Pulsed dye laser therapy for viral warts

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1 British Journal of Plastic Surgery (1999), 52, The British Association of Plastic Surgeons Pulsed dye laser therapy for viral warts J. Kenton-Smith and S. T. Tan* Wellington Regional Plastic and Maxillo-facial Surgery Unit, Hutt Hospital and *Swee Tan Plastic Surgery Trust, Wellington, New Zealand SUMMARY. Twenty-eight patients with 103 recalcitrant and 20 simple viral warts were treated with the Cynosure PhotoGenica V pulsed dye laser at 585 nm, and fluencies of J/cm 2. An eradication rate of 92% for recalcitrant warts after an average of 2.1 (range 1 7) treatments and 75% for simple warts after an average of 1.6 (range 1 2) treatments was achieved with a mean follow-up period of 7.2 (range 3 15) months. Mild hypopigmentation was noted in one patient and superficial infection in another. Unlike ablative treatment modalities, with pulsed dye laser therapy, no wound was created thus avoiding prolonged postoperative pain, disability and scarring. Treatment was well tolerated by patients, most of whom returned to work or normal activities immediately postoperatively. Pulsed dye laser is an effective treatment for both recalcitrant and simple warts. It is the treatment of choice for these lesions in cosmetically sensitive areas The British Association of Plastic Surgeons Keywords: viral warts, pulsed dye laser Viral warts are a common problem affecting approximately 10% of the population. 1 They are often painful, unsightly and may interfere with function. In 20% of affected but otherwise healthy individuals, the warts will resolve spontaneously within 3 months. 2 Conventional treatments for viral warts include repeated application of topical paints, 3 cryotherapy, 3 electrocautery, 4 surgical excision 5 and more recently CO 2 laser 6,7 with cure rates of between 56% and 80%. Warts that fail to respond to conventional treatment have been considered to be recalcitrant. These lesions are often frustrating to patients and present a therapeutic challenge to the physician. The longer the warts have been present, the more difficult they are to eradicate, 8 although the exact response rates for recalcitrant warts are not known. 9 Treating a mixture of simple and recalcitrant warts with topical paints or cryotherapy, Berth-Jones and Hutchinson 8 reported cure rates of 41% to 52%. Newer treatment modalities include cytotoxic agents 10 and H 2 blockers 11 and more recently pulsed dye laser (PDL), 9,12 14 with the last showing variable cure rates ranging from 0% to 93% for both simple and recalcitrant warts. We present our experience with PDL therapy for recalcitrant and simple viral warts. Patients and methods In our study we defined warts to be recalcitrant if they had been present for more than 2 years and had failed to respond to at least one conventional treatment modality. Warts not falling into these stringent criteria were considered simple. Over a 26-month period from January 1996, 28 patients (10 males, 18 females), aged from 5 to 69 (mean 30) years, with 103 recalcitrant and 20 simple warts were treated with PDL. Sixty-nine warts were present on cosmetically sensitive areas such as the face (n = 6) and hands (n = 63). The recalcitrant warts had been present for an average of 4.0 (range 2 15) years. Prior to PDL therapy, patients with recalcitrant warts had received an average of 6.8 (range 1 15) previous other treatments including cryotherapy (average of 3.2 treatments) and topical paints (average of 2.6 treatments). One patient had prior CO 2 laser and radiotherapy. Technique Treatment was carried out by the senior author (STT) as an office procedure, initially without local anaesthetic. However, some patients found this painful and subsequently lignocaine infiltration or nerve block was used routinely. Prior to laser treatment the keratotic component of the warts, when present, was pared with a scalpel blade, taking care to avoid bleeding. Paring allows deeper penetration of the laser beam into the wart. The involved nail plate was trimmed if periungual and subungual warts were being treated. The lesions were treated with the Cynosure PhotoGenica V (Boston, MA) PDL at 585 nm, pulse width of 450 µsec, with a power setting of 6.0 to 9.0 J/cm 2 using a spot size of 5 or 7 mm. The lower energy setting was used for treating facial lesions. The spots were overlapped by 1 mm with treatment extending 5 mm beyond the clinical margin of the wart. Each treated area received three passes. Postoperatively Aloe Vera gel (Healthways Holdings Ltd, NZ) was applied to the treated area, secured with a simple dressing. The patient was allowed to resume normal activity and the dressing was removed within 24 h. The treated areas generally 554

Pulsed dye laser therapy for viral warts 555 Table 1 Site Response of viral warts to PDL Number of warts Simple Recalcitrant Treated Eradicated Treated Eradicated Hand 9 5 54 49 Foot: plantar 1 1 12

1 Range 1 2 1 7 % eradicated 75 92 formed a grey or black eschar within 48 h which separated at 10 14 days leaving healed skin underneath.

2 Pulsed dye laser therapy for viral warts 555 Table 1 Site Response of viral warts to PDL Number of warts Simple Recalcitrant Treated Eradicated Treated Eradicated Hand Foot: plantar other Face Arms and legs Total Number of treatments Average Range % eradicated formed a grey or black eschar within 48 h which separated at days leaving healed skin underneath. Some patients developed blisters at the treatment site which were left intact whenever possible. Savlon cream (ICI Healthcare, NZ) and, if necessary, a simple dressing was applied if the blisters ruptured. Assessment Patients were reviewed at 6 8 weekly intervals to assess the response to treatment which was repeated as necessary. Consecutive patients with a minimum follow-up of 3 months after treatment were included in this study. Treatment was considered successful if the wart was completely eradicated and did not recur and was regarded as a failure if the wart persisted, was only partially removed or if there were warts in the vicinity of the treated site during the follow-up period. All patients were sent a postal questionnaire to assess the pain and disability associated with PDL treatment. Pain was assessed using a Visual Analogue Scale, with 0 as no pain and 10 corresponding to severe pain. The associated disability was assessed as the time taken to resume work or normal activity. To assess satisfaction with treatment, patients were also asked if they would have PDL therapy again if the need arose. Results Twenty-eight patients with 103 recalcitrant and 20 simple warts at various sites (Table 1, Figures 1 4) underwent PDL therapy. Of the recalcitrant warts treated, 95 (92%) were eradicated after an average of 2.1 (range 1 7) treatments. Fifteen of 20 simple warts (75%) were eradicated after an average of 1.6 (range 1 2) treatments. There was no recurrence of the wart at or within the vicinity of the treated site following eradication during an average follow-up period of 7.2 (range 3 15) months. Of the eight patients who were not cured of all of their warts (8 recalcitrant and 5 simple warts), four had one and the remainder had two treatments. These eight patients elected not to receive further treatment. One patient developed a mild degree of hypopigmentation at the treated site for recalcitrant warts on the knee. This patient had developed marked hypertrophic scarring following previous cryotherapy. One patient developed blisters and swelling and superficial infection following PDL treatment of recalcitrant plantar warts which responded to rest and oral antibiotics. This patient resumed vigorous activity postoperatively. Twenty-two of the 28 (79%) patients returned the postal questionnaires. Thirteen of the 16 patients who had undergone previous treatment with topical paints, and 4 of the 16 patients who had undergone Figure 1 (A) A 27-year-old female with recalcitrant warts on the pulp and periungual region of her right thumb for 15 years which were resistant to topical paints and cryotherapy. The lesions were eradicated by a single PDL treatment at 7.5 J/cm 2. (B) Result at 7 months.

556 British Journal of Plastic Surgery Figure 2 (A) A 14-year-old boy with multiple simple warts on his hands

5 J/cm 2 removed half the lesions. The remaining lesions were eradicated with a further treatment session.

Figure 3 (A) A 56-year-old female with multiple recalcitrant warts for 8 years including one on her right heel.

(B) Result at 7 months. Figure 4 (A) A 41-year-old man with recalcitrant warts on his left thumb for 3 years.

The lesions were eradicated after three PDL treatments at 7.4 9.1 J/cm 2. (B) Result at 3 months.

Eighteen out of the 22 patients resumed work or normal activity immediately, three after 1 day and one after 3

3 556 British Journal of Plastic Surgery Figure 2 (A) A 14-year-old boy with multiple simple warts on his hands for 1 year. These lesions were resistant to repeated cryotherapy and wart paints. The first PDL treatment at 7.5 J/cm 2 removed half the lesions. The remaining lesions were eradicated with a further treatment session. (B) Result at 4 months. Figure 3 (A) A 56-year-old female with multiple recalcitrant warts for 8 years including one on her right heel. The lesion resisted repeated cryotherapy. The lesion was eradicated after seven treatments at J/cm 2. (B) Result at 7 months. Figure 4 (A) A 41-year-old man with recalcitrant warts on his left thumb for 3 years. These lesions had resisted cryotherapy and wart paints. The lesions were eradicated after three PDL treatments at J/cm 2. (B) Result at 3 months. previous cryotherapy, found PDL more painful. Pain score associated with PDL therapy is shown in Figure 5. Eighteen out of the 22 patients resumed work or normal activity immediately, three after 1 day and one after 3 days postoperatively. Fourteen of the 22 patients stated that they would have PDL therapy again if the need arose, whilst four were undecided and the remaining four patients would not. The latter groups were amongst the eight patients who were not cured of their warts.

4 Pulsed dye laser therapy for viral warts 557 Pain Scores* Key: x Individual response^ Average Immediately Days Following PDL *Visual analogue pain scores: 0 = no pain, 10 = severe pain ^Individual response with pain score more than 0 Figure 5 Pain scores following pulsed dye laser treatment in 22 patients. infected and proliferating epidermal cells. 12 These treatment modalities may also result in bleeding, infection and scarring. 6 The CO 2 laser has been associated with severe and prolonged postoperative pain, delayed wound healing and scarring. 6 In contrast to ablative treatment modalities, PDL therapy does not normally produce an open wound, thus avoiding these complications. In contrast to other reports, 9,12 14 some of our patients reported significant, early postoperative pain although most resumed work or normal activity immediately after treatment. The very low incidence of scarring associated with PDL 17 makes it the treatment of choice for viral warts in cosmetically sensitive areas such as the face and paronychium. Acknowledgement We are grateful to Mrs C. Marstella for her assistance in the preparation of this manuscript. Discussion Most authors consider any viral wart that has failed to respond to a conventional treatment modality as recalcitrant. 9,12,14 Our stringent criteria define a group of warts that are particularly resistant to treatment. This is relevant in assessing the effectiveness of a new treatment modality which is costly. Previous reports on PDL therapy for viral warts showed conflicting results. 9,12 14 Tan et al 12 in a preliminary report showed 72% of patients were cleared of their recalcitrant warts after an average of 1.68 treatments. Kauvar et al 9 achieved an eradication rate of 93% for recalcitrant warts, after an average of 2.5 treatments. However, Huilgol et al 13 reported complete failure after six treatments for recalcitrant plantar warts. In our series, 11 of the 12 recalcitrant plantar warts were eradicated after an average of 2.8 (range 1 7) treatments. The results of Huilgol et al are unexplained, although they treated 2 mm of surrounding normal tissue in contrast to 5 mm in our study. It is also not clear how many passes each wart received. The patients in our study received three passes of the laser to each lesion. Warts contain dilated, congested blood vessels in the dermal papillae extending along the rete ridges. 12,15 Oxyhaemoglobin within the red corpuscles in the dermal capillaries preferentially absorbs yellow light (585 nm) leading to selective microvascular destruction. Removal of blood supply to the wart, and the heat generated by the laser, may lead to the destruction of the rapidly replicating human papilloma virus infected cells in the basal layer of the dermis. 12 It appears that an intact immune system is also essential as immunocompromised patients with viral warts respond poorly to PDL. 9 It is possible that the local dermal vascular destruction of the wart stimulates cell mediated immune responses known to be important for eradication of viral warts. 16 Conventional therapies for viral warts such as keratolytic agents, cryotherapy, surgical excision, electrocautery and CO 2 laser removal, work by non-specific tissue destruction that ultimately destroys the virally References 1. Rowson KEK, Mahy BWJ. Human paporva (wart) virus. Bacteriol Rev 1967; 31: Bunney MH. Viral warts: a new look at an old problem. Br Med J 1986; 293: Bunney MH, Nolan MW, Williams DA. An assessment of methods of treating viral warts by comparative treatment trials based on a standard design. Br J Dermatol 1976; 94: Burnett JW, Crutcher WA. In: Moschella S, Hurley H (eds), Dermatology, 2nd Ed. Philadelphia: Saunders, 1985; Vol 2: High AS, Crutcher WC. In: Champion RH, Burton JL, Ebling FJ (eds), Textbook of Dermatology, 5th Ed. Oxford: Blackwell, 1992; Vol 2: Logan RA, Zachary CB. Outcome of carbon dioxide laser therapy for persistent cutaneous viral warts. Br J Dermatol 1989; 121: Lim JT, Goh CL. Carbon dioxide laser treatment of periungual and subungual viral warts. Australas J Dermatol 1992; 33: Berth-Jones J, Hutchinson PE. Modern treatment of warts: cure rates at 3 and 6 months. Br J Dermatol 1992; 127: Kauvar ANB, McDaniel DH, Geronemus RG. Pulsed dye laser treatment of warts. Arch Fam Med 1995; 4: Sollitto RJ, Pizzano DM. Bleomycin sulfate in the treatment of mosaic plantar verrucae: a follow-up study. J Foot Ankle Surg 1996; 35: Yilmaz E, Alpsoy E, Barsaran E. Cimetidine therapy for warts: a placebo-controlled, double-blind study. J Am Acad Dermatol 1996; 34: Tan OT, Hurwitz RM, Stafford TJ. Pulsed dye laser treatment of recalcitrant verrucae: a preliminary report. Laser Surg Med 1993; 13: Huilgol SC, Barlow RJ, Markey AC. Failure of pulsed dye laser therapy for resistant verrucae. Clin Exp Dermatol 1996; 21: Jacobsen E, McGraw R, McCagh S. Pulsed dye laser efficacy as initial therapy for warts and against recalcitrant verrucae. Cutis 1997; 59: Lever WF, Schaumberg-Lever G. Diseases caused by viruses. Histopathology of the skin. Philadelphia: JB Lippincott Co., 1983; Morison WL. Viral warts, herpes simplex and herpes zoster in patients with secondary immune deficiencies and neoplasms. Br J Dermatol 1975; 92: Levine VJ, Geronemus RG. Adverse effects associated with the 577- and 585-nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: a study of 500 patients. J Am Acad Dermatol 1995; 4:

5 558 British Journal of Plastic Surgery The Authors J. Kenton-Smith BSc(Hons), FRCS, Plastic Surgery Registrar, Wellington Regional Plastic and Maxillo-facial Surgery Unit, Hutt Hospital, Wellington, New Zealand. S. T. Tans FRACS, Consultant Plastic Surgeon, Swee Tan Plastic Surgery Trust, Bowen Hospital, Churchill Drive, Crofton Downs, Wellington, New Zealand. Correspondence to Mr S. T. Tan Paper received 23 October Accepted 8 February 1999.

Study of the Effect of PDL Treatment of Recalcitrant Plantar Warts

ORIGINAL ARTICLE Study of the Effect of PDL Treatment of Recalcitrant Plantar Warts Ahmed Al-Mutairi, MD, Muhammad Elkashlan, MD Department of Dermatology, Ahmadi Hospital, Kuwait ABSTRACT Forty patients