Successful treatment of topical photodynamic therapy using 5-aminolevulinic acid for plane warts

Management of Difficult-to-Treat Warts: Traditional and New Approaches

Warts are regularly treated by dermatologists, and while many respond readily to first-line treatments, others may represent a therapeutic challenge. Large, deep, numerous, and extensive warts; treatment-resistant lesions with higher risk for side effects, such as hypopigmentation; or patients unable to tolerate or comply with our treatment regimen, may need alternative treatment options. In this work we review the characteristics of select modalities that should be considered for difficult-to-treat warts. We discuss efficacy and tolerability data as well as practical features that can guide us to select the best treatment for every scenario. Novel approaches, still in an investigational phase, are also discussed to illustrate potential future directions of wart treatment.

Efficacy and safety of conventional versus daylight photodynamic therapy in children affected by multiple facial flat warts

BACKGROUND

facial flat warts (FFWs) are a superficial viral skin disease, extremely common in childhood. Recently, conventional photodynamic therapy (C-PDT) has been used for the treatment of FFWs with good outcome. The efficacy of daylight photodynamic therapy (DL-PDT) has not yet been evaluated.

OBJECTIVES

to investigate and assess the efficacy and safety of C-PDT versus DL-PDT using 10% aminolevulinic acid (ALA) in the treatment of recalcitrant FFWs in a paediatric setting.

MATERIALS AND METHODS

30 consecutive patients aged <18 years with FFWs of the face were included and randomly divided into two groups: group A (15 patients) was treated with C-PDT and group B (15 patients) with DL-PDT. Patients underwent treatments for three times with 1-month intervals. The response was assessed on week 4,812 and 24 (T4,T8,T12,T24) and scored as excellent (75-100% reduction of total wart count), very good (74-50% reduction), good (49-25% reduction), poor (<25% reduction or no response). Any adverse event occurring during/after ALA application/irradiation as well as pain intensity were recorded at each visit.

RESULTS

at T4 and T8 no excellent response was achieved in both groups. At week 12, excellent response was observed in 53.3% of group A patients vs 0% of group B patients, although in the latter 66.7% of patients achieved a very good response. Excellent outcome raised to 73.3% and 80% in group A and B, respectively, at week 24. Poor response to therapy was observed in 26.7% of patients in group A and 20% in group B. Both treatment modalities were well tolerated, with transient pain, irritation and hyperpigmentation as main side effects.

CONCLUSIONS

ALA-PDT is effective and safe for FFWs, with striking cosmetic results and no recurrence. Compared with conventional modality, DL-PDT is better tolerated, time-saving, nearly painless and greatly appreciated by young patients.

A Retrospective Study of a Chinese Traditional Medicine YIKEER in the Treatment of Verruca Patients in Liaoning District

Background

There are many possible ways to treat verruca, but no one is the single perfect treatment. YIKEER is a kind of compound preparation of Chinese traditional medicine, which has been used in the treatment of verruca for several years.

Aim

To confirm the effects of YIKEER for verruca.

Method

Patients with verruca vulgaris, verruca plantaris, or verruca plana were instructed to apply YIKEER stock solution or diluent to the lesions once or twice daily for 5–7 days. Then, the YIKEER was ceased for 3–4 days, and sea buckthorn oil was used for wound repairing. The total procession was defined as one session.

Result

Respective 88.05% verruca vulgaris patients, 86.03% verruca plantaris patients, and 82.42% verruca plana patients achieved complete response. Most patients gained complete or partial responses after 4 treatment sessions. The percentage of patients who achieved at least 50% improvement was 90.34% for verruca vulgaris, 90.60% for verruca plantaris, and 80.91% for verruca plana after 4-session treatment. The efficacy of verruca vulgaris or verruca plantaris was better than that of verruca plana.

Conclusion

YIKEER is an effective, safe, and well-tolerated agent for treating verruca including verruca vulgaris, verruca plantaris, and verruca plana.

European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications - field cancerization, photorejuvenation and inflammatory/infective dermatoses

In addition to approved indications in non-melanoma skin cancer in immunocompetent patients, topical photodynamic therapy (PDT) has also been studied for its place in the treatment of, as well as its potential to prevent, superficial skin cancers in immune-suppressed patients, although sustained clearance rates are lower than for immune-competent individuals. PDT using a nanoemulsion of ALA in a daylight or conventional PDT protocol has been approved for use in field cancerization, although evidence of the potential of the treatment to prevent new SCC remained limited. High-quality evidence supports a strong recommendation for the use of topical PDT in photorejuvenation as well as for acne, refractory warts, cutaneous leishmaniasis and in onychomycosis, although these indications currently lack approvals for use and protocols remain to be optimized, with more comparative evidence with established therapies required to establish its place in practice. Adverse events across all indications for PDT can be minimized through the use of modified and low-irradiance regimens, with a low risk of contact allergy to photosensitizer prodrugs, and no other significant documented longer-term risks with no current evidence of cumulative toxicity or photocarcinogenic risk. The literature on the pharmacoeconomics for using PDT is also reviewed, although accurate comparisons are difficult to establish in different healthcare settings, comparing hospital/office-based therapies of PDT and surgery with topical ointments, requiring inclusion of number of visits, real-world efficacy as well as considering the value to be placed on cosmetic outcome and patient preference. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical photodynamic therapy in Dermatology prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.

Off-label photodynamic therapy for recalcitrant facial flat warts using topical 5-aminolevulinic acid

The facial flat wart (verruca plana) is one of the most common reasons for dermatology and primary care visits. Although there are many therapeutic modalities, no single therapy has been proven to be completely curative. Case reports and uncontrolled studies suggested that photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) can effectively treat recalcitrant facial flat warts. A total of 12 patients with recalcitrant facial flat warts were enrolled in the study. ALA gel (10 %) was applied topically to lesions and incubated for 3 h. The lesions were irradiated by an LED light of 630 ± 10 nm at dose levels of 60-100 mW/cm. Clinical assessment was conducted before and after every treatment for up to 24 weeks. Among the ten patients completing three sessions of ALA-PDT, five had complete lesions clearance, and the other five patients were significantly improved. At the 24-week follow-up, the average effective rate was 88.8 %, with no recurrences. No significant side effects were reported. A low-dose topical ALA-PDT regimen using 10 % ALA, 3 h incubation, and a red light source for three treatment sessions are suggested as the optimal scheme for the treatment of recalcitrant flat warts on the face in Chinese patients. Superior efficacy is found in elevated or active period lesions with mild side effects.

Topical PDT in the Treatment of Benign Skin Diseases: Principles and New Applications

Photodynamic therapy (PDT) uses a photosensitizer, light energy, and molecular oxygen to cause cell damage. Cells exposed to the photosensitizer are susceptible to destruction upon light absorption because excitation of the photosensitizing agents leads to the production of reactive oxygen species and, subsequently, direct cytotoxicity. Using the intrinsic cellular heme biosynthetic pathway, topical PDT selectively targets abnormal cells, while preserving normal surrounding tissues. This selective cytotoxic effect is the basis for the use of PDT in antitumor treatment. Clinically, PDT is a widely used therapeutic regimen for oncologic skin conditions such as actinic keratosis, squamous cell carcinoma in situ, and basal cell carcinoma. PDT has been shown, under certain circumstances, to stimulate the immune system and produce antibacterial, and/or regenerative effects while protecting cell viability. Thus, it may be useful for treating benign skin conditions. An increasing number of studies support the idea that PDT may be effective for treating acne vulgaris and several other inflammatory/infective skin diseases, including psoriasis, rosacea, viral warts, and aging-related changes. This review provides an overview of the clinical investigations of PDT and discusses each of the essential aspects of the sequence: its mechanism of action, common photosensitizers, light sources, and clinical applications in dermatology. Of the numerous clinical trials of PDT in dermatology, this review focuses on those studies that have reported remarkable therapeutic benefits following topical PDT for benign skin conditions such as acne vulgaris, viral warts, and photorejuvenation without causing severe side effects.

Comparative study of photodynamic therapy with 5%, 10% and 20% aminolevulinic acid in the treatment of generalized recalcitrant facial verruca plana: a randomized clinical trial

BACKGROUND

Generalised recalcitrant facial verruca plana responds poorly to current therapeutic options, including cryotherapy, topical drugs and carbon dioxide (CO2 ) laser. Case reports and uncontrolled studies suggested that topical photodynamic therapy (PDT) is effective choice of treatment free from potential complications associated with invasive therapies.

AIMS

To investigate the efficacy and safety of PDT with different concentrations of photosensitiser in the treatment of verruca plana.

MATERIALS & METHODS

The two sides of a subject's face were separately randomized to receive aminolevulinic acid (ALA) of 5%, 10% or 20% concentration. All patients were irradiated with 633-nm red light for 339 J/cm(2) total dose. Complete response (CR) rate was assessed on Week 4, 8, and 16 respectively.

RESULTS

The mean overall clearance rate was 74.1%, 68.8%, and 64.6% on Week 4, 8, and 12, respectively, in the 110 treated sides. The CR rate was lower in the 5%-ALA group than in the 10%-ALA group (14.3% vs. 33.3%, p < 0.05) and 20%-ALA group (14.3% vs. 26.3%, p < 0.05) after 12 weeks. The mean severity of pain measured by visual analogue scale (VAS) scoring was 3.8 (range: 2 to 10, depending on the lesion location). The overall recurrence rate was 16.7% (4/24) on Week 12. Hyperpigmentation was observed in 61% (67/110) of all treated sides. On Week 4, 8, and 16, hyperpigmentation was more developed in the 20%-ALA group than in the other two groups (p < 0.05).

DISCUSSION

In terms of complete clearance rate, the 5% ALA-PDT group was significantly inferior to the 10% and 20% ALA-PDT groups at each follow-up. In contrast, the 20% ALA group showed a higher incidence rate of transient hyperpigmentation than the other two groups.

CONCLUSIONS

This randomised clinical trial suggests that PDT with ALA of 10% concentration offers better efficacy and safety than 5% or 20% concentration for generalised recalcitrant facial verruca plana.

Is the step-up therapy of topical 5-aminolevulinic acid photodynamic therapy effective and safe for the patients with recalcitrant facial flat wart?

Facial flat wart, caused by human papilloma virus type 3 and less often, type 10, 27, and 41, often brings many cosmetic problems to children and young adults. Considering the disturbing cosmetic problem, the treatment of facial flat wart is always frustrating and often unsuccessful, although there are many treatment modalities. Considering the possible serious side effects of 5-aminolevulinic acid photodynamic therapy (ALA-PDT), we designed step-up therapy of ALA-PDT on different clinical phases of facial flat wart. As a new protocol of ALA-PDT, we found the step-up therapy of ALA-PDT could also receive excellent effects with the lower side effects. Meanwhile, the tolerance of patients to ALA-PDT could improve with subsequent treatment sessions and escalating doses of ALA-PDT.

The successful treatment of flat warts with auricular acupuncture

BACKGROUND

Flat warts are a common presenting complaint in adolescents and adults and may be a cosmetic problem as well. Patients suffering from flat warts are often unsatisfied with conventional medical care because of adverse effects such as intolerable pain, hyperpigmentation, hypopigmentation, or occasionally allergic contact dermatitis. To offset the possibilities of hyperpigmentation, hypopigmentation, and scar formation, the method of auricular acupuncture was used.

METHODS

Single-blind method adopted, 60 subjects with flat warts were all outpatients and randomly allocated to a treatment group or a control group, with 30 patients in each group. Thirty subjects in the treatment group were treated with weekly auricular acupuncture for 10 weeks while the other subjects in the control group were treated with 0.1% of tretinoin ointment topically for 10 weeks.

RESULTS

Sixteen subjects in the treatment group (53.33%) recovered fully from flat warts without recurrence during the ensuing six months' follow-up after 10 weeks' surgery compared with only one subject in the control group (3.33%). The therapeutic effect of the treatment group was statistically better than that of the control group by Mann-Whitney U-test with SPSS software (P < 0.01). During the treatment period and the ensuing six months' follow-up, no adverse effects were observed by the investigators or reported by patients.

CONCLUSIONS

Our findings suggest that auricular acupuncture may be a viable alternative for the treatment of flat warts. Larger randomized studies are needed to fully evaluate auricular acupuncture against more conventional treatments, and these are planned.

Photodynamic therapy: new treatment for refractory lymphocytic infiltration of the skin

Lymphocytic infiltration of the skin (LIS) is a relatively uncommon skin condition, first described by Jessner and Kanof in 1953. LIS presents mainly on the face, in particular on the cheeks and earlobe, but also on the neck, upper trunk or proximal limbs of middle-aged adults. LIS is often resistant to treatment. Photodynamic therapy (PDT) refers to the process of applying a topical prodrug, such as 5-aminolaevulinic acid (ALA) or methyl 5-aminolaevulinic acid (MAL), followed by irradiation with visible or ultraviolet light. The prodrug is converted by target tissue to photoactive porphyrins, which lead to local tissue destruction when activated by light. We describe a 48-year-old woman with refractory LIS, who was treated with MAL-PDT.

Efficiency of photodynamic therapy in the treatment of diffuse facial viral warts in an immunosuppressed patient: towards a gold standard?

A 64-year-old man with a pulmonary transplant developed diffuse verrucae vulgares of the neck. After the failure of multiple cryotherapy treatments, 3 sessions of photodynamic therapy resulted in rapid therapeutic clinical success. This moderately painful and well-tolerated treatment is reproducible and can be very useful in treating papillomavirus infections in the immunosuppressed patient.

Topical 5-aminolevulinic acid photodynamic therapy for recalcitrant facial flat wart in Chinese subjects

The facial flat wart (verruca plana) is not only a contagious viral disease, but also causes a disturbing cosmetic problem. Because 5-aminolevulinic acid photodynamic therapy has successfully treated human papilloma virus-related diseases, we employed 20% 5-aminolevulinic acid and a light emitting diode on three recalcitrant facial flat wart patients. Most lesions achieved complete remission after three or four sessions. However, a few non-elevated lesions did not respond to this method. An ablative therapeutic mode is required in addition to 5-aminolevulinic acid photodynamic therapy in such lesions. Therefore, we utilized an Er:YAG laser and 20% 5-aminolevulinic acid photodynamic therapy for one session and achieved an excellent result. Patients should be informed of the possible side-effects of this treatment, such as erythema, exfoliation and post-inflammatory hyperpigmentation, and the requirement for sun protection.

Guidelines for topical photodynamic therapy: update

Multicentre randomized controlled studies now demonstrate high efficacy of topical photodynamic therapy (PDT) for actinic keratoses, Bowen's disease (BD) and superficial basal cell carcinoma (BCC), and efficacy in thin nodular BCC, while confirming the superiority of cosmetic outcome over standard therapies. Long-term follow-up studies are also now available, indicating that PDT has recurrence rates equivalent to other standard therapies in BD and superficial BCC, but with lower sustained efficacy than surgery in nodular BCC. In contrast, current evidence does not support the use of topical PDT for squamous cell carcinoma. PDT can reduce the number of new lesions developing in patients at high risk of skin cancer and may have a role as a preventive therapy. Case reports and small series attest to the potential of PDT in a wide range of inflammatory/infective dermatoses, although recent studies indicate insufficient evidence to support its use in psoriasis. There is an accumulating evidence base for the use of PDT in acne, while detailed study of an optimized protocol is still required. In addition to high-quality treatment site cosmesis, several studies observe improvements in aspects of photoageing. Management of treatment-related pain/discomfort is a challenge in a minority of patients, and the modality is otherwise well tolerated. Long-term studies provide reassurance over the safety of repeated use of PDT.

[Photodynamic therapy: non-oncologic indications]

While efficacy of topical photodynamic therapy (PDT) for the treatment of superficial non-melanoma skin cancer is already well-proven by several controlled clinical trials, there are only a few controlled studies showing efficacy of PDT for non-oncologic skin disorders. This report provides information on the use of PDT for inflammatory skin disorders, disorders of the pilosebaceous unit, infections of the skin, sclerotic skin diseases and cosmetic indications.

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.

[Juvenile verrucae planae: treatment with imiquimod 5% cream]

A 6 year old girl presented with flat-topped, skin-colored, partly grouped papules with slightly roughened surface on the left side of the forehead and around the left orbit. In an off-label use imiquimod 5% cream was applied twice a week before bedtime and was rinsed off in the morning. After four weeks of treatment the lesions had vanished completely. We suggest imiquimod 5% cream as a treatment option for juvenile plane warts even in children and in the face.

Successful Treatment of Lymphadenosis benigna cutis with Topical Photodynamic Therapy with Delta-Aminolevulinic Acid

BACKGROUND

Photodynamic therapy (PDT) using topical delta-aminolevulinic acid (ALA) has been used for nonmelanoma skin cancers, including malignant cutaneous T-cell lymphomas. Moreover, PDT has been tried for benign inflammatory or infectious skin lesions.

OBJECTIVE

To evaluate the effects of ALA-PDT on skin lesions of lymphadenosis benigna cutis (LABC).

PATIENTS AND METHODS

Two 16-year-old females with solitary and infiltrated nodules were treated 5 times with topical ALA-PDT.

RESULTS

Both patients responded well and showed dramatic clinical and histopathological improvement without visible scars.

CONCLUSION

The results confirm that topical ALA-PDT is an effective and safe modality for the treatment of LABC, and that such treatment may be cosmetically beneficial.

Human papillomavirus infections in children

PURPOSE OF REVIEW

The human papillomavirus is a ubiquitous 55-nm DNA virus that causes a variety of clinical disease states in children, commonly referred to as warts. The natural history of warts is spontaneous regression through the development of a complex blend of cell-mediated and humoral immunity. Although spontaneous immunity can develop, as many as one third of children will have persistent human papillomavirus infection beyond 2 years. Therapeutic modalities are manifold, primarily because no therapy is universally effective. The purpose of this review is to update the reader with the latest information on the human papillomavirus and its therapeutics in children.

RECENT FINDINGS

Recently, encouraging research has been conducted in human papillomavirus, including destructive and immunologic therapies. Vaccines tailored to genital human papillomavirus strains are just coming into clinical use.

SUMMARY

Manipulation of the immune system through medications or vaccination will likely help contain human papillomavirus in the future and prevent secondary human papillomavirus oncogenesis of the skin and cervix.