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Keywords:

  • flat warts;
  • pulsed dye laser;
  • treatment

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. References

The facial flat wart is not only a contagious viral disease, but also a cause of a distressing cosmetic problem. Although there are many therapeutic options, including salicylic acid, imiquimod, cryotherapy, retinoids, intralesional immunotherapy, and topical 5-aminolevulinic acid photodynamic therapy among others, no monotherapy has been proved to achieve complete remission in every case. Treatment with pulsed dye laser (PDL) seems to be a promising therapeutic option. To assess the efficacy and safety of PDL in a series of patients with viral flat warts on the face, in this prospective study, 32 patients were treated with PDL at 595-nm wavelength, a laser energy density of 9 or 14 J/cm2 with a spot size of 7 or 5 mm, respectively, with air cooling and a pulse duration of 0.5 millisecond. A complete response was noted in 14 patients (44%), and an excellent response was observed in 18 patients (56%) with 1-year follow-up, with only four recurrences. No significant side effects were reported except intense transitory purpuric response. We consider that PDL is a good option of treatment for flat warts on the face due to its good clinical results, fast response, and low incidence of side effects.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. References

Flat warts are most frequently caused by human papilloma virus (HPV) types 3, 10, 28, and 41. They typically present as skin-colored or light brownish, flat-topped papules on the face, beard area, dorsal hands, and shins, which primarily affects children and young adults [1]. Although there are many therapeutic modalities, including salicylic acid, imiquimod, cryotherapy, retinoids, intralesional immunotherapy, and topical 5-aminolevulinic acid photodynamic therapy, no monotherapy has been proved to achieve complete remission in every case [2].

Clinical research has revealed that pulsed dye laser (PDL) can treat HPV-related diseases [3, 4]. The mechanism of action of the PDL is through selective microvascular destruction of dilated capillaries in the warts. Perhaps, this happens as a result of thermal damage occurring upon yellow light absorption (585 nm) by oxyhemoglobin. Thermal damage, removal of the blood supply, and a cell-mediated immune response are believed to contribute to wart healing [5].

We report on 32 cases of recalcitrant facial flat warts and propose an option for this troublesome disease.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. References

In this prospective study, we included 32 patients (25 females and 7 males) with a mean age of 35.3 years (range: 12–56 years). All patients were treated with PDL for facial flat warts at the Department of Dermatology of the Ramón y Cajal Hospital in 2010. Twenty-four of the thirty-two patients had previously been treated with other methods. Five patients were immunosuppressed. The hospital's ethics committee approved the study. Fully informed written consent was obtained from all patients before the first treatment.

Treatment with PDL (Cynergy, Cynosure Inc., Westford, MA, USA) at 595-nm wavelength was performed using a spot size of 5 or 7 mm, a pulse duration of 0.5 millisecond, and fluences of 9 or 14 J/cm2 (see Table 1); one to three passes with a minute delay between each PDL pass were applied per treatment session until reaching an intense purpuric response as the clinical endpoint. Laser sessions were repeated 3 weeks later in only 12 cases. Continuous airflow cooling (Cryo5©, Zimmer Medizinsysteme GmbH, Neu-Ulm, Germany) was always applied at maximum level “6” during laser treatment. Post-laser care consisted of a daily application of a topical antibiotic ointment (fusidic acid 2% cream) for a week and sunscreen with a sun protection factor of 50 to avoid post-inflammatory hyperpigmentation.

Table 1. Clinical characteristics, outcome, and laser parameters
 Parameters (spot; pulse duration; fluence; wavelength)PDL sessionsPassesNo. of flat wartsClearance rateFollow-up (months)RecurrencesPatient satisfaction
  1. PDL, pulsed dye laser.

 1PDL 7 mm; 0.5 millisecond; 9 J/cm2127Complete12No10
 2PDL 5 mm; 0.5 millisecond; 14 J/cm2218Complete12No10
 3PDL 5 mm; 0.5 millisecond; 14 J/cm21321Partial (75–99%)12No9
 4PDL 5 mm; 0.5 millisecond; 14 J/cm21113Complete12No10
 5PDL 7 mm; 0.5 millisecond; 14 J/cm21318Partial (75–99%)12No8
 6PDL 7 mm; 0.5 millisecond; 9 J/cm21125Partial (75–99%)12No8
 7PDL 7 mm; 0.5 millisecond; 9 J/cm2118Complete12No10
 8PDL 5 mm; 0.5 millisecond; 14 J/cm2125Complete12No10
 9PDL 5 mm; 0.5 millisecond; 14 J/cm2116Complete12No10
10PDL 5 mm; 0.5 millisecond; 14 J/cm21218Complete12No10
11PDL 7 mm; 0.5 millisecond; 9 J/cm2228Complete12No10
12PDL 5 mm; 0.5 millisecond; 14 J/cm22213Partial (75–99%)12No8
13PDL 5 mm; 0.5 millisecond; 14 J/cm22321Partial (75–99%)12Yes7
14PDL 5 mm; 0.5 millisecond; 14 J/cm22334Partial (75–99%)12Yes7
15PDL 5 mm; 0.5 millisecond; 14 J/cm22212Partial (75–99%)12No8
16PDL 5 mm; 0.5 millisecond; 14 J/cm2123Partial (75–99%)12No8
17PDL 5 mm; 0.5 millisecond; 14 J/cm2127Partial (75–99%)12No9
18PDL 5 mm; 0.5 millisecond; 14 J/cm2229Partial (75–99%)12No9
19PDL 5 mm; 0.5 millisecond; 14 J/cm21312Complete12No9
20PDL 5 mm; 0.5 millisecond; 14 J/cm2226Complete12Yes9
21PDL 5 mm; 0.5 millisecond; 14 J/cm2124Complete12Yes10
22PDL 5 mm; 0.5 millisecond; 14 J/cm2139Partial (75–99%)6No9
23PDL 5 mm; 0.5 millisecond; 14 J/cm21311Partial (75–99%)6No10
24PDL 5 mm; 0.5 milliseconds; 14 J/cm2227Partial (75–99%)6No9
25PDL 5 mm; 0.5 millisecond; 14 J/cm21212Partial (75–99%)6No9
26PDL 5 mm; 0.5 millisecond; 14 J/cm2223Complete6No10
27PDL 5 mm; 0.5 millisecond; 14 J/cm2137Complete6No10
28PDL 5 mm; 0.5 millisecond; 14 J/cm22210Partial (75–99%)6No10
29PDL 5 mm; 0.5 millisecond; 14 J/cm22211Partial (75–99%)6No10
30PDL 5 mm; 0.5 millisecond; 14 J/cm21226Partial (75–99%)6No8
31PDL 5 mm; 0.5 millisecond; 14 J/cm21221Partial (75–99%)6No8
32PDL 7 mm; 0.5 millisecond; 9 J/cm2127Complete6No10

The clinical response was evaluated as complete (100% lesion clearance), excellent (75–99% lesion clearance), good (50–75% lesion clearance), or poor (<50% lesion clearance). Three different expert dermatologists evaluated the clinical response by visual assessment of the patient's lesions before treatment and every 4 months during the 1-year follow-up. Patient satisfaction was evaluated using a scoring system, in which 0 corresponded to “no satisfaction” and 10 to “complete satisfaction.”

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. References

Thirty-two patients (25 females and 7 males) with flat warts treated with PDL were enrolled in this study. The mean age of the patients was 35.3 years (range: 12–56 years). The total number of treated warts was 382. The number of warts was quantified in every patient before and after laser treatment. The mean duration of the warts was 18 months (range: 7–37 months). Of the 32 patients, 24 (75%) had undergone unsuccessful prior treatments, including cryotherapy, topical salicylic acid, and topical lactic acid.

Of the 382 treated warts, 298 were eradicated and the overall clearance rate was 78%. A complete response was noted in 14 patients (44%) and an excellent response was observed in 18 patients (56%) (FIGS 1 and 2). Only four recurrences were observed during the 12-month follow-up. Of the five immunosuppressed patients, two had complete responses after two PDL sessions; and an excellent response was achieved in the remaining three. Two of these patients had recurrences, which nevertheless responded satisfactorily to a single new PDL session.

figure

Figure 1. A 37-year-old woman with a 2-year history of flat warts on both cheeks showing no clinical response to several topical treatments. (A) Pretreatment; (B) Day 10 after treatment; (C) 21 days after treatment, showing resolution of most warts.

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figure

Figure 2. (A) A woman with 1-year history of flat warts located on the upper right eyelid, with decreased quality of life due to associated low mood and depressive thoughts. (B) The central picture shows transient purpuric response associated with pulsed dye laser treatment. (C) Day 14 after treatment: clearance of all warts.

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Table 1 shows the clinical characteristics, the treatment outcome, and the laser parameters used. PDL at 595-nm wavelength has higher penetration in the tissue than PDL with a 585-nm wavelength, which nevertheless is more selective for oxyhemoglobin. No significant side effects were reported due to therapy. Focal post-inflammatory hyperpigmentation on treated areas was observed in only three patients. However, the hyperpigmentation faded gradually and disappeared after 3 months without any topical medication except sunscreen. The patients' satisfaction degree with this treatment was high or very high.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. References

Recalcitrant flat warts may persist for years despite treatment and frequently cause a significant effect on individual emotional well-being, particularly facial lesions [3, 6].

Due to the unpredictable clinical course, treatment for flat warts depends on the extent of the lesions, the area involved, and the patient's desire for therapy.

Common therapeutic approaches include topical retinoids, salicylic acid, imiquimod, cryotherapy, topical immunotherapy, cimetidine, immunotherapy, Q-switched Neodymium:Yttrium-aluminum-garnet laser, or photodynamic therapy [7].

In recent years, PDL has been used to treat recalcitrant warts including flat, common, palmar/plantar, and periungual warts. The mechanism of action is unclear but may be a result of specific destruction of superficial dilated capillaries in warts by selective photothermolysis of oxyhemoglobin within the microvasculature. The damage of virally infected keratinocytes by PDL may contribute to the treatment of warts as HPV is heat-sensitive [8, 9].

PDL causes minimal postoperative pain, and purpura heals completely in 1–2 weeks [5]. It produces less pain and scarring than CO2 laser treatment and has been used for facial warts with good tolerance in children [10-12].

The reported studies on the efficacy of PDL treatment for viral warts have shown variable response rates with cure rates from 0 to 100% depending on the series [1-3, 9]. Moreover, there are few reports on the efficiency of PDL on the flat variant of warts. In a prospective study on 120 wart patients treated with PDL, Park & Choi found that flat warts were most responsive, followed by palmar/plantar, common, and periungual warts. The reported clearance rate of flat warts in their study was 67.6% [9]. Khandpur & Sharma reported on four flat wart patients with complete response after a mean of 3.25 PDL sessions [6]. Our study showed similar results to those described in the literature. We treated 32 patients with flat warts with PDL at the wavelength of 595 in 1–2 sessions with 1–3 passes for each session. Complete response was noted in 14 patients (44%) and an excellent response was observed in 18 patients (56%). After 1 year of follow-up, most of patients remain free of lesions.

In summary, we consider that PDL is a good option of treatment for flat warts on the face due to its good clinical results, fast response, and low incidence of side effects. In our experience, flat warts are a subtype of warts that respond better to PDL. This might be due to all the energy being superficially retained and also to the lack of hyperkeratosis in this type of warts.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. References