Successful Treatment of Subungual Warts With Pulsed Dye Laser: Report of Four Cases

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Journal of Cosmetic Dermatology, 2025; 24:e16756
https://doi.org/10.1111/jocd.16756
Journal of Cosmetic Dermatology
LETTER OPEN ACCESS
Successful Treatment of Subungual Warts With Pulsed Dye
Laser: Report of Four Cases
ShuangLyu1,2 | ZhenhuaYue1,2 | HuiminZhang1, 2 | Xi'anFu1,2 | HongLiu1,2 | FurenZhang1,2
1Hospital for Skin Disea ses, Shandong First Medical University, Jinan, Shandong Province, China | 2Shandong Provincial Institute of Dermatology and
Venereology, Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
Correspondence: Xi'an F u (f19830827@126.com) | Hong Liu (hongyue2519@hotmail.com)
Received: 5 November 2024 | Revised: 12 December 2024 | Accepted: 16 December 2024
Funding: This work was supported by the Central guidance for local scientific and technological development projects of Shandong Province
(YDZ X2023058), Shandong Provincial Medical and Health Development Project (202320 000621).
Keywords: laser therapy| pulsed dye laser| subungual warts
To the Editor,
Warts are caused by the human papilloma virus (HPV) and have
a considerable impact on quality of life due to pain and embar-
rassment [1]. Treatment of warts requires multiple destructive
procedures, but results are often unsatisfactory. Subungual
warts affecting the nail folds can be painful and interrupt daily
activities. Destructive treatments require disruption of the nail
plate to access the lesion, increasing the risk of injury to the sub-
ungual wedge, underlying bone, or nail matrix [2]. Finding less
invasive and painless therapies for subungual warts is a chal-
lenge for clinicians. Conventional methods include drawbacks
such as scar development, a lengthy recovery period, and a high
recurrence rate; they may also result in nail plate damage, se-
vere pain, and even nail atrophy [2]. In contrast, pulsed dye laser
(PDL) has a low incidence of pain, with only temporary pain and
residual hyperpigmentation, making it a safe, tolerable and rela-
tively effective treatment [3, 4]. We present four cases of subun-
gual warts treated with PDL.
Report of Cases
Four patients had subungual warts: one female and three males
aged 9–40. All four patients had previously undergone cryo-
therapy, which caused significant pain and was ineffective. The
patients were treated with PDL (595 nm, Candela, Israel). Cases
1–4 are presented in Table 1. Clinical pictures were collected
before and after each therapy and were followed up (Figure1).
After cessation of treatment, the lesions achieved long- term re-
mission without nail damage and did not recur during the fol-
low- up period.
Discussion
Warts have been found to respond favorably to PDL [5]. PDL's
therapeutic techniques involve the breakdown of the wart-
supplying capillaries, which results in host cell death. It can also
trigger an immunological response and cause IL- 2 and IL- 4 to
be upregulated within the lesion. Furthermore, PDL destroys
the virus itself due to its susceptibility to heat [3–5].
The type of warts, laser parameters, number of treatment ses-
sions, and treatment intervals are associated with the success
rate of PDL treatments [4, 5]. A retrospective study treating 227
warts patients with PDL found that up to 6 sessions with inter-
vals of 3–4 weeks apart and a fluence of 12.5–15.0 J/cm2 had the
best efficacy [5]. Another study showed that higher success rates
were associated with higher flow settings (9.5 J/cm2) and also an
increased number of sessions (up to 6) at 3–4 week intervals [4].
Park etal. have reported that there was no significant difference
in lesion clearance between 2- and 3- week treatment intervals
[3]. Our patient 1 was healed after just two treatments with a
one- week gap, indicating that shorter treatment intervals could
This is a n open access ar ticle under the terms of t he Creative Commons Attr ibution License, which p ermits use, dis tribution and repro duction in any medium, p rovided the orig inal work is
properly cited.
© 2025 T he Author(s). Journal of Cosm etic Dermat ology publishe d by Wiley Periodic als LLC.
Xi'an F u and Hong Liu are the joint c orresponding a uthors of this art icle.

2 of 3 Journal of Cosmetic Dermatology, 2025
be more effective and reduce the number of sessions. The mean
length of treatment in our patients was 4.1 months and the mean
number of sessions was 4.5. Notably, patient 4 received 8 treat-
ments, which may be attributed to individual differences, dis-
ease duration, and lesion thickness.
PDL appears to eliminate warts only while sparing the sur-
rounding nail plate, causing transient pain similar to that of a
rubber band snapping [6]. Our patient 4 was a 9- year- old boy
who fully tolerated the pain of PDL treatment. PDL is a relatively
safe procedure with acceptable side effects [3], produces satisfac-
tory results in cosmetically sensitive areas, and has little effect
on daily activities.
The high cost of PDL and the requirement of multiple treat-
ments may result in patients or clinicians choosing it less fre-
quently. However, due to the special location of subungual
warts, traditional cryotherapy can be affected by the nail and
significantly painful. In conclusion, PDL is an option for sub-
ungual warts, especially in children who cannot tolerate pain.
This report illustrates the advantages of PDL for the treatment
of subungual warts, provides references for treatment parame-
ters and frequency, and provides evidence on effectiveness and
safety. However, in clinical practice, attempts have been made
to combine it with other treatment modalities (e.g., superficial X-
ray therapy, photodynamic therapy or cryotherapy) to improve
efficacy and reduce recurrence rates. Further studies with larger
sample sizes are still needed.
Author Contributions
Conceived by Furen Zhang, Hong Liu and Xi'an Fu. Collected pho-
tographs by Zhenhua Yue and Huimin Zhang. Written and edited by
Shuang Lyu and Xi'an Fu.
TABLE  | Ca ses introduction.
Patient 1 2 3 4
Age (years) 25 31 40 9
Disease course 1 years 4 months 3 months 3 years
Gender F M M M
Position Left index Right index Left thumb Right thumb, middle finger
and left pointer finger
Parameters 21 J/c m2, 3 ms 21 J /cm2, 3 ms 21 J/cm 2, 3 m s 23 J/cm2, 3 ms
(energy, pulse width)
No. of sessions 2 4 4 8
Inter vala1 we ek 3– 4 weeks 4 we eks 2 we eks
Follow- up (months) 20 month s 3 months 4 months 5 months
Previous treatments (failed
therapy)
Cryotherapy Cr yotherapy Cryotherapy Cryotherapy
Adverse reaction Immediate pain Immediate pain Immediate pain Immediate pain
aInterval: time between each session of treatment.
FIGUR E  | Clinical images before PDL treatment and at f inal follow- up. Patient 1: A, G; Patient 2: B, H; Patient 3: C, I; Patient 4: Right thumb (D,
J), middle finger (E, K) and left pointer finger (F, L).

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Acknowledgments
We thank all the patients who participated and the doctors who pro-
vided cases.
Ethics Statement
Patients provide informed consent, including treatment and disclosure
of case details and images.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available on request
from the corresponding author. The data are not publicly available due
to privacy or ethical restrictions.
ShuangLyu
ZhenhuaYue
HuiminZhang
Xi’anFu
HongLiu
FurenZhang
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