Cytotoxic Antibiotic — Intralesional Use (Sclerotherapy) Pregnancy: Contraindicated — teratogenic at systemic doses; avoid intralesional in pregnancy.

Bleomycin (Intralesional — Keloid/Wart Treatment)

Brand names: Bleomycin Sulfate Injection

Adult dose

Dose: Keloids: 1.5 IU/mL bleomycin solution, inject 0.1–0.5 mL per cm² intralesionally; repeat every 4–6 weeks for 2–6 sessions. Warts: 1 IU/mL intralesional injection, 0.1–0.2 mL per lesion

Route: Intralesional injection (with lidocaine pre-infiltration for analgesia)

Frequency: Every 4–6 weeks (keloids); single session often sufficient for warts

Max: 1.5 IU per cm² (keloids); cumulative systemic dose limits apply if extensive use — seek oncology input

Mechanism: bleomycin causes DNA strand breaks in rapidly proliferating cells → apoptosis of fibroblasts → reduced collagen synthesis. Also scleroses blood vessels within keloids. Used as second-line treatment alongside or after triamcinolone. Combined bleomycin + triamcinolone injections increasingly used.

Paediatric dose

Route: Intralesional

Frequency: Every 4–6 weeks

Max: Same as adult dose per lesion area

Can be used in older children and adolescents for keloids under specialist dermatology/plastic surgery guidance. Local anaesthetic required. Not licensed specifically for paediatric keloid treatment.

Dose adjustments

Renal

Reduce dose if significant systemic absorption expected (large surface area treatment) — bleomycin is renally cleared. Seek oncology advice for extensive lesions.

Hepatic

No specific adjustment for intralesional use.

Clinical pearls

Combination therapy superiority: bleomycin + triamcinolone acetonide combination is superior to either alone for keloid treatment — triamcinolone reduces fibroblast proliferation and induces fibroblast apoptosis while bleomycin disrupts DNA replication. Multiple case series show >70% response rate with combination
Raynaud's caution for digit use: MHRA warning on bleomycin intralesional — Raynaud's phenomenon, digital ischaemia, and gangrene have been reported with intralesional bleomycin to fingers; do NOT inject near digital vessels; use with extreme caution in patients with vascular disease or smoking history
Wart treatment evidence: intralesional bleomycin (1 IU/mL, 0.1–0.2 mL per wart) is highly effective for recalcitrant plantar warts resistant to salicylic acid, cryotherapy, and other treatments — response rates of 70–90% reported; single treatment often curative

Contraindications

Pulmonary fibrosis or pre-existing lung disease (bleomycin pulmonary toxicity — even with minimal systemic absorption from intralesional use in susceptible patients)
Hypersensitivity to bleomycin
Pregnancy (teratogenic at systemic doses — avoid)
Renal failure (eGFR <30 — reduced clearance)

Side effects

Pain at injection site (significant — local anaesthetic pre-treatment mandatory)
Raynaud's phenomenon (digit injections — cold sensitivity, digital ischaemia; MHRA warning)
Hyperpigmentation at injection site
Tissue necrosis (if incorrectly placed or overdosed)
Pulmonary toxicity (rare from intralesional but possible with repeated large-dose use)

Interactions

Other bleomycin (cumulative pulmonary toxicity risk — document all prior bleomycin exposure)
Cisplatin (reduces renal clearance — increases systemic bleomycin levels; oncology input needed if extensive use)

Monitoring

Local tissue response (necrosis, hyperpigmentation)
Digital vascularity (Raynaud's signs — if injecting near digits)
Pulmonary function (rare but required if multiple sessions with large surface area)
Scar/keloid dimensions and texture (treatment response)

Reference: BNFc; BNF 90; Naeini et al. Dermatol Surg 2006 (bleomycin keloids); MHRA SPC Bleomycin Injection; BBA Scar Management Guidelines 2019. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators