Pulsed dye laser treatment of recalcitrant verrucae: a preliminary report

Energy-Based Devices for the Treatment of Cutaneous Verrucae: A Systematic Review

BACKGROUND

Warts are one of the most common benign neoplasms caused by human papillomavirus infection and often pose a therapeutic challenge.

OBJECTIVE

To summarize the current evidence on the safety and efficacy of laser and energy-based devices for the treatment of cutaneous verrucae.

METHODS

A comprehensive systematic review of the literature on laser and energy-based devices for the treatment of cutaneous verrucae was performed.

RESULTS

A total of 904 unique studies were identified, of which 109 were included in this review. The most commonly used lasers as a single treatment modality for verrucae included the long-pulsed Nd:Yag (n = 20) and pulsed dye (n = 18) lasers. Other modalities included the CO2 ablative laser (n = 10), photodynamic therapy (n = 11), local hyperthermia (n = 11), microwave therapy (n = 2), and nanopulse stimulation (n = 1). Other studies combined energy-based modalities with additional treatments, such as retinoids, imiquimod, and intralesional bleomycin. Overall, such devices were generally well-tolerated, with only a mild side effect profile.

CONCLUSION

Overall, the use of laser and energy-based devices is a safe and well-tolerated option for cutaneous verrucae that is relatively less invasive than surgical interventions. Future studies using more consistent outcome assessment tools will be valuable to help clinicians develop device-specific protocols and treatment regimens to ensure replicable and effective outcomes.

Photodynamic Therapy Combined with Liquid Nitrogen Cryotherapy and Curettage for the Treatment of Recalcitrant Periungual and Subungual Warts: Clinical Experience and Literature Review

Warts are caused by human papillomavirus (HPV) infection and can involve multiple parts of skin and mucosa, of which periungual and subungual warts are the most difficult to treat. Periungual or subungual wart is verruca vulgaris growing around or under the fingernail, destroying and deforming the nail and nail bed. Currently, liquid nitrogen cryotherapy and CO2 laser are often used for the treatment. Clinically, few doctors routinely use photodynamic therapy (PDT) to treat viral warts. We used PDT combined with liquid nitrogen cryotherapy and curettage to successfully treat a case of intractable periungual and subungual warts.

Dual-wavelength long-pulsed 755-nm alexandrite/1,064-nm Nd:YAG laser versus Nd:YAG alone for treatment of palmoplantar verruca

We compared the effectiveness and safety of the long-pulsed neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser alone and combined with a 755-nm alexandrite laser for treating palmoplantar warts. We divided patients into two groups to receive up to four monthly treatments with Nd:YAG alone (single-wavelength) or combined with the alexandrite laser (dual-wavelength). We assessed treatment responses (according to clearance rate), vascular/hyperkeratosis grades, and patient satisfaction and pain ratings. The differences in treatment response (p = .348), patient satisfaction (p = .560), and pain ratings (p = .728) between the groups were not significant. The single- and dual-wavelength treatment options were equally effective in treating recalcitrant palmoplantar warts.

Efficacy of the Treatment of Plantar Warts Using 1064 nm Laser and Cooling

Cutaneous plantar warts may be treated using several optional methods, with the use of laser surgery having increased in the last few years. This work examined the efficacy of laser treatment combined with simple cooling to reduce pain. The cure rate was approximately 84%. There were no significant differences in the efficacy of treatment for different viral genotypes. The laser parameters were 500 msec pulses, 30 W of power, and a fluence of 212 J/cm² delivered in up to four sessions. Successful treatment was achieved after an average of 3.6 sessions.

Photodynamic therapy using methylene blue and intense pulsed light versus intense pulsed light alone in treatment of verruca: A randomized controlled study

BACKGROUND

Many therapeutic modalities are available for treatment of warts, but no single therapy is universally effective. Photodynamic therapy (PDT) using intralesional methylene blue (MB) followed by intense pulsed light (IPL) could be a successful option for treatment by several mechanisms.

METHODS

This prospective randomized controlled trial was carried out on eighty patients with verrucae. Patients were randomized into three groups; group A (30 patients) received MB/IPL/PDT sessions, group B (30 Patients) received IPL sessions, and group C (control). Response was assessed by clinical and dermoscopy score (0,1, 2, or 3 according to extent of clinical and dermoscopic resolution), cure rate (percent of verrucae clinically and dermoscopy cleared), and imageJ analysis (surface area of wart and haemorrhagic structures or vessels).

RESULTS

Clinical and dermoscopic clearance was achieved in 43.3% and 20% of patients in groups A and B respectively. Cure rate was 40.9% for group A compared to 23.4% for group B. ImageJ analysis revealed more reduction of surface area in group A being 80.05 ± 27.12% for verrucae and 89.28 ± 19.19% for vessels and haemorrhagic dots compared to 48.16 ± 34.21% and 65.99 ± 30.58% in group B.

CONCLUSIONS

MB/IPL/PDT is an effective option for treatment of warts with a success rate of around 40%, based on clinical and dermoscopic assessment. The efficacy was found to be higher on using imageJ utilizing both the surface area of the wart and surface area of vessels and haemorrhagic dots with the latter being more effected by treatment.

Histologic effect of the potassium-titanyl phosphorous laser on laryngeal papilloma

Objectives

Tissue effects occurring with potassium‐titanyl phosphorous (KTP) laser treatment are difficult to quantify due to the multiple variables that affect not only the fluence (energy delivered) but also the laser–tissue interaction. This histopathologic analysis of recurrent respiratory papilloma (RRP) removed after treatment with KTP laser therapy permits correlation of histologic effect with method of laser treatment.

Methods

The histopathology of RRP resected specimens in a single patient was compared following treatment with KTP laser in contact and non‐contact modes as documented with intraoperative photography and video imaging.

Results

Epithelial‐sparing injury selective to the microvasculature was identified on histopathologic assessment of a specimen treated with noncontact angiolysis. Highly cauterized papillomatous epithelium without identifiable vascular structures was identified on tissue removed after treatment with the KTP laser in contact mode.

Conclusion

The histopathologic assessment of acute KTP laser effect on papilloma permits correlation between technique of application and tissue effect. Similar assessments may be helpful to modify dosimetry for individual patients requiring repeated treatment and may also assist in refining the development of existing KTP laser treatment classification systems.

Level of Evidence

4

Quadrivalent human papilloma virus vaccine for the treatment of multiple warts: a retrospective analysis of 30 patients

Background: Various therapeutic modalities have been implemented for wart treatment, with limited efficacy. Recently, resistant warts treated using quadrivalent human papilloma virus (HPV) vaccine have been reported, although original articles on the efficacy of quadrivalent HPV vaccine on warts are rare. Objective: We performed the present study to evaluate the efficacy of quadrivalent HPV vaccine in the treatment of multiple warts. Methods: We retrospectively reviewed 30 patients from our centers. Patient demographics, clinical features such as duration of disease, number and location of lesions, therapeutic response, and adverse reactions were assessed. Results: Regarding therapeutic response, 14 patients (46.67%) showed "Complete response", 5 (16.67%) showed "Partial response", and 11 (36.67%) showed "No response". There were no statistically significant differences in sex, age, disease duration, and lesion number and location between the three groups divided by treatment response. No severe adverse events after quadrivalent HPV vaccination were noted. Conclusion: The advantage of quadrivalent HPV vaccine in the treatment of warts is that it is more convenient and less painful. HPV vaccine might be a good alternative to conventional destructive methods for incompetent cases such as those including multiple warts, dangerous lesion locations, and uncooperative patients.

Noninvasive real-time characterization of non-melanoma skin cancers with handheld optoacoustic probes

Currently, imaging technologies that enable dermsurgeons to visualize non-melanoma skin cancers (NMSC) in vivo preoperatively are lacking, resulting in excessive or incomplete removal. Multispectral optoacoustic tomography (MSOT) is a volumetric imaging tool to differentiate tissue chromophores and exogenous contrast agents, based on differences in their spectral signatures and used for high-resolution imaging of functional and molecular contrast at centimeter scale depth. We performed MSOT imaging with two- and three-dimensional handheld scanners on 21 Asian patients with NMSC. The tumors and their oxygenation parameters could be distinguished from normal skin endogenously. The lesion dimensions and depths were extracted from the spectral melanin component with three-dimensional spatial resolution up to 80 μm. The intraclass correlation coefficient correlating tumor dimension measurements between MSOT and ex vivo histology of excised tumors, showed good correlation. Real-time 3D imaging was found to provide information on lesion morphology and its underlying neovasculature, indicators of the tumor's aggressiveness.

Pulsed Dye Laser Therapy in the Treatment of Warts: A Review of the Literature

BACKGROUND

Warts or verrucae vulgaris are common cutaneous infections with currently no definitive curative treatments available.

OBJECTIVE

To determine the efficacy of pulsed dye laser (PDL) in the treatment of warts.

MATERIALS AND METHODS

A literature search was performed using the PubMed and MEDLINE databases. A search using {(Wart[s], verruca or condylomata)} AND [(Pulsed dye laser)] was used. Forty-four articles were identified as relevant to this review.

RESULTS

Simple warts were very responsive to PDL, being treated successfully in over 95% of patients. Facial and anogenital warts also demonstrated excellent outcomes. Recalcitrant warts, displayed significant variability in their response, ranging between 50% and 100% across all articles. The response rates seen in peripheral warts (involving the hands and feet) were also very variable, ranging between 48% and 95%. Recurrence rates at 4 months of follow-up were documented as 0% to 15%. Complications have been described as very few and rare, the main ones being topical discomfort and erythema.

CONCLUSION

Pulsed dye laser is a safe and effective modality in the treatment of warts that can be applied to most body parts. Cost and availability remain a limitation to the use of PDL; however, this modality can be used when other more traditional and accessible treatments have failed.

Safety and Efficacy of Intralesional Vitamin D3 in Cutaneous Warts: An Open Uncontrolled Trial

Background:

Cutaneous warts are treated primarily with destructive methods such as cryotherapy or electrocautery. These modalities of treatment are time-consuming and may be associated with scarring in multiple warts. Immunotherapy is emerging as a new modality of treatment which acts on enhancing cell-mediated immunity against human papillomavirus for clearance of both treated and distant warts.

Aims:

This study aims to evaluate the safety and efficacy of intralesional Vitamin D3 for the treatment of cutaneous warts.

Materials and Methods:

Patients with multiple warts were selected for immunotherapy. Vitamin D3 (0.2 ml, 15 mg/ml) was injected to the base of warts after injecting with lignocaine (0.2 ml, 20 mg/ml). The injections were repeated 2 weeks apart for a maximum of 4 sessions or until complete clearance, whichever was earlier. A maximum of 2 warts were treated per session and patients were followed up for 6 months after the last injection.

Results:

Forty-two patients with multiple warts were recruited for the study who completed the 6-month follow-up period and were available for analysis. Of these, 23 had palmoplantar warts, 18 had verruca vulgaris and 1 patient had filiform wart. In total, 33 of 42 patients (78.57%) showed complete response, 6 patients (14.28%) showed moderate response and three patients (7.14%) showed mild response. Recurrence was observed in one patient with the palmoplantar wart. No serious adverse effects were reported.

Limitations:

Lack of control group was the main drawback in our study.

Conclusion:

Intralesional Vitamin D3 is safe and effective for treatment of multiple cutaneous warts.

Office-based Management of Recurrent Respiratory Papilloma

This review will highlight the indications and benefits of office-based therapy for recurrent respiratory papillomatosis (RRP) and discuss the utilization of photo-dynamic lasers and adjuvant medical therapy in office-based settings. Office-based management of RRP allows for more timely interventions, is preferred by the majority of patients, and negates the risk of general anesthesia. Current literature argues for the utilization of KTP laser over CO₂ laser for office-based treatment of RRP. Medical therapies for RRP are limited, but agents such as bevacizumab are promising and have been shown to reduce disease burden. Medical therapies that can induce disease remission are still needed. Office-based procedures save time and healthcare expenses compared to like procedures in the operating room. However, the increased frequency for office-based procedures predicts similar overall healthcare costs for office-based and OR laser excision of RRP. Office-based management of RRP is a feasible and well-tolerated strategy in appropriately selected patients with adequate local anesthesia.

The role of lasers and intense pulsed light technology in dermatology

The role of light-based technologies in dermatology has expanded dramatically in recent years. Lasers and intense pulsed light have been used to safely and effectively treat a diverse array of cutaneous conditions, including vascular and pigmented lesions, tattoos, scars, and undesired hair, while also providing extensive therapeutic options for cosmetic rejuvenation and other dermatologic conditions. Dermatologic laser procedures are becoming increasingly popular worldwide, and demand for them has fueled new innovations and clinical applications. These systems continue to evolve and provide enhanced therapeutic outcomes with improved safety profiles. This review highlights the important roles and varied clinical applications that lasers and intense pulsed light play in the dermatologic practice.

Immunotherapy with intralesional Candida albicans antigen in resistant or recurrent warts: a study

BACKGROUND

Warts are sometimes resistant or they tend to recur after every possible destructive therapy. Immunotherapy with skin-test antigens has been used as a viable therapeutic option in such recalcitrant cases.

AIM

The aim of the study was to evaluate the response of resistant or recurrent warts to intralesional Candida albicans antigen immunotherapy.

MATERIALS AND METHODS

A total of 40 patients with resistant or recurrent warts who showed a positive test reaction to C. albicans antigen were given intralesional injections of purified C. albicans antigen solution in a single wart at 3-weekly intervals for a total of three doses. The patients were monitored for resolution of the injected wart as well as other untreated warts. The patients who responded positively were then followed up for any relapses over the next 6 months. Adverse events, if any, were also documented.

RESULTS

Of the 40 patients enrolled in the study, 34 completed the total treatment protocol of three injections and 6 months of follow-up. In these 34 patients, 19 (56%) showed a complete resolution of warts at all places on the body. In addition, two patients (6%) showed a partial or complete resolution of the treated wart, but there was no effect on the untreated warts. Thirteenpatients (38%) failed to show any response to the treatment regimen. In all patients showing resolution of all the warts, there were no relapses at any site over the next 6 months of follow-up. The most common adverse effect seen was pain during the intralesional injection.

CONCLUSIONS

Intralesional Candida immunotherapy seems to be an effective treatment option in more than half of the patients who fail to show a positive response to destructive modes of treatment or in whom there are multiple recurrences.

LIMITATIONS

The small sample size and lack of control group are the main limitations of the study.

Long-pulsed Nd:YAG laser treatment of warts: report on a series of 369 cases

Various treatment methods have been adopted in the management of warts; however, there is still no consensus on first-line treatment. This study was designed to evaluate the efficacy of long-pulsed Nd:YAG laser in the treatment of warts. Over the course of 1 yr, 369 patients with recalcitrant or untreated warts were exposed to a long-pulsed Nd:YAG laser. The following parameters were used: spot size, 5 mm; pulse duration, 20 msec; and fluence, 200 J/cm(2). No concomitant topical treatment was used. In all, 21 patients were lost during follow up; hence, the data for 348 patients were evaluated. The clearance rate was 96% (336 of the 348 treated warts were eradicated). The clearance rate of verruca vulgaris after the first treatment was very high (72.6%), whereas the clearance rate of deep palmopantar warts after the first treatment was low (44.1%). During a median follow-up period of 2.24 months (range, 2-10 months), 11 relapses were seen (recurrence rate, 3.27%). In conclusion, long-pulsed Nd:YAG laser is safe and effective for the removal or reduction of warts and is less dependent on patient compliance than are other treatment options.

Successful treatment of periungual warts using photodynamic therapy: a pilot study

AIM

The aim of this pilot study was an investigation on photodynamic therapy (PDT) whether it is a good alternative for treating periungual and subungual warts of the hands.

STUDY DESIGN

Twenty patients (mean age: 30.5 years) with a total of 40 periungual and subungual warts were treated with PDT. A photosensitizer, 20%delta-aminolevulinic acid was applied on the warts. After a mean incubation time of 4.6 h (SD: 1.2), the warts were irradiated with the VersaLight for 5-30 min (15.2 +/- 4.3 min).

RESULTS

After a mean of 4.5 treatments a mean clearance of 100% was achieved in 90% of the patients. One patient (5%) showed a clearance of 50% and another showed no improvement. The subungual or periungual location of the wart had no influence on the number of treatments or end result (P > 0.05). There were two recurrences during the mean follow-up period of 5.9 months (SD: 7.6). Besides mainly pain and hyperpigmentation, most treatments had no side-effects.

CONCLUSION

PDT can offer a good alternative for treating periungual warts of the hands. Larger studies are indicated.

Pulsed dye laser: what's new in non-vascular lesions?

BACKGROUND AND OBJECTIVE

In dermatology, the pulsed dye laser (PDL) is the therapeutic instrument of choice for treating most superficial cutaneous vascular lesions. In addition, clinical experience over the last decade allowed us to treat patients with an ever increasing number of non-vascular indications. The purpose of this report is to summarize and critically appraise the scientific evidence that support the role of PDL in treating non-vascular skin lesions.

METHODS

A literature-based study has been conducted, including the review of publications over the period January 1995 to December 2006, using the Medline Database. We also included our own experience in managing non-vascular lesions with the PDL. Four sets of preoperative and postoperative photos are presented.

RESULTS

For viral skin lesions, PDL proved to be an alternative to other therapy options. This applies particularly to periungual warts and mollusca contagiosa. The mechanism of PDL with inflammatory dermatoses has not yet been elucidated. The effect seems to be better if there is a vascular component to the disease. With most of these indications (such as psoriasis and acne), PDL currently plays a rather minor or complementary role. Regarding collagen remodelling (hypertrophic scars, keloids, stretch marks, and skin rejuvenation), the question of whether a therapy makes sense or not has to be decided from case to case.

CONCLUSION

With PDL, it is possible to achieve good results with numerous, partly less well-known indications (i.e. lupus erythematosus). With other diseases, PDL has so far been considered to be a complementary therapy method or to be in an experimental state.

Pulsed dye laser therapy for pediatric warts

Viral wart infections constitute one of the most common pediatric skin diseases, and various modalities have been used to manage them. Although pulsed dye laser therapy is known to be a safe and efficacious modality, the reported cure rates for this method have varied, and no studies have reported treatment of pediatric patients alone. This prospective, nonblinded, nonrandomized study was performed to evaluate the efficacy and safety of pulsed dye laser therapy for pediatric warts. We found that this method is safe, relatively effective, and worth considering as an additional therapeutic option for viral warts in children, although not as a first-line therapy.

Traitement des verrues palmo-plantaires par le laser à colorant pulsé à 595 nm : étude randomisée en simple insu contre placebo

INTRODUCTION

Pulse dye laser (PDL) appears an attractive method to treat warts. However, data concerning the efficacy of this approach are based chiefly upon open clinical studies or case reports and results vary widely from one study to another. The purpose of this study was to compare the efficacy and safety of PDL with a placebo in the treatment of a homogeneous group of patients presenting palmoplantar warts.

METHODS

This was a randomized, prospective, placebo-controlled, single-blind study conducted between December 2004 and July 2005 in patients consulting for palmoplantar warts at the Dermatology Department of the University Teaching Hospital of Nice. The treatment settings used for the 595-nm PDL were as follows: spot diameter 5 mm, pulse duration 0.45 ms, fluence 9 J/cm2 with 5 passes at a frequency of 1 Hz. Cryogen spray cooling (system incorporated in the machine) was given at a rate of 50 spurts of 40 ms prior to each laser pulse. In patients in the placebo group, cooling pulses alone were given. For the plantar warts (in both groups), hyperkeratosis was removed manually with a scalpel before each session. A maximum of three sessions was administered at 3-week intervals. The type and number of warts was counted and recorded in a treatment schedule before the start of therapy, at each session and 5 weeks after the final session. The global safety of the treatment was evaluated using a visual analog scale between 0 (intolerable) and 10 (completely safe).

RESULTS

Nineteen patients were included in the laser group and 16 were included in the placebo group. Sixty-four per cent (48/75) of warts in the laser group resolved completely compared with 13% (4/30) in the placebo group (p<0.001). In the PDL group, 6 of 19 patients (31.5%) no longer had warts by the end of the study compared with 3 of 16 patients (18.75%) in the placebo group (p=0.46). The global safety score of the treatment as assessed by the patients themselves was 8.31 in the laser group and 9.81 in the placebo group.

DISCUSSION

Pulse dye laser appears to be an effective treatment in palmoplantar warts but the efficacy of this method seems to be only equivalent to that of standard treatments (cryotherapy or salicylic acid preparations). Safety is excellent and constitutes one of the major advantages of this technique. The absence of any proven superiority over the standard treatments in terms of efficacy, coupled with the high costs involved, means that PDL should only be used second-line therapy in patients wishing to avoid constraints affecting their professional activity.

Treatment of Verrucae Vulgaris and Molluscum Contagiosum with Photodynamic Therapy

The use of 5-aminolevulinc acid photodynamic therapy in the treatment of recalcitrant verrucae vulgaris and in the treatment of recalcitrant molluscum contagiosum has been shown to substantially reduce the lesion count and severity. Clinical research published in the medical literature and personal experience of both of the authors support the use of 5-aminolevulinc acid photodynamic therapy in appropriate individuals with recalcitrant verrucae vulgaris and molluscum contagiosum lesions. This article reviews the medical literature and identifies the various lasers and lights sources used to treat these conditions.

An armamentarium of wart treatments

Patients and clinicians experience the frustration of cutaneous viral warts caused by infection with the human papilloma virus (HPV).Warts appear in various forms on different sites of the body and include common warts (verruca vulgaris), plane or flat warts, myrmecia, plantar warts, coalesced mosaic warts, filiform warts, periungual warts, anogenital warts (venereal or condyloma acuminata), oral warts and respiratory papillomas. Cervical infection with HPV is now known to cause cervical cancer if untreated. A review of the medical literature reveals a huge armamentarium of wart monotherapies and combination therapies. Official evidence-based guidelines exist for the treatment of warts, but very few of the reported treatments have been tested by rigorous blinded, randomized controlled trials.Therefore, official recommendations do not often include treatments with reportedly high success rates, but they should not be ignored when considering treatment options. It is the purpose of this review to provide a comprehensive overview of the wart treatment literature to expand awareness of the options available to practitioners faced with patients presenting with problematic warts.

Verruca vulgaris: pulsed dye laser therapy compared with salicylic acid + pulsed dye laser therapy

BACKGROUND

In recent years, lasers have been used in verruca therapy and some successful results have been obtained in some types of verruca. In some of these laser studies, peeling processes have been used to increase penetration.

OBJECTIVE

This study aimed to compare the effects of pulsed dye laser (PDL) therapy with the effects of PDL therapy following salicylic acid (SA) application. The purpose of the SA application is to increase the laser penetration by decreasing the hyperkeratosis of verruca vulgaris.

METHODS

This controlled study included 66 lesions from 19 patients enrolled in the study. PDL was applied to 33 lesions following 30% SA application twice a day for 5 days, and the remaining 33 lesions underwent PDL therapy. PDL was administered in both groups at 4-week intervals varying from one to five sessions. In the comparison of these two groups, the changes in verruca dimensions were recorded in width x length x height (mm3), and the results of the therapy were evaluated statistically.

RESULTS

In both PDL and SA + PDL groups, the regressions observed in the size of the lesions were statistically significant at the end of the fifth session compared with those observed at the onset of the therapy (P < 0.05). At the end of the fifth session, the difference between the two groups was not statistically significant (P = 0.451); however, the clearance rate in the SA + PDL group was more statistically significant than that in the PDL group after the second session (P = 0.049). The complete clearance rate in the SA + PDL group was 54.6% after the second session, but 66.4% in the PDL group only after the fifth session. Complete clearance in the SA + PDL group was observed after 2.2 sessions, and in the PDL group after 3.1 sessions (P < 0.05).

CONCLUSIONS

Although there was no difference between the clearance rate of the SA + PDL group and that of the PDL group after the fifth session, adding SA to PDL decreased the number of sessions to a large extent.

Comparative Study of Aminolevulic Acid Photodynamic Therapy plus Pulsed Dye Laser versus Pulsed Dye Laser Alone in Treatment of Viral Warts

OBJECTIVE AND BACKGROUND

A number of scientific publications describe the removal of viral warts using photoselective laser destruction with pulsed dye laser (PDL) or photodynamic therapy (PDT). Although both methods represent an enormous improvement in therapy, the results are not sufficiently consistent to consider these methods as the "gold standard" for therapy.

METHODS

With a view to further improvement we combined a photoselective dye laser (595 nm, 20 J.cm(-2)) with photodynamic therapy using aminolevulic acid. The results of this method were compared against traditional laser photodestruction (of identical physical parameters) and against traditional photodynamic therapy (of similar parameters).

RESULTS

After combined therapy (PDT + PDL) of 86 warts in 24 patients, 100% were cured, with an average of 1.96 therapeutic sessions. Therapy with PDT alone failed in 3 of 76 warts even after 5 sessions (96%), with an average of 2.54 therapeutic sessions. Therapy with PDL alone failed in 21 of 112 warts even after 5 sessions, with an average of 3.34 therapeutic sessions.

CONCLUSIONS

All three therapeutic methods are able to cure infectious warts with high probability (>80%). However, a combination of PDT and PDL is the most effective and the most favored therapy. If other investigators also confirm results near or equal to 100% success, this therapy could become a treatment of choice for this indication.

Periungual verrucae diagnosis and treatment

To diagnose periungual verrucae, the practitioner must be able to rely on clinical judgment and choose the best treatment for the patient. This article provides multiple treatment options with advantages and disadvantage to aid the decision-making process.

Cutaneous manifestations of disease in athletes

In this first part of a two part series, we will discuss infectious means of skin injury and contact sensation in regard to athletic participation. Part 2 will address mechanical means and environmental means of skin injury as well as performance enhancing drugs used in sports and their effects on the skin.

Verrucae vulgares: flashlamp-pumped pulsed dye laser treatment in 134 patients

BACKGROUND

Various approaches have been taken in the management of verrucae vulgares, but there is still no first-choice treatment. Thus, a study was designed to evaluate the efficacy of a flashlamp-pumped pulsed dye laser (FPDL) in the treatment of verrucae vulgares.

METHODS

Within 18 months, 134 patients with recalcitrant or untreated verrucae vulgares on their hands or feet, or in other sites, were exposed to a 585-nm FPDL every 3.26 weeks. The following parameters were used: energy density, 8 J/cm2; spot size, 7 mm; pulse duration, 450 micro s. Concomitant topical treatment was not recommended.

RESULTS

Eight patients were lost to follow-up. The data of 126 patients were evaluated. Up to eight laser treatments led to total remission in 62.69% of patients and partial remission in 21.42%; 9.52% did not respond to this type of management; 6.34% of patients classified the method as too painful and withdrew after the first one or two treatments. In a median follow-up period of 5.38 months (2-16 months), one relapse occurred.

CONCLUSIONS

FPDL is safe and effective for the removal or reduction of verrucae vulgares, and requires less patient compliance compared with other treatment options.

Lasers in dermatology: four decades of progress

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.

The treatment of facial verrucae with the pulsed dye laser

OBJECTIVES/HYPOTHESIS

To evaluate the treatment of facial verrucae with the pulsed dye laser.

STUDY DESIGN

A prospective, nonrandomized, nonblinded pilot study evaluating the treatment of facial verrucae with the pulsed dye laser.

METHODS

Twelve patients with facial verrucae (four recalcitrant) were identified and followed in the study in the setting of a tertiary referral center. The treatment consisted of the flash-lamp pumped pulsed dye laser (585 mn) with a spot size of 5 mm at fluences between 9.0 and 13 J/cm. Each lesion received one or two pulses with 2 mm of surrounding normal skin included in the treatment. One patient had paring prior to pulse treatment. The patients were examined 3 to 4 weeks after each procedure, and clinical assessment of the lesion was documented.

RESULTS

Patient ages ranged from 18 to 47 years. Four patients had refractory lesions, and eight patients had never undergone previous treatment. All 12 patients had full resolution of their facial warts after one to three treatment sessions. No complications such as scarring, alopecia, or recurrence were encountered. Follow-up ranged from 10 to 33 months.

CONCLUSIONS

Pulsed dye laser therapy is highly effective and safe therapy for facial verrucae. This method appears to selectively destroy warts without damaging surrounding skin.

Pulsed dye laser and intralesional bleomycin for treatment of resistant viol hand warts

BACKGROUND AND OBJECTIVE

Viral warts affect 7-10% of the population and are a major burden on time and resources of dermatology departments everywhere. Some warts prove resistant to multiple therapies, and this is particularly common in the immunosuppressed patient. Numerous treatments are available, but no one treatment has emerged as the treatment of choice. Bleomycin has been shown to be effective in treating warts, but administration can be difficult with risk of local complications. To demonstrate a new technique for easily and safely administrating bleomycin into warts, we undertook an open study to assess the practicality, efficacy, and tolerability of pulsed dye laser immediately followed by intralesional bleomycin in resistant viral hand warts.

STUDY DESIGN/MATERIALS AND METHODS

Ten subjects, all with resistant viral hand warts of at least 3 years duration were recruited. Four subjects were on long-term immunosuppressant drugs. Eighteen warts treated in total. Area of the wart was anaesthetized with 1% lignocaine, then treated with a pulsed dye laser (7 mm spot, fluence 10 J/cm2). Immediately following this bleomycin (0.5 IU/ml) was injected into the base of the wart. Monthly follow-up and treatment until satisfactory clearance.

RESULTS

Sixteen out of eighteen warts cleared (89%). Eight out of ten warts in the immunosuppressed subjects cleared. The remaining two warts responded partially to two treatments, but the patient was happy with the result and did not wish further treatment. All warts in the immunocompetent subjects cleared. No serious side effects were seen.

CONCLUSIONS

The initial treatment of the wart with pulsed dye laser serves to "prepare" the wart for the bleomycin injection, which can then be given very easily. This ensures the drug is deposited into the base of the wart where it is most needed and minimises the risk of infiltration of normal skin or the operative environment. This method of combining pulsed dye laser and intralesional bleomycin appears to be a safe, rapid, well tolerated, and successful treatment for resistant hand warts. It has proven to be effective in warts in immunosuppressed patients and at difficult sites (e.g., subungual warts). These findings need confirmation from a larger controlled study.

585-nm pulsed dye laser treatment of glottal papillomatosis

Treatment of recurrent respiratory papillomatosis of the glottis is often challenging. The surgeon and patient must cooperatively balance decisions regarding airway safety, effects of multiple general anesthesias, employment disturbance, and vocal dysfunction. A pilot study was done in 41 adult cases (23 patients; 78 vocal folds) without complication to evaluate the effectiveness of a 585-nm pulsed dye laser (PDL; 450-micros pulse width; fluence of 38 to 255 J/cm2; 1- to 2-mm spot size) in the treatment of this disorder. Thirty-seven of the 41 cases (90%) were bilateral disease. Twenty-six of the 41 cases (63%; including 20 cases with involvement of the anterior commissure) were treated by bilateral photocoagulation of the lesions' microcirculation without microflap resection of tissue. Clinical observation revealed that irradiated but unresected disease involuted without development of an anterior commissure web. In the initial 13 of the 41 cases (32%), PDL treatment was followed by cold instrument microflap resection. The PDL enhanced the epithelial excision by improving hemostasis and by creating an optimal dissection plane between the basement membrane and the underlying superficial lamina propria. The PDL at 585 nm was less effective in the management of exophytic lesions because of its limited depth of penetration (approximately 2 mm). In this initial trial, the PDL was a relatively safe and efficacious treatment for glottal recurrent respiratory papillomatosis. Since the lesions involute without complete resection of the diseased epithelium, the anterior commissure can be treated to minimize the number of procedures. To study patterns of recurrence will require longer follow-up.

Treatment of anogenital warts by pulsed dye laser

BACKGROUND

Treatment of anogenital warts is difficult in that the disease spectrum is wide. Moreover, varying degrees of improvement are obtained.

OBJECTIVE

To study the treatment of persistent anogenital warts by pulsed dye laser.

METHODS

Pulsed dye laser was used with the following settings: spot size 7 mm, pulse duration 1500 microsec, and fluence 7.5 J/cm2. Two different wavelengths were used: 585 and 595 nm.

RESULTS

Lesions healed completely using both wavelengths after one treatment.

CONCLUSION

Pulsed dye laser has been found to be safe, effective, satisfactory, and less traumatic compared to other options for treatment of perianal warts in children.

Lasers in dermatology. An overview of types and indications

Advances in laser technology have been so marked over the past two decades that successful eradication of many cutaneous pathologies and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair, can now be fully realized. Because of the relative ease with which many of these lesions can be removed, coupled with a low incidence of adverse postoperative sequelae, demand for laser surgery has increased substantially. In this review, the currently available laser systems with cutaneous application are outlined, with special reference to recent advancements and modifications in laser technology that have greatly expanded the laser surgeon's armamentarium and improved upon overall treatment efficacy.

Treatment of recalcitrant-pigmented flat warts using frequency-doubled Q-switched Nd-YAG laser

BACKGROUND AND OBJECTIVE

Recalcitrant-pigmented flat warts may persist for years despite treatment. Many methods have been used to manage pigmented flat warts, but their efficiencies are varied. Since pigmented flat warts are very similar to lentigo clinically, we used frequency-doubled Q-switched (FDQS) Nd-YAG laser at the wavelength of 532 nm to treat recalcitrant-pigmented flat warts and evaluated the effect.

STUDY DESIGN/MATERIALS AND METHODS

Seven patients with recalcitrant-pigmented flat warts were enrolled in this study. We set the FDQS Nd-YAG laser to deliver 2.5 J/cm(2) fluence at the wavelength of 532 nm to treat these lesions. After 6 months, we evaluated the recurrence of pigmented flat warts, pigmentary, and textural changes on the treated areas.

RESULTS

There were absences of recurrent lesions, pigmentary, and textural changes on the treated areas of these seven patients after 6 months.

CONCLUSIONS

Through both selective photothermolysis effect and propagation of photoacoustic waves, FDQS Nd-YAG laser at the wavelength of 532 nm can be used as an effective alternative to treat recalcitrant pigmented flat warts.

Laser treatment of epidermal and dermal lesions

The CO2 laser is a versatile and effective tool for the treatment of warts and various other epidermal and dermal lesions where there is no easily targeted chromophore other than water. The development of high peak-power short-pulsed or rapidly scanned resurfacing CO2 lasers has significantly improved the safety and efficacy of this treatment modality. Many lesions amenable to CO2 laser vaporization, however, can be treated by other, far less expensive methods, and it is the laser surgeon's responsibility to use the CO2 laser only when it is demonstrably the best treatment option. The pulsed dye laser has some utility for selected recalcitrant warts. Because of their greater safety margin and more precise ablation, resurfacing CO2 and Er:YAG lasers are replacing the continuous wave CO2 laser for the ablation of many superficial lesions.

The pulsed dye laser for cutaneous vascular and nonvascular lesions

The pulsed dye laser was originally developed for the treatment of vascular lesions, especially hemangiomas and port-wine stains. The central concept of pulsed-dye laser is to preserving the epidermis by allowing hemoglobin to be more precisely targeted within lesions. More recently, the pulsed dye laser has also been used in the treatment of a wide spectrum of nonvascular lesions. Because of its safety profile, and its selectivity in targeting lesions, therapists can comfortably treat a wide variety of lesions in all age groups and anatomic sites.

Lasers for the dermatologist

This article reviews the current uses of lasers in dermatological practice. It outlines safety issues and legislation and attempts to summarize the relevant physics and light interactions. The article is divided into sections pertaining to selective photothermolysis of structures containing the major skin chromophores: haemoglobin, melanin and water. The lasers used and conditions treated are discussed with reference to a literature review.