verruca vulgaris is caused by a human papillomavirus ( hpv ) infection of the epidermis . verruca in the external auditory canal ( eac ) has rarely been reported . a previous case report introduced surgical excision for verruca treatment because there was no available nonsurgical treatment for verruca in the eac . we present a case of verruca in both eacs that was successfully treated with intralesional bleomycin injection . a 32-year - old male patient presented with ear fullness and palpable lumps in both eacs . the lumps were identified 18 months prior to the examination and the patient indicated that the lumps appeared to be getting larger . otoscopic examination revealed multiple pinkish , papillomatous masses that filled both of his eacs ( fig . however , we performed intralesional bleomycin injection , which is a simple and effective method for treatment of verruca vulgaris on the hands , feet or face . bleomycin was diluted with 1% lidocaine to make a 1-u / ml bleomycin solution . a 1-ml syringe with a 30-gauge needle the bleomycin solution was injected twice ; 0.5 ml at the first injection and 0.2 ml at the second injection one month later . one month after first injection , the verruca decreased to approximately one - third of the initial size ( fig . two months after the second injections , the verruca was not observed and there was no scarring or necrosis ( fig . eight months after the second injection , the patient confirmed that there was no recurrence . verruca vulgaris is caused by an hpv infection , and there are over 100 human papilloma dna viruses that belong to the dna papovaviridae family . histopathological examination is used for a definitive diagnosis , and revealed characteristic features of hyperkeratosis , papillomatosis , parakeratosis , acanthosis , and koilocytosis . it is associated with low - risk hpv infections ( types 6 and 11 ) that often result in a benign clinical course with no recurrence or malignant transformation . eac infections are thought to be associated with a history of repeated manipulation using the finger tips or ear picking tools . in addition , it has been suggested that the hair follicles may serve as possible reservoirs . eac verruca causes mechanical obstruction which can lead to pressure necrosis of the adjacent bone or conductive hearing impairments , although tympanic membrane involvement is seldom reported . there are currently several methods to treat verruca , which include topical treatments , cryotherapy , immunotherapy , photodynamic therapy , laser therapy , curettage and cautery , radiation therapy , surgical excision and intralesional bleomycin injections . a case report introduced surgical excision of verruca in the eac as the preferred treatment because of difficulty to apply nonsurgical treatment such cryotherapy , photodynamic therapy or laser therapy . however , the most common complication associated with surgical excision is the possibility of scarring and subsequent eac stenosis . intralesional bleomycin injections have been used to treat verruca on the hands , forearm , feet and face . bleomycin was originally isolated from the fungus , streptomyces verticillus , and is frequently used as an antitumor agent . bleomycin blocks the cell cycle at g2 , cleaves single - stranded and double - stranded dna and degrades cellular rnas ; it also forms a complex with metal ions , which reduce oxygen to free radicals . other possible underlying mechanisms are endothelial damage , which induce tumor necrosis factor , hemorrhage of subepidermis and intraepidermis , and the appearance of apoptotic cells . the cytotoxic effect and uptake of bleomycin is increased by mixing drug with local anesthetics because local anesthetics disrupt the cell membrane structure . after bleomycin intralesional injection , verruca on the hands and feet has exhibited hemorrhagic black eschars which suggest adequate bleomycin infiltration . eschar formation is thought to be caused by absolutely decreased blood flow , necrosis , and subsequent detachment of the lesion . however , verruca on the face indicated that the verruca gradually shrank after injection , and disappeared without eschar formation . we thought that the blood supply is decreased after injection but not completely interrupted because of rich and large dermal capillaries of the face . incomplete blockage of blood flow may not cause hemorrhagic necrosis , eschar formation and consequential verruca detachment . induction of endothelial and keratinocyte apoptosis by direct or indirect damage may be result in verruca shrinkage without necrosis or eschar . its clinical course was similar to one of verruca on the face . in conclusion , we present a case of large and multiple verruca in both eacs that was successfully treated with twice intralesional bleomycin injections at one - month interval . an intralesional bleomycin injection is simple , easy to apply without any difficulty and limitation , and had a high degree of patient satisfaction for treatment of verruca in the eac . we propose that it may be an effective , first - line treatment of verruca in the eac .