Carbon dioxide laser-treatment of resistant verrucae vulgaris: retrospective analysis

Evaluation of combined treatment with Er:YAG laser and long-pulsed Nd:YAG laser for the treatment of recalcitrant warts: A prospective randomized controlled trial

BACKGROUND

Viral warts are common infectious skin disease induced by human papillomavirus (HPV). Lasers have been used for warts treatment in recent years with variable success rates.

OBJECTIVE

This study aimed to prospectively evaluate combined treatment with Er:YAG laser and long-pulsed Nd:YAG laser compared to Er:YAG laser for the treatment of recalcitrant warts after one session.

MATERIALS AND METHODS

This study included 240 lesions from 24 patients. All the lesions were diagnosed clinically as recalcitrant warts after failure of topical treatment and cryotherapy. About 120 lesions underwent a combined therapy of Er:YAG and long-pulsed (LP) Nd:YAG lasers, and the remaining 120 lesions underwent Er:YAG laser therapy only. The clearance rate was evaluated 5 weeks after and classified by three-graded evaluation: complete response, partial response and poor response.

RESULTS

The clearance rate in the combined Er:YAG + LP Nd:YAG lasers group was, statistically significant, higher than that of the Er:YAG laser group (p = 0.008). The complete response rate was 48% (58 of 120 warts) for the Er:YAG +LP Nd:YAG lasers group and only 29% (35 of 120 warts) for the Er:YAG laser group.

CONCLUSION

The combination of Er:YAG and long-pulsed Nd:YAG lasers is more effective than Er:YAG laser alone in treating recalcitrant warts after single session.

A comprehensive review of treatment options for recalcitrant nongenital cutaneous warts

Introduction: The treatment of recalcitrant nongenital cutaneous warts has always been challenging for dermatologists as they often recur and relapse. Multiple treatment options have been investigated to improve the outcome. This review provides an overview of the current treatment modalities and summarizes the efficacy and side effects of each treatment option for recalcitrant nongenital cutaneous warts.Methods: A PubMed search was performed through July 2019 to include all English language reports investigating the treatment for recalcitrant nongenital cutaneous warts, regardless of design.Results: A total of 144 studies were included in this review. The treatment options for recalcitrant nongenital cutaneous warts can be divided into three groups: destructive treatment, immunotherapy, and cytotoxic agents. Although both destructive therapies and cytotoxic agents demonstrated high complete response rates, immunotherapy, which is a minimally invasive method, was superior in terms of the clearance of distant warts. Intralesional mumps-measles-rubella injections and purified protein derivatives currently demonstrate high efficacy with well-established clinical evidence.Conclusions: Many upcoming treatment modalities, especially immunotherapy, are promising. However, more comparative studies are required to verify the efficacy and safety profile.

Cryotherapy versus CO2 laser in the treatment of plantar warts: a randomized controlled trial

Background

Warts are one of the most common infections in humans. Plantar warts are a subtype of non-genital warts, and several procedures and topical treatments have been used in its treatment. Cryotherapy is one of the most popular modalities, but it is time-consuming and remission rates vary in different studies. CO₂ laser was the first laser used for treating warts. To date, no clinical trial has been done to compare CO₂ laser with cryotherapy in the treatment of plantar warts.

Patients and Methods

This randomized controlled trial was performed in order to compare the efficacy and number of sessions needed to treat plantar warts in 60 patients who had received no previous treatment in the previous 3 months. They were randomly allocated to the cryotherapy or CO₂ laser group. The number of sessions needed for response and the recurrence rate after a 3-month follow-up was compared in the 2 groups.

Results

Sixty patients with plantar warts were randomly allocated to either the CO₂ laser or cryotherapy groups. Median age was 25 (range=18–53) and 27 (range= 18–75) years in the cryotherapy group and CO₂ laser groups, respectively. Both groups were matched for age and sex (56% male and 44% female in the cryotherapy group and 34% male and 66% female in the CO₂ laser group). The median number of sessions needed for complete resolution of the warts in the CO₂ laser and cryotherapy groups were 1 (range=1–2) and 3 (range=1–12), respectively. The difference in the number of sessions was statistically significant between the 2 groups (P-value≤0.001). Recurrence rates after a 3-month follow-up was not statistically significant (P-value= 0.069).

Conclusion

The number of sessions needed to treat plantar warts was less using CO₂ laser than cryotherapy; therefore, this modality can be a good addition to the already existing anti-wart armamentarium.

T* reatment of vulgar and plantar warts

The article presents data on clinical forms of warts associated with different types of human papillomavirus. The authors analyze the following wart treatment methods: excision, chemical and immune. Based on literature sources, the authors assess the efficacy, advantages and disadvantages of well-known treatment methods. The authors describe their own experience of treating primary and recurrent vulgar and plantar warts with an up-to-date chemical destruction drug - Mardil Zinc Max, a solution containing a complex compound of 1.5% zinc 2-chloropropionate in 2-chloropropionic acid. The efficacy of treatment of vulgar warts was 100%, and that of plantar ones - 62.5%. Clinical recovery was observed both in case of primary and recurrent processes. The treatment had no adverse effects or complications and was characterized by a low injury rate, good tolerance and full tissue recovery without any cosmetic defects.

Imiquimod in the treatment of cutaneous warts: an evidence-based review

INTRODUCTION

Cutaneous warts are highly prevalent lesions caused by the infection of keratinocytes by different types of human papillomaviruses. Although cutaneous warts are capable of resolving spontaneously, these infections can persist for long periods of time by evading the host immune system, and, as a result, many patients choose to seek treatment. Imiquimod is an immune response modifier that is approved as a topical cream for the treatment of anogenital warts by the US Food and Drug Administration. However, the efficacy of imiquimod in the treatment of cutaneous warts has not been well established.

OBJECTIVE

The purpose of this article is to systematically review the published literature regarding the efficacy of imiquimod in the treatment of cutaneous warts, and to evaluate the quality and outcomes of these studies.

METHODS

A literature search was performed through clinical queries PubMed (National Library of Medicine) database and the Cochrane database. All completed studies written in English and published through May 2014 were considered. Studies evaluating the use of imiquimod for anogenital warts were excluded. There were no other restrictions based on patient age, sex, ethnicity, or skin type. The studies were evaluated and assessed based on study design, patient population, treatment regimen, clinical outcome, and adverse events.

RESULTS

A total of 393 records were identified in the initial search; 23 full-text articles were assessed for eligibility and included in the review. Of these studies, six publications reported on immunocompromised individuals only. The highest quality study identified was a grade B, level 3 case-control cohort study in which patients with multiple warts had certain warts treated with imiquimod and others left untreated to serve as a control. The remaining studies identified were level 4 non-controlled case series (grade C) and level 5 case reports (grade D). In immunocompetent patients enrolled in non-controlled studies, the combined rate of patients achieving complete response to therapy was 44%, ranging from 27 to 89%. However, there was variation in the dose frequency and application among these studies. In immunosuppressed patients, two studies and four case reports were identified. Clinical improvement was seen in 33-50% of patients, with no patients experiencing complete clinical clearance.

CONCLUSION

There have been several studies demonstrating the successful use of imiquimod to treat recalcitrant cutaneous warts, either alone or as combination therapy. However, these studies are limited in number, include small populations, and are non-controlled. Further studies are needed to determine the efficacy of imiquimod, dose frequency and application, and optimal combination with other therapeutic measures such as paring, salicylic acid, or other destructive procedures.

The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology

BACKGROUND

Tremendous advances have been made in the medical application of the laser in the past few decades. Many diseases in the dermatological field are now indications for laser treatment that qualify for reimbursement by many national health insurance systems. Among laser types, the carbon dioxide (CO2) laser remains an important system for the dermatologist.

RATIONALE

The lasers used in photosurgery have wavelengths that differ according to their intended use and are of various types, but the CO2 laser is one of the most widely used lasers in the dermatology field. With its wavelength in the mid-infrared at 10,600 nm, CO2 laser energy is wellabsorbed in water. As skin contains a very high water percentage, this makes the CO2 laser ideal for precise, safe ablation with good hemostasis. In addition to its efficacy in ablating benign raised lesions, the CO2 laser has been reported to be effective in the field of esthetic dermatology in the revision of acne scars as well as in photorejuvenation. With the addition of fractionation of the beam of energy into myriad microbeams, the fractional CO2 laser has offered a bridge between the frankly full ablative indications and the nonablative skin rejuvenation systems of the 2000s in the rejuvenation of photoaged skin on and off the face.

CONCLUSIONS

The CO2 laser remains an efficient, precise and safe system for the dermatologist. Technological advances in CO2 laser construction have meant smaller spot sizes and greater precision for laser surgery, and more flexibility in tip sizes and protocols for fractional CO2 laser treatment. The range of dermatological applications of the CO2 laser is expected to continue to increase in the future.

Thermotherapy in dermatologic infections

The use of local induced hyperthermia or thermotherapy for dermatologic infections has not been fully explored in the more recent medical literature. Herein, we discuss the rationale behind the use of thermotherapy and review reported clinical experience with its use in the management of cutaneous infections.

Er:YAG Laser Ablation of Plantar Verrucae with Red LED Therapy–Assisted Healing

OBJECTIVE

The aim of this study was to evaluate Er:YAG ablation of plantar verrucae with red light-emitting diode (LED) therapy to assist healing.

BACKGROUND DATA

Successful removal of troublesome plantar verrucae still presents problems, particularly regarding complete removal and pain both postoperatively and during healing. A further problem is a high recurrence rate due to the aggressive viral dissemination associated with this kind of wart.

METHODS

Over 2 years, the author treated 121 plantar warts under local anesthesia in 58 patients with Er:YAG laser ablation followed by red LED therapy to assist wound healing. The Er:YAG laser (96 J/cm2, 2.0 J/pulse, 350 microsec pulsewidth, 2-mm collimated handpiece) is used first to ablate precisely the verrucous tissue until normal architecture is seen. Immediately after treatment, a red LED therapy system is applied (633 nm, 20 min, 96 J/cm2) to the wound and surrounding area. LED therapy at the same parameters is repeated on postoperative days 2, 6, and 10. A representative plantar verruca case is presented.

RESULTS

The Er:YAG laser precisely and cleanly ablates the plantar verrucae with clear margins into normal skin architecture, exhibiting minimal secondary thermal damage. After the first treatment session, patients are usually able to walk normally without any pain, even those who have bilateral verrucae, and no exudate is usually seen from postoperative day 2 on. By postoperative day 6, the wounds have shrunk noticeably and are filled with healthy granulation tissue, and by day 15 they are usually completely healed, with minimal scarring. At the 12-month follow-up, recurrence rates have been less than 6% (3/58 patients).

CONCLUSION

From the author's experience in 121 cases, the Er:YAG laser is ideally suited for precise and speedy ablation of plantar verrucae with minimal thermal damage to surrounding tissue, which, when coupled with visible red LED therapy, has given excellent, accelerated, and pain-free healing in these difficult-to-treat and slow-to-heal lesions with very low recurrence rates.

Anecdotal reports of 3 cases illustrating a spectrum of resistant common warts treated with cryotherapy followed by topical imiquimod and salicylic acid

Imiquimod is an immunomodulator with indirect antiproliferative and antiviral properties known to be effective against anogenital warts. However, its use for common warts has not been validated in prospective, controlled trials. We present 3 anecdotal case reports illustrating one treatment approach for a spectrum of resistant, common warts with combination therapy consisting of cryosurgery followed by administration of imiquimod and salicylic acid. The efficacy of this combined destructive and immunomodulatory therapy proved to be 50% to 100% effective after 6 to 9 weeks.

Treatment of common warts and actinic keratoses by Er:YAG laser

BACKGROUND AND OBJECTIVES

The use of ablative lasers in the treatment of common warts and precancerous actinic keratoses has been reported in the literature, showing variable response rates and relapse rates. The erbium:YAG laser (Er:YAG) with a wavelength of 2.94 microm allows precise ablation avoiding strong inflammation. The authors have evaluated the potential benefits of Er:YAG laser treatment for difficult-to-treat warts and actinic keratoses.

PATIENTS AND METHODS

A total of 69 patients with difficult-to-treat warts (periungual or plantar) with a mean age of 30.1 +/- 16.1 years (range 11-58 years), and 29 patients with actinic keratoses with a mean age of 73.5 +/- 9.7 years (range 58-90 years) were treated by Er:YAG laser. Ablative therapy was performed with a spot size of 3 mm, a frequency between 8 Hz and 15 Hz, and a fluence of 5.7-11.3 J cm(-2) (warts) or 5.7-7.1 J cm(-2) (actinic keratoses).

RESULTS

After a single laser treatment a complete response (CR) was observed in 50 patients with warts (72.5%). Plantar warts were more resistant (13.5% non-responder) compared with periungual warts (5.9% non-responder). Twelve patients with a CR showed a relapse within 3 months after treatment (24.0%). All but one suffered from plantar warts. Twenty-six patients with actinic keratoses showed a CR after a single laser treatment, and in three patients a partial response (PR) was achieved. None of the patients treated with Er:YAG laser developed pigment changes, wound infections or scarring.

CONCLUSION

Treatment of common epithelial lesions such as common warts or actinic keratoses by Er:YAG laser is safe and effective. In patients with plantar warts, however, a significant rate of relapse may occur, requiring additional therapy.

Guidelines for the management of cutaneous warts

These guidelines for the management of cutaneous warts have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.