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PULSED DYE LASER TREATMENT FOR RECALCITRANT VIRAL WARTS: AUTO-SIMULTANEOUS LASER TREATMENT
Abstract
Verruca vulgaris is a benign proliferative lesion of the skin caused by the human papillomavirus (HPV). It is commonly seen in dermatologic and/or plastic surgery clinics. The diagnosis is straightforward, but the treatment of the lesion may be difficult and lengthy. Several treatment methods have been reported but no specific therapy of choice has been developed. It has been suggested that pulsed dye laser treatment is highly effective in the treatment of viral warts which have not responded to other treatments. Pulsed dye laser treatment is a safe method with low side effects and is mostly well-tolerated by patients. Several authors have recently reported the efficiency of pulsed dye laser treatment for warts, but no report has paid attention to the influence of low levels of laser irradiation about the periphery of the treated lesion which may induce immune activation and pain alleviation. We believe these effects are mainly due to the athermal and atraumatic simultaneous Low reactive Level Laser Therapy effect on photobiomodulated cells at the periphery of the treated lesion. We call this coincident duality of thermal damage and athermal stimulation ‘auto-simultaneous laser treatment’. We report herein on pulse dye laser treatment for a recalcitrant huge viral wart and consider the vital response. © 2010, International Phototherapy Association. All rights reserved.
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Twenty-eight patients with 103 recalcitrant and 20 simple viral warts were treated with the Cynosure PhotoGenica V pulsed dye laser at 585 nm, and fluencies of 6.0-9.0 J/cm(2). An eradication rate of 92% for recalcitrant warts after an average of 2.1 (range 1-7) treatments and 75% for simple warts after an average of 1.6 (range 1-2) treatments was achieved with a mean follow-up period of 7.2 (range 3-15) months. Mild hypopigmentation was noted in one patient and superficial infection in another. Unlike ablative treatment modalities, with pulsed dye laser therapy, no wound was created thus avoiding prolonged postoperative pain, disability and scarring. Treatment was well tolerated by patients, most of whom returned to work or normal activities immediately postoperatively. Pulsed dye laser is an effective treatment for both recalcitrant and simple warts. It is the treatment of choice for these lesions in cosmetically sensitive areas.
Background and Objective
The objective of this study was to establish the 585nm flashlamp-pulsed tunable dye laser (PTDL) as a potentially effective modality in the treatment of plantar verrucae. Furthermore, this study attempted to identify if certain regions of the plantar surface yielded a different clearance rate in comparison to others.Study Design/Materials and Methods
Thirty-three patients were recruited for this case series study, representing a total of 97 plantar warts. Patients were treated using the flashlamp-PTDL with a pulse duration of 450 μsec, a spot diameter of 5.0 mm, and energy fluences ranging between 8.1 and 8.4 J/cm2. Patients were followed-up an average of 2–24 weeks assessing for recurrence of verrucae.ResultsEach patient exhibited one to eight plantar lesions. Of the 97 verrucae treated by the flashlamp-PTDL, 68 (70.1%) resolved with 100% clearance of the lesion. The overall mean clearance of the 97 lesions was 95.1 ± 16.5%. Of the 97 lesions treated to maximal clearance, 14 lesions recurred after a mean follow-up period of 9.0 weeks.Conclusion
Results of this study have established the 585nm flashlamp-pulsed tunable dye laser as a potentially effective modality treatment of plantar warts. Furthermore, it was determined that there was no significant difference in the clearance rate of warts located at a given plantar site when compared to the clearance rates of the other plantar sites (F3/44 = 0.58, P = 0.634). Laser Surg. Med. 21:500–505, © 1997 Wiley-Liss, Inc.
Genital warts represent benign epithelial proliferations induced by human papillomavirus. The goal of treatment is the clearance of visible warts. Different regimens are available. Flashlamp-pumped pulsed dye laser (FPDL) represents one of many treatment options for the management of viral warts (verrucae vulgares), its effectiveness being comparable with that of conventional therapies. We evaluated the effectivity of FPDL light for the treatment of genital warts.
A prospective study was performed to examine the efficacy of FPDL in untreated genital warts in which 22 patients were included.
All patients showed complete remission after 1.59 (1-5) laser sessions and no scarring was observed.
This study demonstrate that FPDL is a simple and safe, cost and time saving alternative treatment option for genital warts and should be listed in genital warts treatment guidelines.
A prospective, non-blinded, non-randomized study on 120 wart patients treated with pulsed dye laser was performed to evaluate the efficacy and safety of pulsed dye laser treatment for viral warts and to demonstrate the proper application and effective technique of this method. The overall clearance rate was 49.5%. The clearance rates of flat warts, periungual warts, plantar warts and common warts were 67.6%, 51.1%, 47.6% and 44.3%, respectively. Overall, the response rates of pediatric warts, recalcitrant warts and old warts were superior to those of adult warts, simple warts and non-old warts, respectively; however, those trends were not statistically significant. We concluded that pulsed dye laser treatment is a safe, tolerable and relatively effective treatment method for viral warts. Pulsed dye laser treatment may be a more efficacious method for flat warts and recalcitrant periungual warts, and it can be an effective modality for newly-developed warts. The highest clearance rate was noted at a fluence of 9.5 J/cm2 (P < or = 0.05) and it is recommended that practitioners perform pulsed dye laser treatments for viral warts at the fluences of 9.0-9.5 J/cm2. A replacement of pulsed dye laser treatment should be considered unless prominent improvement is observed after three treatment sessions.
Summary Four-hundred consecutive referrals with viral warts of the hands and/or feet were investigated to determine the cure rate from a combination of cryotherapy, keratolytic wart paint and paring. For treatment failures after 3 months, the value of continuing cryotherapy and of additional treatment with the immunomodulator inosine pranobex were assessed.
Subjects were treated for 3 months with wart paint and cryotherapy and were randomized to receive, or not, paring in addition. Those who did not respond by 3 months were randomized to receive, or not, 3 months further cryotherapy, and to receive inosine pranobex 60 mg/kg/day for 1 week each month, or matching placebo.
Fifty-two per cent of subjects were cured by 3 months. The chance of cure was inversely related both to the length of history and to the diameter of the largest wart. Paring improved the cure rate for plantar warts but not for hand warts. During the second 3 months the cure rate fell to 41%. Neither cryotherapy nor inosine pranobex significantly improved this response.
We measured a dermatology department's workload from wart treatment in terms of time and numbers, and we studied the use made of routine treatments according to the site of the warts and the age of the patient. Twenty-one per cent of new referrals were for warts and 19% of clinic time was used for wart treatment, 9% of clinic time was for plantar warts alone and 29.5% of new patients failed to attend. Overall cryotherapy was the commonest treatment, particularly for warts on the hands and face, 73.2% of patients treated for hand warts defaulted from follow-up and 11.3% were referred back for further treatment. The implications of the results are discussed and we argue that hospital budget holders should fund community-based wart treatment facilities.
Patients with recalcitrant warts on the fingers and hands, periungual, and other parts of the body including verrucae plana and plantar surfaces were treated using the pulsed dye laser at 585 nm, 450 usec, and a spotsize of 5 mm diameter. Of the 39 patients treated, 28 (72%) were cleared of their warts after an average of 1.68 treatments at fluences of 6.25-7.5 J/cm2. Seven (18%) patients had a reduction of between 80-95% of their warts after 1.3 treatments, and verrucae reduced by 50% in four of the 39 patients after one treatment. The average follow-up period of the 28 cases cleared of their warts has been 5 months. Of this group, those with periungual warts have been followed for up to 6.4 months, compared to 4.8 months for those with warts on other parts of their body, 4.0 months for those with finger and hand warts, and 2.0 months for plantar warts. Only one of the 28 patients has had a recurrence after 3 months of clearance.
Pulsed dye (vascular) laser therapy is effective against verrucae (warts) that have not responded to other treatments. These observations suggest that vascular laser therapy might be particularly efficacious against verrucae not previously treated. Of the thirty-two patients with verrucae in this study, nineteen had been previously treated (recalcitrant group) and thirteen had not (no prior treatment group). All warts were treated an average of 1.72 times with the Candela vascular laser at 585 nm, 8 J/cm2. Patients were treated at one- to two-month intervals. Response rates were as follows: 68 percent of the recalcitrant warts were completely cleared, and 47.1 percent of the warts with no prior treatment were completely cleared. In the recalcitrant group, 45.9 percent were treated three times, the maximum number of treatments offered. In the no prior treatment group, only 5.9 percent of warts were treated at all three laser clinics offered. Vascular laser therapy appears to be effective as therapy in the treatment of verrucae, especially those that have not been eradicated by other treatments. Patients who had received no prior treatment for their warts were less likely to proceed with therapy, but had a satisfactory clearance rate with minimal treatment.
The clinical management of verrucae vulgaris is often challenging, and no ideal treatment currently exists. Early studies suggested that pulsed-dye laser (PDL) therapy might be highly effective in the treatment of verrucae, although more recent reports have been less optimistic. Previous studies have been retrospective or have consisted of a series of patients treated with PDL alone.
Our objective was to prospectively evaluate the efficacy of PDL therapy versus conventional therapy with liquid nitrogen cryotherapy or cantharidin in the treatment of warts.
Forty healthy adult patients with verrucae were randomized to receive either PDL (585 nm) therapy or conventional therapy. All enrollees also performed home therapy. Patients were eligible for up to 4 treatment sessions at 1-month intervals. Warts were individually counted and measured at the time of each treatment session. Complete response was defined as complete absence of verrucae with the presence of dermatoglyphics, and partial response was defined as a 50% or greater reduction in wart size.
A total of 194 warts were evaluated by the conclusion of the study. Complete response was noted in an average of 70% of the warts treated with conventional therapy and in 66% of those in the PDL group; this was statistically insignificant. Partial response was observed in an average of 82% of the warts in patients treated with conventional therapy and 87% in the PDL group. Verruca vulgaris responded more readily than verruca plantaris in both treatment groups. The mean number of treatments to achieve success was similar in both groups.
The PDL is an efficacious form of therapy for verrucae, as is conventional therapy. PDL therapy should be considered among the better established approaches in the treatment of warts, although data from this trial suggest that this approach is probably not superior.
The prevalence, incidence and ecology of diseases of the skin
- A Rook
- J A Savin
- D S Wilkinson