, nonhealing wounds.3 The underlying principle involves creating a controlled, acute inflammatory state that releases growth factors and cytokines, thereby leading to secondary immune response.
This same mechanism provides a strong rationale for its application in treating recalcitrant warts. Warts persist by creating a localized environment of immune tolerance.4 By injecting a hyperosmolar irritant like dextrose, it is hypothesized that this immune privilege can be disrupted, triggering a nonspecific inflammatory response that subsequently enables the host’s immune system to recognize and clear the HPV-infected cells. Here, we present a case of a large, recalcitrant common wart successfully treated with intralesional dextrose prolotherapy.
Case report
A 54-year-old immunocompetent male presented with a persistent, hyperkeratotic wart on his right extensor elbow that had been present for more than 3 years (Fig 1). The lesion measured approximately 20 mm in diameter and was subject to frequent irritation and occasional bleeding due to its location over a bony prominence. The patient had previously undergone multiple unsuccessful treatments, including 12 sessions of cryotherapy and several months of daily topical 40% salicylic acid application.
Fig 1.
Clinical images of the recalcitrant wart on the patient right elbow. Before treatment, showing a large, hyperkeratotic verruca vulgaris.
Given the recalcitrant nature of the wart and the patient’s explicit preference to avoid surgical excision due to concerns about potential scarring and impaired wound healing over a mobile joint, an alternative approach was sought. Intralesional dextrose prolotherapy was proposed as a novel treatment option. After a thorough discussion of the risks, benefits, and off-label nature of the procedure, the patient provided written informed consent.
After preparing the area with an alcohol swab, 0.5 mL of sterile 25% dextrose solution was injected directly into the base of the wart using a 30-gauge needle. The procedure was well tolerated, with the patient reporting only mild, transient discomfort. He was advised to expect a localized inflammatory response, including mild erythema and tenderness, as part of the therapeutic mechanism. The injections were repeated every 3 weeks.
Following the first session, the patient noted mild erythema and tenderness at the site, which resolved within 48 hours (Fig 2, week 3). After the second injection (Fig 3, week 6), the wart began to show visible signs of regression, with a noticeable decrease in its verrucous texture and overall bulk. By the third session (Fig 4, week 9), the lesion had flattened significantly.
Fig 2.
Clinical images of 3 weeks of follow-up.
Fig 3.
Clinical images of 6 weeks of follow-up, showing flattening of the wart.
Fig 4.
Clinical images of 9 weeks of follow-up, showing significant flattening and shrinkage of the wart.
Complete clinical resolution, with a full return of normal skin texture and no evidence of scarring, was achieved after the fourth treatment session at week 12 (Fig 5). The patient was examined at a 6-month follow-up and showed no signs of recurrence.
Fig 5.
At 12-week follow-up after 4 sessions of intralesional dextrose prolotherapy, showing complete clinical resolution with restoration of normal skin architecture.
Discussion
The therapeutic challenge of recalcitrant warts stems from HPV ability to evade host immunity by residing in the relatively immune-privileged epidermis.2 The success of intralesional immunotherapy hinges on its ability to disrupt this evasion by presenting viral antigens to the immune system.
The mechanism of action for dextrose prolotherapy in this context is believed to be multifactorial. The hyperosmolar dextrose solution acts as a potent, localized irritant, inducing osmotic stress and cellular dehydration, which is interpreted by the body as an invasion signal.5 This osmotic cell death triggers a sterile inflammatory cascade, leading to the release of proinflammatory cytokines and growth factors that recruit macrophages, lymphocytes, and antigen-presenting cells, such as Langerhans cells, to the site.2,4,5 This controlled inflammation disrupts the wart’s immune-privileged environment, facilitating the recognition of HPV antigens and initiating a secondary but effective T-cell–mediated immune response that can eliminate the HPV-infected keratinocytes.4 This can lead to clearance of the treated wart and, in some cases, a systemic response clearing distant, untreated war (author’s anecdotal experience).
This case adds to the growing evidence supporting intralesional dextrose as a viable treatment for recalcitrant warts. It is a simple, safe, and cost-effective procedure that can achieve complete resolution with an excellent cosmetic outcome, even when multiple first-line and second-line therapies have failed. Dextrose prolotherapy represents a valuable addition to the therapeutic armamentarium for difficult-to-treat verrucae, and further randomized controlled trials are warranted to establish optimal concentrations and treatment intervals.
Declaration of generative AI and AI-assisted technologies in the writing process
Generative AI was not used in the development or editing of this manuscript.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
Patient consent: The authors attest that they have obtained written consent from patient/s, their legal guardian/s or person/s with legal authority, for their photographs and medical information to be published in print and online and with the understanding that this information may be publicly available. Patient consent forms were not provided to the journal but are retained by the authors to be made available upon request.
IRB approval status: Institutional review board approval was not required for this single-patient case report.
References
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