Bleomycin vs. 5-FU in Dermatology: Which Intralesional Agent Reigns Supreme?

🔍 Key Finding Intralesional bleomycin and 5-fluorouracil (5-FU) are effective treatments for various dermatological conditions like hypertrophic scars, warts, skin cancers, and vitiligo, with bleomycin showing slightly higher efficacy but potentially causing more pain. 5-FU offers a cheaper and less painful alternative, especially for intralesional scar treatment.

🔬 Methodology Overview

• Design: Literature review.
• Data Sources: PubMed.
• Selection Criteria: Articles published between January 1, 1980, and December 31, 2023, on the use of bleomycin and 5-fluorouracil (5-FU) in dermatology. Included studies and reviews examining bleomycin and/or 5-FU as single or combination therapies.
• Exclusion Criteria: Studies lacking objective efficacy data, reports using outdated/experimental treatments, and non-dermatological focus.
• Analysis Approach: Qualitative comparison of efficacy and safety of bleomycin and 5-FU across various dermatological conditions.
• Scope: Clinical efficacy and safety of bleomycin and 5-FU in dermatological applications including hypertrophic scar, wart, skin cancer, vascular malformation, hemangioma, and vitiligo.

📊 Results

• Intralesional Bleomycin vs. Other Treatments for Hypertrophic Scars/Keloids: Bleomycin demonstrated greater efficacy compared to triamcinolone and 5-FU.
• Intralesional Bleomycin vs. Cryotherapy for Warts: Bleomycin showed significantly higher cure rates than cryotherapy, particularly for recalcitrant warts.
• Topical 5-FU + Cryotherapy for Actinic Keratosis: This combination therapy resulted in higher clearance rates compared to cryotherapy alone. 0.5% 5-FU cream offered similar efficacy to 5% with less irritation.
• Intralesional 5-FU for Squamous Cell Carcinoma: One study reported a 92% (158/172 lesions) clinical resolution rate with intralesional 5-FU. Another case series showed a 95% (19/20 patients) clearance rate without recurrence.
• Topical/Intralesional 5-FU for Vitiligo: 5-FU, particularly when combined with microneedling or erbium:YAG laser, showed promising results in repigmentation for stable vitiligo. Intralesional 5-FU was more effective than intralesional triamcinolone (p=0.025 for face, p=0.043 for acral lesions).
• Intralesional Bleomycin for Vascular Malformations: Bleomycin sclerotherapy demonstrated efficacy in lymphatic malformations (84%) and venous malformations (87%).
• Intralesional Bleomycin vs. Triamcinolone for Hemangioma: Bleomycin was found to be more effective (87.5% excellent/good response) than triamcinolone (p=0.037) in reducing hemangioma size.

💡 Clinical Impact Intralesional bleomycin and 5-fluorouracil (5-FU) offer effective, well-tolerated treatment options for various dermatological conditions like hypertrophic scars, warts, skin cancers, and vitiligo, potentially reducing the need for surgery in some cases; 5-FU, being cheaper and less painful, may be preferred for certain indications. Further research on pain management and bleomycin’s role in skin cancer is warranted.

🤔 Limitations

• Limited data comparing the effects of bleomycin and 5-FU in dermatological disorders.
• Scarce data on the use of 5-FU for actinic keratosis with cryotherapy.
• Limited trials and case studies on the use of intralesional 5-FU for basal cell carcinoma.
• Scarce data on the use of bleomycin for squamous cell carcinoma and keratoacanthoma.
• Scarce data on the use of 5-FU and bleomycin for primary melanoma.
• Lack of studies on vitiligo treated with intralesional bleomycin.
• Scarce and outdated data regarding intralesional bleomycin for skin cancer.
• Limited research on pain reduction associated with intralesional bleomycin and 5-FU.

✨ What It Means For You This review supports the use of intralesional bleomycin and 5-FU as effective, generally safe alternatives or adjuncts to surgery for various dermatological conditions like hypertrophic scars, warts, and some skin cancers, especially in patients with surgical contraindications. While bleomycin may offer slightly higher efficacy, 5-FU presents a less painful and more affordable option, allowing clinicians to tailor treatment based on individual patient needs and lesion characteristics. Further research is needed to optimize treatment protocols and minimize injection-related pain.

Reference Kim S, Woo YR, Cho SH, Lee JD, Kim HS. Clinical Efficacy of 5-Fluorouracil and Bleomycin in Dermatology. J. Clin. Med. 2024;13:335. https://doi.org/10.3390/jcm13020335