CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS

This is a retrospective study of the cure rates of forty patients with subungual and periungual viral warts treated with carbon dioxide laser vapourisation (total of 69 lesions). 70.6% (48/68) lesions had failed treatment with cryotherapy and/or electrocautery treatment previously. 20/68 were treated with CO2 laser vapourisation as a first line treatment. The overall cure rate over 10 months follow-up period was 57.4% (39/68). Most recurrences (24/25) occurred within the first 3 months of vapourisation. The carbon dioxide laser vapourisation cure rate for warts in which previous cryotherapy and/or electrocautery had failed was 47.9% whereas those treated with carbon dioxide laser vapourisation as a first line treatment had a cure rate of 80% (p = 0.043). Subungual warts responded slightly better with a cure rate of 64.7% compared with periungual warts (54.9%) (n.s.). The carbon dioxide laser vapourisation cure rate for recurrent subungual and periungual warts (which failed previous carbon dioxide laser vapourisation) was 73.3% (11/15). Our findings appeared to indicate that periungual and subungual warts can be eradicated by CO2 laser vapourisation. Recurrent warts can be effectively eradicated by further vapourisation. Recalcitrant periungual and subungual warts which have previously failed to respond to cryotherapy and/or electrocautery can be effectively eradicated with CO2 laser vapourisation.     

Efficacy and tolerability of a new topical nitric‐zinc preparation for “difficult‐to‐treat” warts

Treating plantar, periungual, and external genital warts can be challenging. A prospective study from four centers in Italy evaluated 37 immunocompetent patients with single or multiple warts and treated each lesion with a nitric‐zinc topical solution composed of organic and inorganic acids meant to devitalize tissue and destroy HPV DNA in infected keratinocytes. Thirty of the 37 patients had external genital warts, two had plantar warts, two had palm and finger warts, and three had subungual warts for a total of 55 lesions treated. Nitric‐zinc aqueous solution was applied over each wart utilizing a 30 µL capillary tube until a whitening response was observed. Additional applications as needed were accomplished at 2‐week intervals until the wart was gone. In those with hand, plantar, and subungual warts, there was a 100% clearance after two to three sessions. Three with external genital warts had only a partial response and one no benefit after four applications. Thus, this approach was effective in external genital and other “difficult‐to‐treat” warts in 90% of patients after one to four applications. It also was easy to use with no adverse events noted.     

Photodynamic therapy with 20% aminolevulinic acid for the treatment of recalcitrant viral warts in an Asian population

BACKGROUND: Topical photodynamic therapy (PDT) is based on the principle of targeted tissue destruction using selective photosensitization via a topical porphyrin precursor, followed by light exposure. It is well established for the treatment of actinic keratoses and superficial nonmelanoma skin cancers. Some studies have reported good efficacy when using PDT to treat viral warts in the Western population. METHODS: We carried out a prospective, single-arm, phase II study of 5-aminolevulinic acid (5-ALA)-PDT in the treatment of recalcitrant viral warts in an Asian population. Recalcitrant viral warts were surgically pared, and then treated with 20% 5-ALA cream (Medac, Hamburg, Germany) under occlusion for 4 hours before irradiation with a red light source (Waldmann PDT1200; wavelength, 590-700 nm) at an irradiance of 50 mW/cm(2) and a total dose of 50 J/cm(2). PDT was repeated fortnightly for a maximum of four times. RESULTS: Twelve adult Asian patients were enrolled into the study (10 males, two females). The mean age of the patients was 32.8 years (range, 18-70 years). They had skin phototypes III-IV. Nine patients had plantar warts and three patients had hand warts (two had warts on the fingers, one had a wart on the palm). Five patients (42%) showed complete disappearance of their warts, one patient (8%) showed partial clearance (greater than 50% decrease in the wart area), five patients (42%) had stable disease (less than 50% decrease in the wart area), and one (8%) showed progressive disease (increase in the wart area). Adverse effects included mild to moderate pain and erythema, which lasted no longer than 48 hours and was well tolerated by all patients. None of the patients withdrew from the study because of side-effects. CONCLUSION: 5-ALA-PDT, given its noninvasiveness, minimal adverse effects, and good cosmetic results, is a promising alternative treatment for recalcitrant viral warts. Further studies with a larger cohort of patients would be of value.     

Topical Immunotherapy with Diphenylcyclopropenone Is Effective and Preferred in the Treatment of Periungual Warts

Background

There exists a treatment challenge with periungual warts. Topical immunotherapy with diphenylcyclopropenone (DPCP) has recently been reported to be an effective treatment for recalcitrant warts, including periungual types.

Objective

We aimed to evaluate the effectiveness and preference of topical immunotherapy with DPCP in treating periungual warts.

Methods

Twenty-seven patients with periungual warts who were treated with DPCP immunotherapy (2007 through 2010; Dongguk University Ilsan Hospital, Goyang, Korea) were retrospectively recruited. Other treatment modalities were also used in some patients. Lesions were grouped into the types according to the following locations: proximal nail fold, lateral nail fold and hyponychium. Total and group clearance rates as well as treatment periods according to location and disease duration were evaluated. A patient questionnaire was performed to assess the satisfaction for the treatments in those who received multiple therapies.

Results

Total success rates were 85% (by subjects) and 91% (by individual lesions). Success rate and treatment period for proximal nail fold type seemed more desirable than other locations. Success rate decreased and treatment period increased as disease duration increased. The questionnaire revealed a significantly higher satisfaction rate for DPCP immunotherapy than for cryotherapy and pulsed-dye laser.

Conclusion

Topical immunotherapy with DPCP is an effective and preferred method in the treatment of periungual warts.     

Compared therapeutic efficacy between intralesional bleomycin and cryotherapy for common warts: a randomized clinical trial

In spite of many available studies on bleomycin and cryotherapy in treating warts, little head to head research is done to compare efficacy of these treatments. Our aim was to compare the therapeutic effects of intralesional bleomycin and cryotherapy on common warts of the hands and feet. In this clinical trial 44 patients above 12 years of age referred to the dermatology clinic of Bouali University Hospital were enrolled. The patients were required to have warts on at least two symmetric limbs (hands or feet). The warts located on right and left limbs of each patient were examined and counted. Each patient received both cryotherapy and intralesional bleomycin on his or her warts. The two treatment types were randomly allocated to either right sided or left sided warts. Each patient was evaluated at 2 week intervals and retreated if necessary up to three times. Data were analyzed by SPSS 11 and EPI Info 2002 statistical packages. The mean number of warts was 5.2 on upper limbs and 4.6 on lower limbs. In 86.4 percent of the cases all warts on the limb side treated by intralesional bleomycin were cleared compared with 68.2 % for cryotherapy (P<0.05). Relative risk for the effect of bleomycin compared to cryotherapy in this regard was 1.27 (1相似文献   

Pulsed dye laser treatment for viral warts: a study of 120 patients

A prospective, non-blinded, non-randomized study on 120 wart patients treated with pulsed dye laser was performed to evaluate the efficacy and safety of pulsed dye laser treatment for viral warts and to demonstrate the proper application and effective technique of this method. The overall clearance rate was 49.5%. The clearance rates of flat warts, periungual warts, plantar warts and common warts were 67.6%, 51.1%, 47.6% and 44.3%, respectively. Overall, the response rates of pediatric warts, recalcitrant warts and old warts were superior to those of adult warts, simple warts and non-old warts, respectively; however, those trends were not statistically significant. We concluded that pulsed dye laser treatment is a safe, tolerable and relatively effective treatment method for viral warts. Pulsed dye laser treatment may be a more efficacious method for flat warts and recalcitrant periungual warts, and it can be an effective modality for newly-developed warts. The highest clearance rate was noted at a fluence of 9.5 J/cm2 (P < or = 0.05) and it is recommended that practitioners perform pulsed dye laser treatments for viral warts at the fluences of 9.0-9.5 J/cm2. A replacement of pulsed dye laser treatment should be considered unless prominent improvement is observed after three treatment sessions.     

Topical 5-fluorouracil has no additional benefit in treating common warts with cryotherapy: a single-centre, double-blind, randomized, placebo-controlled trial

The role of topical 5-fluorouracil (5-FU) in treating common warts is not well defined. We tried to evaluate the efficacy and adverse effects of combination cryotherapy and topical 5% 5-FU ointment in the treatment of common warts. The study was a single-centre, double-blind randomized placebo-controlled trial. In the study, 80 patients with common warts were randomized into two groups and underwent two 10-second freeze/thaw cycles of cryotherapy with liquid nitrogen once every three weeks for a maximum of five treatments. Between treatments, patients applied either topical 5% 5-FU ointment (group A) or placebo aqueous cream (group B) twice daily. The mean +/- SD reduction in wart area was 58.57 +/- 0.06% in group A and 65.29 +/- 0.06% in group B. In total, 19 patients in group A and 24 patients in group B had wart size reduced by 75% or more (P = 0.50), while 12 patients in group A and 17 patients in group B had clearance of their warts (P = 0.245). Logistic regression with age, sex, smoking status, immune status, site, duration and number of warty lesions, history of previous treatment, and treatment group found that only a history of previous treatment and acral lesions were significant adverse predictors of improvement. There was no significant difference in the number of adverse events between the two groups, although there was a trend towards more pain and blistering associated with topical 5-FU. We concluded that topical 5-FU has no added benefit in treating common warts with cryotherapy.     

Outcome of carbon dioxide laser therapy for persistent cutaneous viral warts

Twenty-two adults with persistent, symptomatic viral warts on the hands or feet which had failed to respond to conventional therapy were treated by carbon dioxide (CO2) laser ablation under local anaesthesia. Four patients did not return for follow-up treatment. Of the remaining 18 patients, 12 had plantar warts, the other six had warts on the hands that were mainly periungual. The median duration of the warts prior to laser treatment was 5 years. The areas treated were solitary in eight and multiple in 10 cases. After an average follow-up period of 10 months (minimum 6 months), all of the treated areas were clear of warts in 10 patients (56%), some had cleared in three, and all the treated warts had relapsed in the other five patients. Side-effects were commonly observed, especially post-operative pain, temporary loss of function of the treated part and scarring. The use of the CO2 laser may clear otherwise resistant viral warts but a significant morbidity may occur with this method of treatment.     

Cryotherapy of common viral warts at intervals of 1, 2 and 3 weeks

We studied the efficacy, and time to clearance, of more frequent cryotherapy of viral warts, by randomizing 225 patients to receive treatment at 1-, 2- or 3-weekly intervals. The mean times to clearance of warts in each group were 5.5, 9.5 and 15 weeks in the weekly, 2-weekly and 3-weekly groups, respectively (P < 0.01). Cure rates after 3 months correlated with frequency of treatment (P < 0.05). After 3 months, 43% (66% of non-defaulters) had cleared in the group treated weekly, 37% (47%) of the group treated every 2 weeks, and 26% (30%) of those treated every 3 weeks. The mean numbers of treatments needed to achieve clearance were similar in each group (5.5, 4.75 and 5 treatments). After 12 treatments, cure rates were similar for all three groups: 43% for the weekly- treated group (3 months), 48% for the 2-weekly group (6 months), and 44% for the 3-weekly group (9 months). Percentage cure is related to the number of treatments received, and independent of the interval between treatments. A more rapid cure may, therefore, be achieved by more frequent treatment.     

The SILVER study. Efficacy of topical nitric‐zinc complex solution in the treatment of resistant warts: A postmarketing evaluation

The treatment of cutaneous viral warts caused by human papillomavirus (HPV) infection is often subject to local recurrence and a long clinical and treatment course. Our aim was to analyze real‐life data on the treatment of difficult‐to‐treat warts from a multicenter postmarketing surveillance assessment on the efficacy, tolerability, and safety of a commercially available nitric‐zinc complex solution (NZCS). Dermatologists from 14 Italian centers completed a questionnaire about their clinical experience on treatment of “difficult‐to‐treat” warts, which included warts in the plantar, periungual, anogenital and aesthetically sensitive areas. The questionnaire was designed to obtain detailed information on wart treatment and compare NZCS efficacy with previous treatments. Of 106 questionnaires returned, 83 reported NZCS use; 67 had previous treatments (23 cryotherapy, 2 electrocoagulation, 12 other topical application, and 30 combined treatment, such as laser, cryotherapy, and/or electrocoagulation). NZCS had superior efficacy to that of previous treatments (p < .0001), resulting in 84.1% with a full or partial clearance (vs. 44.8% for previous treatments), and had better local tolerability (p < .0001). NZCS showed better efficacy and tolerability than other previous wart treatments.     

The Use of Diphenylcyclopropenone in the Treatment of Recalcitrant Warts

Background: The treatment of recalcitrant palmoplantar and periungual warts using topical immunotherapy with diphenylcyclopropenone (DPC) was reviewed retrospectively over a seven-year period. Methods: Two hundred eleven patients were sensitized during this time. The patients consisted of 90 males and 121 females and were between 5 and 78 years old. Twenty-three patients were lost to followup. Of the remaining, 4 were undergoing treatment at the time of evaluation, 1 patient failed sensitization, and 1 patient became pregnant. Four discontinued because of side effects, 3 because of financial reasons, and 18 patients discontinued treatment prior to completing the minimum required applications (defined as 6), producing a dropout rate of 12% (25/211). Three patients had additional treatment during the course of DPC and were not included in the study. The remaining 154 patients were classified as nonresponders or responders. Results: The responders consisted of 135 individuals (87.7%) that had complete clearance of warts. Reported adverse effects were local and included with pruritus (15.6%), with blistering (7.1%), and with eczematous reactions (14.2%). The majority of the patients tolerated the treatment very well. One patient developed local impetigo. Patients had an average of 5 treatments over a 6-month period. Conclusions: Topical immunotherapy using DPC is an effective treatment option for recalcitrant warts. It should be considered as first-line treatment for warts based on its high response rate, absence of scarring, and painless application.     

5-氨基酮戊酸光动力疗法预防尖锐湿疣复发

目的观察5-氨基酮戊酸光动力疗法(ALA-PDT)对于预防尖锐湿疣复发的作用。方法107例尖锐湿疣患者经CO2激光祛除疣体,并在创面愈合后随机分为二组,治疗组55例在原疣体部位局部外敷10%5-氨基酮戊酸(ALA)霜剂,包括皮损周围1.0～2.0cm,并用薄膜封包3h,再用光动力治疗仪照射,时间为20min/光斑,光斑直径2.0cm,1次/w,连续2次,此后每2～4w随访1次,连续6个月;对照组52例,创面痊愈后,不用任何药物,仅每2～4w随访1次,连续6个月,观察两组治疗区的疣体复发情况。结果治疗组有4例在治疗部位(光斑直径2.0cm范围内)出现疣体,复发率为7.27%,对照组共有35例在治疗范围(直径2.0cm内)出现疣体,复发率为67.30%。结论ALA-PDT对尖锐湿疣复发具有很好的预防作用。     

Periungual and subungual arteriovenous tumours

We describe the clinicopathological findings in five cases of an acquired vascular tumour involving periungual or subungual tissue. We believe that these represent acral arteriovenous tumours (cirsoid aneurysms). There are no previous reports of subungual or periungual acral arteriovenous tumours.     

Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud

BACKGROUND: Viral warts represent a large workload for dermatology departments. Cryotherapy with liquid nitrogen is the most widely used method of treatment by dermatologists and is increasingly used by general practitioners in the U.K. Existing data relating to the response to cryotherapy are virtually all derived from the use of a cotton wool bud as the applicator. There is an increasing trend to use the cryo-spray to freeze warts and it has been assumed that this is equally effective. In view of the workload involved it is important to test this assumption. OBJECTIVES: This prospective study was undertaken to compare these two methods of liquid nitrogen cryotherapy with regards to cure rate after 3 months of treatment. METHODS: Patients referred to two hospital dermatology departments with hand or foot warts were allocated to have liquid nitrogen applied with either a cryo-spray or with a cotton wool bud. Using either technique, liquid nitrogen was applied until ice-ball formation had spread from the centre to include a margin of 2 mm around each wart. Treatment was done fortnightly for up to 3 months. Plantar warts were pared and treated with a double freeze-thaw cycle. The endpoint of the study was complete clearance of all warts. RESULTS: Three hundred and sixty-three patients were enrolled, mean age 21 years (range 3-75), 188 male and 175 female. The mean duration of the warts was 98 weeks (median 78, range 2-936). The number of warts on the hands and feet varied from one to 80 (mean 5). The treatment groups were comparable with regards to baseline demographics. Two hundred and seven patients were evaluable. Cure rates at 3 months were 47% in the cotton wool bud group and 44% in the cryo-spray group (P = 0.8). Warts that had been present for 6 months or less (n = 31) had a greater chance of clearance (84%) compared with warts that had been present for more than 6 months (39%, n = 176) (P < 0.0005). CONCLUSIONS: Cryotherapy with liquid nitrogen for hand and foot warts in our study was equally effective when applied with a cotton wool bud or by means of a spray.     

光动力联合二氧化碳激光治疗顽固性跖疣的研究

目的观察外用5-氨基酮戊酸(5-ALA)光动力联合二氧化碳(CO2)激光治疗顽固性跖疣的临床疗效。方法收集顽固性跖疣患者30例,超脉冲CO2激光去除厚硬的角质层,20%5-ALA霜封包4～5 h,633 nm的红光照射20 min(126 J/cm2),用聚合酶链反应技术(polymerase chain reaction,PCR)技术进行人乳头瘤病毒(humanpapillomavirus,HPV)病毒分型,分析各型HPV对光动力治疗反应的差异。结果本组30例患者经3次光动力治疗,16例患者完全缓解(完全缓解率53.3%),4例(13.3%)患者部分缓解,10例(33.3%)患者无反应。各型HPV对光动力治疗的反应差异无统计学意义。结论外用5-ALA光动力联合二氧化碳激光治疗顽固性跖疣是一种新的、有效的、安全的治疗方案,可以作为跖疣的二线治疗方案。     

Cryotherapy Versus Podophyllin in the Treatment of Genital Warts

Abstract: 572 patients with solitary or multiple genital warts attending the Department of Genitourinary Medicine at the Royal Victoria Hospital, Bournemouth, U.K. between lanuary 1981 and December 1981 were allocated to either pedophilic or cryotherapy for the treatment of their warts. Of 350 patients successfully treated for their warts and returned for a follow-up examination 6 weeks or more after completing their treatment, 206 (139 men and 67 women) were treated with pedophilic, and 144 (86 men and 58 women) with cry therapy. One hundred five (51 %) of those treated with pedophilic and 114 (79%) treated with cryotherapy were free of warts at their follow-up examination. Patients treated with podophyllin required a mean of 6,7 SD 3.5 treatments over a mean of 4.7 SD 2.4 weeks, whereas those receiving cryotherapy required a mean of 2.6 SD 2.0 applications over a mean of 2.3 SD 1.2 weeks.     

系统性红斑狼疮患者末梢血液改变的激光散斑成像观察

目的 利用激光散斑衬比分析（LSCA）技术无创性观察分析和评价系统性红斑狼疮（SLE）患者治疗前后末梢血流改变与健康人之间的差异,探讨气温、年龄、性别因素对末梢血流改变的影响。方法 收集47例SLE患者第1次就诊时的天气温度（≥ 20 ℃组和＜20 ℃组）、年龄（< 20岁、20 ~ < 40岁、 ≥ 40岁组）、性别及血尿常规、补体、抗体免疫学检查等临床资料,依据 SLEDAI评分法进行病情评估,与LSCA技术测量的末梢血流改变进行相关性分析,并与30例健康人进行比较。结果 47例SLE患者末梢血流甲下为7.017 ± 0.356,甲周为7.821 ± 0.662,与30例健康人（甲下9.765 ± 0.337,甲周3.129 ± 0.128）相比,差异均有统计学意义（t值分别为5.182、5.414,P < 0.05）。SLEDAI评分与甲下及甲周血流改变程度之间存在正相关性（r分别为0.601、0.260,P < 0.05）。随访的28例患者治疗后甲周血流（5.204 ± 0.476）改善明显,与治疗前（7.967 ± 0.913）比较,t = 4.644,P < 0.05;甲下血流（7.578 ± 0.554）改善不明显,与治疗前（7.039 ± 0.635）比较,t = 2.064,P＞0.05。气温对甲下血流有影响（t = 2.415,P < 0.05）,对甲周无明显影响（t = 0.758,P＞0.05）;性别和年龄对患者甲下及甲周血流的改变影响不明显。结论 SLE患者末梢血流较健康人改变明显,治疗后有一定程度的改善,气温对患者甲下血流改变影响较大。LSCA技术或许可更加便捷、量化地作为SLE患者病情严重程度评价的补充方法。     

Closing the feedback loop: an audit of the use of imiquimod for the treatment of genital warts

A retrospective case-note audit of 74 patients with 81 treatment episodes of anogenital warts with imiquimod from April 1999 until July 2000 was performed. The majority of patients had failed to clear their warts with other treatments, had recurrences after other treatments, or had other medical problems complicating their genital wart treatment. The overall clinically confirmed complete clearance rate was 33%. This is lower than other published data, but may be so because it includes patients with immunosuppression and difficult-to-treat warts. The complete clearance rate in immunocompetent patients was 37%. In addition, in this audit of clinical practice 17% of the patients did not return for full response to be assessed. The complete clearance rate in those who were able to tolerate treatment and who returned for follow-up was 45%. Based on the results of the audit we have extended the indications for the use of imiquimod in the clinic treatment guidelines. Patients are now offered imiquimod if six or more episodes of other treatments fail to give a good response. Earlier treatment with imiquimod is also offered to those patients with recurrent anogenital warts, and it is recommended as a first-line therapy for patients with multiple keratinized warts.     

Comparative study of autoimplantation therapy and intralesional injection of MMR vaccine in warts treatment

Autoimplantation is a simple technique and considered as a novel method of immunotherapy in treating warts. Intralesional immunotherapy by mumps, measles, and rubella (MMR) vaccine is also a promising treatment modality for multiple warts. To compare the efficacy and safety of both the methods in treating multiple warts, the study included 80 patients divided into two groups (Group A and Group B), each containing 40 patients. Informed consent was taken from each patient before enrollment into the study. Group A patients were treated by autoimplantation technique every 2 weeks for a maximum of four treatments. Similarly, Group B patients received MMR intralesional injection at a dose of 0.5 ml every 2 weeks for a maximum of four treatments. Complete clearance of the donor wart was observed in 60% patients in Group A, whereas complete clearance in the Group B injected by MMR was 72.5%. On the other hand, a significant difference (p < .05) was found in the therapeutic response among nonmanipulated warts in both groups, where complete clearance was observed in 47.5% of Group A patients versus 20% of Group B patients. Autoimplantation is a suitable approach for patients with multiple warts associated with distant lesions, while MMR injection is ideal for a single or fewer number of warts.     

Contact immunotherapy with squaric acid dibutylester for the treatment of recalcitrant warts.

BACKGROUND: Contact immunotherapy has been shown to be effective for warts. Two previous studies on the use of squaric acid dibutylester (SADBE) for warts have reported widely divergent cure rates (10% and 60%). OBJECTIVE: Our purpose was to determine the efficacy of SADBE in the treatment of recalcitrant warts. METHODS: We treated 29 patients with SADBE for warts that were resistant to other therapies. The patient population had warts for a mean duration of 2.1 years. Patients were sensitized with 1% or 2% SADBE in acetone under occlusion, then treated with 0.5% to 5% SADBE applied to their warts every 2 to 4 weeks in the office. RESULTS: Clearing of all warts was seen in 20 of 29 patients (69%), improvement in 3 patients (10%), and no change in 6 patients (21%). For the cured patients, mean duration of treatment was 4.2 months (range, 1 to 12 months) and mean number of treatments was 5.7 (range, 2 to 15). Adverse effects included acute contact dermatitis with 6 patients experiencing blisters and one experiencing hypopigmentation. CONCLUSION: SADBE treatment is worth considering in patients with recalcitrant warts, especially in those who tolerate painful procedures poorly.