Long-pulsed 1064-nm neodymium:yttrium-aluminum-garnet laser treatment for refractory warts on hands and feet

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.

Fingertip soft tissue defect caused by periungual warts: A case report

Periungual warts are frequently encountered in the field of dermatology. Here, we describe the case of a 69-year-old individual who presented with hand warts. The wart growth extended to the finger stump, resulting in a soft tissue defect on the fingertip of the right thumb. A treatment approach involving superficial x-ray therapy in combination with tretinoin was employed to address this finding. The warts disappeared after completing 26 days of the treatment regimen. Fingertip soft tissue defects due to periungual warts are a rare occurrence in clinical settings. This report serves as the first documented case of such a problem successfully managed with the treatment approach mentioned above.

Long-pulsed neodymium-doped yttrium-aluminum-garnet laser versus cryotherapy for the treatment of cutaneous warts: A randomized controlled trial

BACKGROUND

Observational studies have shown promising therapeutic effects of long-pulsed neodymium-doped yttrium-aluminum-garnet (LP-Nd:YAG) laser on warts.

OBJECTIVE

To evaluate whether LP-Nd:YAG laser was superior to cryotherapy for cutaneous warts.

METHODS

In this study, 150 adult patients with warts were randomized equally to receive laser or cryotherapy every 3 to 4 weeks, for a maximum of 4 sessions. The primary outcomes were the cure rates at 16 weeks and 6 months; secondary outcomes included time to clearance of warts and treatment-related adverse effects.

RESULTS

There was no difference in the cure rate for laser versus cryotherapy at 16 weeks (54.1% vs 46.7%, respectively) and 6 months (59.5% vs 57.3%, respectively). However, time to clearance of warts, up to 16 weeks and 6 months, tended to be shorter for laser versus cryotherapy (P = .04 and .08, respectively). Post hoc analyses showed a significantly higher cure rate for laser versus cryotherapy in 3 subgroups of human papillomavirus 2/27/57-induced recalcitrant warts but not in their counterpart subgroups. Laser had more mild adverse effects.

LIMITATIONS

Single center.

CONCLUSIONS

The overall therapeutic effects of LP-Nd:YAG laser were similar to cryotherapy, but laser may be more effective to relatively recalcitrant warts and may be associated with shorter time to clearance of warts.

Our experience using 1064 nm Nd:YAG in palmoplantar warts

Common warts (verruca vulgaris) are the most commonly seen benign cutaneous tumors occurring in both males and females of various ages. However, warts on the hands and feet (plantar warts and palmar warts) often respond poorly to traditional treatments such as topical salicylic acid, cryotherapy, surgical excision, electrocautery, and bleomycin injection. Recently, the long-pulsed 1064 nm Nd:YAG laser (LPNYL) has attracted attention in the treatment of palmoplantar warts. This study aims to evaluate the effectiveness of the LPNYL in the treatment of palmoplantar warts. We conducted a comparative cross-sectional descriptive study in 88 patients (49 males and 39 females) with palmoplantar warts. During the period from 2018 to 2020, the patients underwent up to three treatment sessions at intervals of 2-4 weeks between sessions. The LPNYL parameters comprised a spot size of 5 mm, 30 ms pulse width, 1 Hz repetition rate, and a fluence range of 140-180 J/cm². The patient mean age was 29.0 ± 14.5 years (range, 4-66 years). Good results were seen in 72.9% (64/88) of patients. The remaining 27.1% (24/88) felt their treatment was unsuccessful. As for adverse events, 5 (5.6%) patients reported hemorrhagic blistering after treatment. At the 3- and 6-month follow-up assessments, no recurrence was seen (Figures 2-4). Our study showed that the LPNYL treatment was safe and effective in the majority of palmoplantar warts. The duration of treatment was shorter than most traditional methods; however, the limitations of this method are that the treatment required several sessions, the procedure was painful, and adverse events occurred in just over 5% of the patients.

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.

Pulsed dye laser versus Nd:YAG laser in the treatment of recalcitrant plantar warts: an intraindividual comparative study

Plantar warts are common cutaneous lesions caused by the human papillomavirus. Treatment of recalcitrant plantar warts stays a continuous challenge, and they are more refractory to treatment than common warts. To compare the efficacy of Long-Pulsed neodymium: yttrium-aluminum-garnet (Nd:YAG) laser versus pulsed dye laser (PDL) on the therapy of multiple recalcitrant plantar warts. Thirty patients with recalcitrant plantar warts were included in the current study. Half the number of warts were treated by PDL in each patient, while the other half were treated by Nd:YAG. Laser sessions were applied every 2 weeks for a maximum of six sessions. Patients were followed up both clinically and using dermoscopy. There was a complete clearance of warts in 20 patients (66.7%) with Nd:YAG laser and 19 patients (63.3%) with PDL with no statistically significant difference between both types of lasers. Pain during laser sessions was higher with Nd:YAG laser PDL and it was statistically significant (p = .0001). Both Nd:YAG laser and PDL showed efficacy and safety for the treatment of recalcitrant plantar warts. The use of dermoscopy adds great value in evaluating treatment response and in decreasing the incidence of recurrence.

Successful treatment of periungual warts with local hyperthermia: report of two cases

Periungual warts are common warts that grow on the periungual or nail margin, and it's challenging to remove them due to their particular location, causing its high recurrence rate and brings difficulties to the treatments. We successfully cured two cases of stubborn periungual warts by local hyperthermia. A male with warts on his hands and knees and a girl with periungual warts on her fingers received local hyperthermia of 44 °C for 30 min a time. One month after the last treatment, their lesions disappeared entirely and did not relapse during the follow-up period. These two cases showed that local hyperthermia might be a safe and effective method for treating periungual warts in patients with poor traditional treatment.

Cidofovir Intralesional Injection for Recalcitrant Common Warts: A Comparison with Sodium Tetradecyl Sulfate Intralesional Injection

Background

A novel treatment method is required for recalcitrant common warts.

Objective

This study aimed to compare the complete wart removal rate of cidofovir, a broad-spectrum antiviral agent, intralesional injection and sodium tetradecyl sulfate intralesional injection.

Methods

This retrospective study included 45 patients with recalcitrant common warts on the hands and/or feet, treated with cidofovir or sodium tetradecyl sulfate intralesional injection.

Results

The treatment results were evaluated in three groups as follows: (1) failure - recalcitrant common warts remaining despite three or more injections, (2) success - free from warts for more than 6 months after the injection, and (3) recurrence. The cidofovir group (n=22) showed significantly higher treatment success rates than the sodium tetradecyl sulfate group (n=23) (90.91% vs. 26.09%, p<0.001). Two immunosuppressed patients in the cidofovir group had recurrent lesions after 2 months of being declared free from warts. Considering adverse effects, two patients in the cidofovir group complained of bulla formation with severe pain requiring narcotic painkillers.

Conclusion

Although this study has the limitations of a small sample size and retrospective design, patients with recalcitrant common warts showed a dramatic response to the treatment with cidofovir intralesional injection, with minimal complications.

Laser therapy in cutaneous and genital warts: A review article

Traditional treatment modalities for wart require long-term treatment course and usually have high recurrence rates and unwanted side effects. In this review article, we evaluated different types of laser therapy in the treatment of warts. Published articles since 2000 up to July 2020 about laser therapy in genital and non-genital warts were searched and assessed. Fifty articles were selected for the final review, including 22 pulsed dye laser (PDL), 10 neodymium-yttrium-aluminum-garnet (Nd: YAG), 3 erbium-doped yttrium-aluminum-garnet (Er: YAG), 14 carbon dioxide (CO₂ ) laser and one systematic review. Complete response rates were different in terms of laser type used (0%-100%, 9.1%-100%, 83.3%-100%, and 59.15%-100% for PDL, Nd: YAG, Er: YAG, and CO₂ laser, respectively). There was no significant difference between conventional treatment modalities and laser therapy regarding efficacy and recurrence rate. Combination of lasers with keratolytic agents, immunomodulators and photodynamic therapy can be helpful especially in immunosuppressed patients, refractory, and recurrent lesions. PDL has the lowest occurrence of adverse effects relative to other types of lasers.

Wart removal without anesthesia using long-pulse 1064-nm Nd:YAG laser

BACKGROUND

Warts are benign epithelial proliferations that result from human papillomavirus (HPV) infection occurring on the skin and mucosa. Patients express a significant reduction in quality of life due to this cosmetic nuisance, as well as functional problems and physical discomfort. Newer methods of wart removal include different energy-based devices, mostly lasers. Nonablative lasers such as Nd:YAG have a higher success rate and are usually used with topical or infiltrative anesthesia. The procedure may be safer without anesthesia but still tolerable with an appropriate cooling and technique.

AIMS

The purpose of this study is to report on our experience over 3 years since the approach without anesthesia has been utilized.

PATIENTS/METHODS

A retrospective chart review analysis of all 85 patients who underwent 1064 nm Nd:YAG wart removal without anesthesia between November 2016 and August 2019 was conducted. One of the main outcome measures was determining the number of sessions required in order to get full clearance.

RESULTS

The mean number of sessions was 2.2 (range 1-7). The mean VAS pain score during the procedure was 6 (range: 2-10), and side effects were negligible.

CONCLUSION

Long-pulse 1064-nm Nd:YAG laser without any chemical anesthesia is safe and effective for the treatment of warts.

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.

Efficacy of intralesional methotrexate in the treatment of plantar warts

Warts are tumors or growths caused by infection with human papilloma virus (HPV). Currently, over 170 HPV types have been identified. This study aimed to evaluate the efficacy and safety of intralesional injection of methotrexate (MTX) for the treatment of plantar warts. Sixty patients presented with plantar warts were divided into two groups. Group A patients were injected with intralesional MTX (2 mg/ml). Group B patients were injected with intralesional saline as a placebo. The injections were repeated every week for a maximum of six sessions or until complete clearance, whichever was earlier. The patients were followed up for 6 months after the last injection. In the intralesional MTX group, 2 patients (6.7%) showed complete improvement, 8 patients (26.7%) showed partial improvement, and 20 patients (66.7%) showed no improvement. In the intralesional saline group, 3 patients (10%) showed complete improvement, 4 patients (13.3%) showed partial improvement, and 23 patients (76.7%) showed no improvement. Reported adverse events were local reactions in the form of swelling, pain, and infection in both groups. There was no statistically significant difference between the therapeutic responses to intralesional MTX injection and saline.

Use of Topical Nitric-Zinc Complex Solution to Treat Palmoplantar and Periungual Warts in a Pediatric Population

Introduction

Nitric–zinc complex solution (NZCS) is a topically applied solution containing nitric acid, zinc, copper, and organic acids that induce a painless caustic effect on “difficult-to-treat” warts, including palmoplantar and periungual locations. The objective of the present prospective clinical study was to describe the efficacy and tolerability of NZCS in the treatment of palmoplantar and periungual warts in children.

Methods

Eligible patients were immunocompetent children and adolescents, with at least one palmoplantar or periungual wart. NZCS was topically applied every 2 weeks in clinic. Efficacy was recorded by clinical evaluation, and acceptability assessments were measured using a visual analogue scale (VAS).

Results

Pediatric patients (N = 12) were equally distributed by gender, and the mean age was 9.60 ± 3.34 years. The youngest patient was 4 years old. A total of 31 warts were identified: 24 periungual warts (77.4%), 2 palmar warts (6.45%), and 5 plantar warts (16.12%). We observed complete resolution in 83.9% of the warts treated with NZCS, achieving total cure considered as therapy success in 87.5% of periungual warts and 71% of palmoplantar warts, with a mean of 6.0 treatment sessions. The esthetic results evaluated by the investigator were considered excellent in 83.3% of cases and good in 16.7%. In 100% of the completely resolved cases, no scars, erythema, hyperpigmentation, hypopigmentation, or hypertrophy in the area surrounding the treated warts were observed by the investigator. The esthetic results evaluated by the patients or parents/guardians were excellent. Pain and burning sensation were minimal and well tolerated. No clinically relevant adverse events were reported.

Conclusion

NZCS was an effective treatment of warts in this pediatric population. The painlessness, simplicity, and twice-monthly dosing regimen of this treatment represents an advantage over standard approaches.

Funding

ISDIN.

Trial Registration

Retrospectively registered 6 September 2019, ISRCTN90862249.

A comparative study of pulsed dye laser versus long pulsed Nd:YAG laser treatment in recalcitrant viral warts

BACKGROUND

Viral warts are common infectious skin disease induced by human papillomavirus (HPV). But the treatment of recalcitrant warts is still challenging.

OBJECTIVE

In this study, we compared the effectiveness of pulsed dye laser (PDL) and long pulsed Nd:YAG (LPNY) laser in the treatment of recalcitrant viral warts.

METHODS

We retrospectively analyzed the medical records of patients with recalcitrant warts treated with laser therapy between January 2013 and February 2016.

RESULTS

Seventy-two patients with recalcitrant warts were evaluated. Thirty-nine patients were treated with pulsed dye laser and thirty-three patients were treated with LPNY laser. The following parameters were used: PDL (spot size, 7 mm; pulse duration, 1.5 ms; and fluence, 10-14 J/cm²) and LPNY (spot size, 5 mm; pulse duration, 20 ms; and fluence, 240-300 J/cm²). Complete clearance of two patients (5.1%) in PDL group, and three patients (9.1%) in LPNY group were observed without significant side effects. The patients who achieved at least 50% improvement from baseline were 20 (51.3%) in PDL and 22 (66.7%) in LPNY, respectively.

CONCLUSION

This research is meaningful because we compared the effectiveness of the PDL and LPNY in the recalcitrant warts. Both PDL and LPNY laser could be used as a safe and alternative treatment for recalcitrant warts.

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.

Nail Disease for the Primary Care Provider

Nail disorders are a common presenting complaint for both the primary care physician and the dermatologist. Nail diagnoses are broad in scope and include infectious, inflammatory, and neoplastic conditions. Onychomycosis is an especially common nail condition, and treatment should always be preceded by appropriate fungal studies for confirmation of diagnosis. Inflammatory conditions of the nail unit can mimic onychomycosis, and a dermatologist can assist with diagnosis and treatment recommendations. Likewise, subungual tumors often require biopsy, and should be evaluated by a dermatologist who is experienced in nail evaluation and treatment.

Intralesional Vitamin D Injection May Be an Effective Treatment Option for Warts

Background:

Plantar warts are typically resistant to treatment. In recent years, treatments have included administration of intralesional tuberculin; measles, mumps, rubella vaccine; and Candida albicans antigen immunotherapy. To the best of our knowledge, there are no reports of intralesional vitamin D administration for the treatment of warts.

Aim:

To evaluate the efficacy and safety of intralesional vitamin D treatment for plantar warts.

Methods:

Twenty patients with single or multiple plantar warts were included in this study. Vitamin D3 (0.2 mL, 7.5 mg/mL) was injected into the base of the warts after prilocaine (0.1 mL, 20 mg/mL) injection. A maximum of 5 warts were treated in 1 session, with at maximum 2 injections performed at 4-week intervals.

Results:

In total, 16 of 20 patients (80%) showed complete resolution of warts, and 1 patient showed partial resolution. Three patients failed to show any response. No recurrence or serious adverse effects were observed.

Conclusion:

Intralesional vitamin D3 may be an effective treatment option for warts.

The Overlapped Triple Circle Pulse Technique with Nd:YAG Laser for Refractory Hand Warts

BACKGROUND AND OBJECTIVE

Inadvertent superficial treatment of hand warts causes recurrence, whereas aggressive treatment can lead to tissue defects resulting in hand dysfunction. This study aimed to determine the effectiveness of a novel laser treatment modality for recalcitrant hand warts.

MATERIALS AND METHODS

The study included 51 patients who were treated for 146 recalcitrant hand warts using 1064 nm long-pulsed Nd:YAG laser between 2011 and 2014. The laser treatment method is novel because each treated wart was aligned at the intersection point of the circles of 3 laser pulses per session.

RESULTS

Among the 146 hand warts, 88.35% were successfully treated with one session and 100% of those that required a second treatment session were treated successfully, based on the 12 month follow-up examination.

CONCLUSIONS

Long-pulsed Nd:YAG laser treatment was observed to be a safe, rapid, and effective method for treating recalcitrant hand warts.