Laser treatment of warts and other epidermal and dermal lesions

Sequential Use of CO2 Laser Prior to Nd:YAG and Dye Laser in the Management of Non-Facial Warts: A Retrospective Study

Background and Objectives: Warts are benign lesions of viral etiology characterized by a hyperkeratotic appearance tending to spread across the skin surface. Various treatments have been proposed to manage this condition, such as acids, imiquimod, photodynamic therapy, cryotherapy, and various lasers. Materials and Methods: In this paper, we describe a combination protocol using CO₂ laser prior to Nd:YAG laser for lesions interesting the palmoplantar areas or dye laser for lesions on other skin surfaces in the management of non-facial warts resistant to traditional therapies. In total, 34 patients with 103 warts suffering from wart infection resistant to traditional therapies treated from 1 January 2019 to 1 June 2020 were retrospectively enrolled at the Dermatological Unit of Magna Graecia University (Catanzaro, Italy). Two dermatologists measured clinical results, classifying lesions with complete resolution, partial resolution, or non-responding. Patients at four months follow-up were asked to evaluate their degree of satisfaction with a visual analog scale (VAS). Results: Almost all patients reported the complete resolution of lesions, with no patient reporting scarring. Five patients reported hypopigmentation in the treated areas. The mean satisfaction level was high. Only three patients experienced a relapse of the condition. Conclusions: Using a vascular laser following a CO₂ superficial ablation of warts may help reduce the risk of scarring and decrease the incidence of relapses for lesions resistant to traditional therapies. Therefore, more extensive studies will be necessary to confirm the obtained results.

The status of treatment for plantar warts in 2021: No definitive advancements in decades for a common dermatology disease

Plantar warts are among the most common skin conditions and are classically resistant to treatment. To perform an evidence-based evaluation of the efficacy and safety of available treatment options for plantar warts, we conducted a systematic review of PubMed and Cochrane databases to identify large interventional and observational studies involving more than 100 patients who were treated for plantar warts from inception to October 2020. We identified only nine contributions meeting our inclusion criteria (N ≥ 100), representing 1,657 adult and pediatric patients with plantar warts. Treatments included in this review were topical keratolytic agents, cryotherapy, laser therapies, and intralesional and systemic treatments. Our evidence-based review of the larger studies suggests keratolytic agents and destructive treatments, in particular salicylic acid and cryotherapy, remain the primary treatments for plantar warts. Treatment with pulsed dye laser had the lowest rate of recurrence. Newer treatments and intralesional treatments were not represented owing to lack of large studies involving these modalities.

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.

Novel Treatment Approach for Deep Palmoplantar Warts Using Long-Pulsed 1064-nm Nd:YAG Laser and a Moisturizing Cream Without Prior Paring of the Wart Surface

OBJECTIVE

The present study aimed to assess the safety and efficacy of palmoplantar wart removal using long-pulsed 1064-nm Nd:YAG laser after application of a moisturizing cream.

BACKGROUND

Previously described laser treatments for wart removal are associated with negative side effects and need to pare the warts before laser treatment.

PATIENTS/METHODS

Two hundred forty patients (142 males, 98 females) were treated for 1-40 palmoplantar warts by long-pulsed 1064-nm Nd:YAG laser (spot size 4-6 mm, pulse duration 20 msec, fluence 200 J/cm²) after covering the wart surface with a thin film of a moisturizing cream. The endpoint was lesion graying or whitening with or without development of a hemorrhagic bulla beneath the treated wart. Color photographs were taken before and immediately after each laser session and at 1, 4, and 16 weeks after the last session.

RESULTS

The overall clearance rate was 97%, with 90% of treated patients cured after one session, 4% after two, and 3% after three. Clearance rate after three laser sessions decreased linearly with the number of warts from 100% to 95%. Less accessible wart location in interdigital spaces also decreased the cure rate after three sessions from 100% to 95%. Additionally, warts became more difficult to eradicate as they aged. Remission lasted up to 6 years, and complications were mild and infrequent (17.5%).

CONCLUSIONS

This novel method is effective in removing palmoplantar warts. It is easier, time-saving, and safer than other methods described in previous studies conducted with ablative or nonablative lasers.

Carbon dioxide laser treatment of epidermal nevi: response and long-term follow-up

BACKGROUND AND OBJECTIVES

Epidermal nevi, which are benign skin growths, have been treated using a range of approaches, with varying results. Topical treatments are ineffective and, while surgical excision is a more definitive treatment, it causes scar formation. In recent decades, epidermal nevi have been treated with various types of laser therapy. We describe our experience with the use of carbon dioxide (CO(2)) laser therapy to treat epidermal nevi and inflammatory linear verrucous epidermal nevi (ILVEN).

PATIENTS AND METHODS

Twenty patients (15 with epidermal nevi and 5 with ILVEN) underwent CO(2) laser treatment at our hospital between 2002 and 2010.

RESULTS

Response was good (>50% reduction in lesion size) in 50% of cases and excellent (>75% reduction) in 30%. A greater resistance to treatment was observed in patients with ILVEN (only 40% had a good response). Long-term follow-up (at least 18 months) showed a recurrence rate of 30%. The side effects were hypopigmentation (25% of patients) and scarring (20%).

CONCLUSIONS

We consider CO(2) laser therapy to be the treatment of choice for epidermal nevi as it is well tolerated and has proven to be safe and effective in the long term. While the response in patients with ILVEN was limited, CO(2) laser therapy might be a good option for selected cases or for palliative treatment since no other treatments have yet proven effective in this setting.

Epidermal nevi treated by carbon dioxide laser vaporization: A series of 25 patients

BACKGROUND

Epidermal nevi are benign proliferations of epidermis. Numerous treatment modalities have been tried, but no ideal treatment is yet available.

OBJECTIVE

To report our experience with CO(2) laser vaporization in the treatment of verrucous epidermal nevi, and to identify which factors could have influence in long-term results.

METHODS

A total of 25 patients were treated with the CO(2) laser in the superpulsed mode, focalized at 2 W/cm(2). The patients were between 3 and 41 years old (mean: 17 years). A total of 44% of lesions were <20 cm(2), 40% measured between 20 and 100 cm(2) and 16% were >100 cm(2). The follow-up was 4-79 months (mean: 28 months). In 76% of patients, multiple treatment sessions were required.

RESULTS

Good results were achieved in 92% of patients with soft, flattened nevi and in only 33% patients with keratotic nevi. In addition, 87% of the latter had moderate results and 12.5% had poor results.

CONCLUSION

We conclude that the CO(2) laser in superpulsed mode is an effective and safe treatment for verrucous epidermal nevi and provides fewer recurrences than other laser therapies. We also believe that the most determining factor for the cosmetic result is thickness of the nevus.

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.

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.

Seguimiento a largo plazo de angiofibromas tratados con láser de CO2 en 23 pacientes con esclerosis tuberosa

INTRODUCTION

Tuberous sclerosis is an autosomal dominant disease in which hamartomas form in multiple organs. Cutaneous changes are one of the primary characteristics of this disease. These include angiofibromas (AF), a common form of presentation that causes significant cosmetic and medical problems. The CO2 laser has been used satisfactorily in treating these lesions, but there are few studies that evaluate its long-term results. The aim of our study is to assess the long-term response of the treatment of angiofibromas.

METHODS

A retrospective study was carried out on 23 patients with angiofibromas treated with CO2 laser. The patients were treated between 1991 and 2000, inclusive, with continuous or superpulsed CO2 laser. We classified the angiofibromas by size, initial treatment results and patients' ages (< 20 years and 20 years or older).

RESULTS

Ages ranged from 12 to 39 years, with a median age of 22.5 years. After treatment, patients were followed up for a period of six months to 10 years. In the long-term analysis, we found that 30.1 % maintained the initial result, and 60.9 % showed different degrees of recurrence, with a mean recurrence time of 3 years. When we analyzed the long-term results by the size of the angiofibromas, initial result and patients' ages, we found no statistically significant differences among the different groups. The survival analysis of the age groups, with Kaplan-Meier curves, showed that the youngest patients (< 20 years) had earlier recurrences than the older ones (logarithmic range 4.01 and p < 0.05).

CONCLUSIONS

CO2 laser treatment achieves good short-term results. On the other hand, one of the biggest problems is recurrence over the long term; this is probably due to the fact that, because of their nature, these lesions cannot be eliminated permanently. This work coincides with earlier studies which found no factors that would make it possible to predict the recurrence of the lesions. However, we can conclude that recurrence takes place at a later date in older patients, and therefore they have better cosmetic results over the long term.

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.

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.

A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles

Facial skin treatments with laser resurfacing, dermabrasion, and chemical peels were responsible for a significant portion of the 2.7 million cosmetic procedures performed in 1998. Perioral wrinkles are a common problem for which plastic surgical consultation is obtained. The aim of this study was to compare and quantify the advantages and disadvantages of laser resurfacing versus dermabrasion in the treatment of perioral wrinkles. Twenty female patients provided informed consent and participated in the study. Half of the perioral area was treated with dermabrasion and half was treated with the UltraPulse CO2 laser. The two procedures were compared using high-quality photographs; a biophysical evaluation of skin color, hydration, and mechanical properties; and patient evaluation of outcomes. Photographs were evaluated by 10 board-certified plastic surgeons who were blinded to the treatment methods. The laser treatment had a significantly higher erythema score at 1 month and a small but significantly greater improvement in perioral wrinkles at 6 months. Thirteen subjects selected the laser treatment as producing the best result, despite the greater intraoperative pain for this procedure. Biomechanical measurements suggest that the laser treatment produced a skin state more similar to skin in younger patients, presumably with higher levels and/or greater organization of the collagen and elastin. Patient preference was inferred from the resurfacing method that they would recommend to a friend. Although the laser was selected as the best result in a majority of cases, patient preference was equally distributed between the two treatments. The authors think that by studying and quantifying the biophysical changes that occur as a result of CO2 laser resurfacing, greater improvements in restoring actinic damage (e.g., wrinkles) can be achieved. Patients consider more than the objective skin changes from a resurfacing technique when making a recommendation to a friend.

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.

Cutaneous laser resurfacing

Cutaneous resurfacing with the new generation of carbon dioxide and erbium lasers has recently come into favor for the treatment of facial rhytides, photodamage, and scarring. The precise control of these resurfacing lasers over the extent of tissue vaporization minimizes thermal damage to the skin while maximizing therapeutic efficacy. Proper use of resurfacing lasers is contingent upon a complete understanding of their clinical, histologic, and ultrastructural effects, as well as an appreciation of the principles of laser safety. An organized approach to the preoperative, intraoperative, and postoperative management of the patient undergoing laser resurfacing will be provided, including a discussion of prevention and treatment of postoperative side effects and complications. (J Am Acad Dermatol 1999;41:365-89.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical, histologic, and ultrastructural effects of resurfacing lasers and be able to discuss the preoperative, intraoperative, and postoperative management of patients undergoing laser resurfacing.

Cutaneous resurfacing with CO2 and erbium: YAG lasers: preoperative, intraoperative, and postoperative considerations

The development and integration of pulsed and scanned CO2 and erbium:YAG laser systems into mainstream surgical practice over the past years has revolutionized cutaneous resurfacing. These lasers are capable of delivering to skin high peak fluences to effect controlled tissue vaporization, while leaving an acceptably narrow zone of residual thermal damage. The inherent technological differences that exist between the two distant laser systems in terms of ablation depths, degree of thermal coagulation, and postoperative side-effects and complications guide patient selection and management. This article reviews the basic principles of CO2 and erbium:YAG laser resurfacing, including preoperative, intraoperative, and postoperative patient considerations. Side-effects and complications encountered after laser resurfacing are discussed with specific guidelines provided on their appropriate management. Anticipated future developments and cutting-edge research endeavors in cutaneous laser resurfacing are also briefly outlined.