Pulsed Dye Laser Treatment of Warts: An Update

BACKGROUND: Warts are a therapeutic challenge. New studies indicate that pulsed dye laser therapy may be effective, with clearance rates of 72 to 93%. OBJECTIVE: To determine clearance rate in pulsed dye laser treatment of warts and compare our rate to those of other published studies. METHODS: Thirty-three patients with 96 warts received pulsed dye laser treatment for recalcitrant plantar, digital, peri- and subungual, and body warts. RESULTS: Forty-eight percent of patients had complete wart clearance; 45% partially cleared. Sixty-nine percent of those who cleared remained wart-free for an average of 11 months. Mean fluence was 9.4 J/cm2, with an average of 3.4 treatments. Body and palmar warts responded best, digital and peri- and subungual next, and plantar lesions worst. No significant side effects were observed. CONCLUSION: Pulsed dye laser is an effective treatment option for recalcitrant warts with an excellent side effect profile. However, our response rates were not as high as those previously reported, and we feel that further studies would be useful.     

Photodynamic Therapy: New Treatment for Therapy-Resistant Plantar Warts

BACKGROUND: Plantar wart treatment remains a challenging one. Various treatment modalities have been previously used and are still in current use. The problem remains in the degree of response to these treatments and the side effects associated with them. OBJECTIVE: The aim of this study was to test a new treatment modality for therapy-resistant plantar warts. METHODS: Thirty-one patients with 48 plantar warts were randomly selected from the Department of Laser Therapy, Medical Centre Maastricht, The Netherlands. The mean age of the patients was 29 years (range 6-74 years). The mean incubation time was 6.8 hours, and the mean treatment time was 18.7 minutes per wart. Each wart was treated an average of 2.3 times, with a median fluence of 100 cm2. RESULTS: Forty-two of 48 (88%) warts showed a complete response. A trend was found between total clearance and size of the warts, age of the patient, and the mean treatment time. No significant side effects were seen postoperatively. CONCLUSION: This study showed that recalcitrant plantar warts were successfully treated with no significant side effects; however, the user needs sufficient experience for this new effective treatment application.     

Pulsed Dye Laser Treatment is Effective in the Treatment of Recalcitrant Viral Warts

BACKGROUND Verrucae vulgaris can be removed in a variety of ways but a specific therapy of choice has not yet been developed. Doctors are faced with a challenge, especially in the treatment of recalcitrant warts. It has been suggested that the success of pulsed dye laser treatment lies in the fact that warts contain an increased number of dilated blood vessels.
METHODS Seventy-three patients (42 female, 31 male) with verrucae vulgaris on their hands or feet (1:1.5) were given a maximum of 12 treatments with a flashlamp-pumped pulsed dye laser every 2 weeks over a period of 24 weeks until complete clearance had been achieved. A laser energy density of 8 to 12 J/cm² with a spot size of 5 mm and a pulse duration of 450 μsec were used. The minimum follow-up period was 6 months.
RESULTS A total of 15.1% patients achieved complete clearance after 1 session and 47.9% after 2 to 5 sessions, resulting in a remission of 63.0% patients after a maximum of 5 treatment sessions. A remission of 23.3% patients was seen after 6 to 9 treatments and a total of 89.0% of patients showed remission after a maximum of 10 sessions. Only three patients (4.1%) failed and five patients (6.9%) stopped the treatment on account of pain/noncompliance. Only one patient, from a group of patients treated between January 2003 and April 2004, has relapsed.
CONCLUSION Pulsed dye laser treatment is effective and safe in the treatment of recalcitrant viral warts.     

Treatment of common warts with surgery and systemic isotretinoin

Warts, or verrucae, are benign epithelial proliferations of the skin and mucosa caused by infection with human papilloma viruses. These are slow-growing lesions that can remain subclinical for long periods of time. Since there is no single treatment that is 100% effective, and the lesions may effect the patient's life quality, combinations of treatment modalities may be used. A case of hornlike warts on both hands and all over the body is presented. He was treated with surgical excisions and systemic isotretinoin at a dose of 1 mg/day administered for 6 months. The warts were largely resolved by the 6th postoperative month.     

The efficacy of laser surgery for verruca plantaris: report of a study

Many therapeutic modalities are available to eradicate plantar verrucae. Lately, lasers have gained a great deal of notoriety in the treatment of verrucae. In this study, we chose to evaluate the success of using one laser treatment for full eradication of verrucae. The results indicated that the greatest success rate occurred with solitary lesions. Other studies of methods of verrucae treatment yielded similar results to those of the laser, with cryotherapy achieving the highest success rate. However, the higher rate was based on an average of two treatments, whereas this study obtained similar results with just one. The laser also has the advantages of minimal postoperative pain, minimal healing time, and less damage to perilesional tissue. These advantages make the laser a viable option in the treatment of verrucae plantaris.     

Pulsed dye laser therapy for viral warts.

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 6.0-9.0 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.     

Warts of the Nail Unit: Surgical and Nonsurgical Approaches

BACKGROUND: Warts are the most common nail tumor and mostly affect children and young adults. Periungual warts are usually due to HPV-1, 2, and 4. Development of periungual warts is favored by maceration and trauma, especially nail biting. OBJECTIVE: To discuss the biology, clinical features, and medical and surgical treatment of periungual warts. METHODS: Review of the literature and personal experience. RESULTS: The natural course of warts makes aggressive approaches restricted to selected cases. Medical treatments, usually topical, include keratolytic agents, virucidal agents, and immunomodulators. All choices have been utilized successfully, but keratolytic agents are the best first-line approach. Surgical treatments include cryotherapy, surgical excision, electrosurgery, infrared coagulation, localized heating with a radio-frequency heat generator and laser therapy, especially the Er:YAG laser, which has an excellent safety profile. CONCLUSIONS: Definitive cure is not guaranteed by any therapy and periungual warts can recur and become larger after correct treatment.     

Results after Morton's neuroma resection via plantar approach

PurposeThe purpose of the study is to present the results after resection of Morton's neuroma via the plantar approach.Materials and methodsIn total 415 consecutive patients were operated on Morton's neuroma. The average follow-up was 39 months (range: 9–94). The mean age at the time of surgery was 56 years (range: 28–86). In 217 cases the neuroma was located in 2nd–3rd and 256 cases in the 3rd–4th interdigital space. A 174 neuromas were seen at the left and 170 at the right foot; 64 cases were bilateral. A 356 patients could be followed-up with a VAS and modified Kitaoka-score. All patients were operated via a plantar approach.ResultsA 328 of the 356 patients were subjectively satisfied with the results. The most significant improvement was documented for pain relief during daily activity. The average Kitaoka-score at the follow-up was 72 points (range: 35–75). In 6 cases postoperatively superficial wound healing problems occurred which were treated conservatively. A 10 patients complained about the plantar scar, in 32 patients a shoe conflict was observed for less than 6 months.ConclusionSurgical resection of a Morton's neuroma via the plantar approach lead to good and reproducible results.     

Giant Verruca Vulgaris

BACKGROUND: Common warts (verrucae vulgares) are hyperkeratotic papulonodules that are most often seen on the hands, arms, and legs, but they can be seen anywhere on the glabrous skin. Common warts represent the most frequent clinical lesions produced by the human papillomavirus (HPV). OBJECTIVE: Although they are diagnosed easily, giant, chronic, isolated, solitary, recalcitrant verruca vulgaris involving nail and nail bed on the digits can be misdiagnosed, and the differential diagnosis should be made carefully and verified by biopsies. METHOD: A 50-year-old male patient had a giant periungual verruca vulgaris on his left second finger. It was present for 2 years, was unresponsive to any treatment modality, and was treated by surgical excision. RESULTS: After 18 months of follow-up, there was no evidence of recurrence, and both aesthetic and functional results were quite satisfactory. CONCLUSION: Lesions of long duration generally lose their characteristic histopathologic features, and HPV cannot be detected in these lesions by polymerase chain reaction. Therefore, multiple sections should be examined histopathologically, and extreme care should be taken in order to avoid misdiagnosis.     

Combined cryotherapy/70% salicylic acid treatment for plantar verrucae.

Although common, warts are inconsistently treated by any single method. The authors present a review of the literature for various treatments with regard to the methodology and success rate of each treatment modality. The authors also present a therapeutic regimen of combined cryotherapy/ 70% salicylic acid. This treatment involves in-office application of the cryogenic agent and daily application of 70% salicylic acid by the patient. The cryotherapy was combined with daily patient application of salicylic acid to increase destruction of the verruca. In a study of 29 patients with 65 warts, the authors found this method successful in 58 warts in 25 patients, showing a 89.2% rate of eradication of verrucae in 86.2% of patients. The method is recommended due to its consistent efficacy in the patient population, and its relatively gentle and noninvasive approach.     

Management of vulvar condylomata acuminata with argon laser

One hundred and one female patients with vulvar condylomata acuminata were treated with the argon laser. Most were managed under regional or general anesthesia because of the large size and extent of the warts. Ten patients were lost to follow-up after the first session. Of 91 other patients, 78 (86%) were free of lesions on follow-up examinations after one or two treatments. The 13 other patients had recurrent lesions: seven patients underwent three laser sessions; four required four sessions, and 2 others required five and six sessions, respectively. These results were comparable with those achieved with the carbon dioxide laser.     

Glycolic acid 15% plus salicylic acid 2%: a new therapeutic pearl for facial flat warts

Background: Facial flat warts are a contagious viral disease that can cause disturbing cosmetic problems. Topical glycolic acid has been reported to be effective in dermatological treatment depending on the exfoliant capacity, but has not often been reported to be effective in the treatment of facial flat warts. Objective: The aim of this paper was to evaluate the efficacy and safety of glycolic acid 15% topical gel plus salicylic acid 2% in the treatment of recalcitrant facial flat warts. Methods: A total of 20 consecutive patients 7 to 16 years of age with recalcitrant facial flat warts were enrolled in this study. Patients having warts by the eye and lip regions were excluded from the study. A fine layer of face gel was applied to the treatment area once daily. Most of the participants had tried different treatments with no success. Assessments for the response and the occurrence of side effects were performed every two weeks at Weeks 2, 4, 6, and 8. Results: All the patients were clinically cured within eight weeks. Seven patients cleared in four weeks, and 13 patients cleared in eight weeks. No noticeable adverse events were related to the skin. Conclusion: Topical gel of glycolic acid 15% plus salicylic acid 2% is safe and effective when applied to facial flat warts once daily until clearance and may be considered as first-line treatment.Flat viral warts are circumscribed papules with hyperkeratotic surfaces that can occur singly or in groups. In these types of warts, the human papilloma virus (HPV) has been shown to infect the koilocytes. Although no viral subtype is absolute, typically the infection is with HPV types 3, 10, 28, and 41. These warts are small in size (1–5mm), flat, or slightly elevated lesions. Flat viral warts typically present as skin-colored or light brownish, flat-topped papules on the face, beard area, or on the back of the hands, and primarily affect children and young adults.1 Their evolution is variable, and although two thirds of cases regress spontaneously in the course of two years due to immunological mechanisms, they occasionally are long lasting.1 Flat viral warts can greatly affect a patient''s quality of life, and their persistence and/or recurrence can cause frustration. Moderate-to-extreme discomfort is reported in 51.7 percent of patients, and social or leisure activities are affected to a moderate-to-extreme degree in 38.8 percent of patients.2     

Long-term results of carbon dioxide laser treatment of meatal condylomata acuminata

A group of 74 men who underwent carbon dioxide laser treatment of meatal condylomata were observed for an average of 18 months. The cure rate after 1 treatment of isolated meatal lesions was 78%; the presence of external lesions lowered the rate to 32% and additional external and urethral warts to 25%. Following multiple treatments all but 6 patients were cured; 83% of the recurrences developed within 3 months. One urethral and 6 meatal strictures occurred more than 3 months after treatment; 9 patients had a spraying stream many years after treatment and 2 complained of frequency.     

Carbon dioxide laser management of plantar verruca: a 6-year follow-up survey

Patients receiving treatment for plantar verruca by carbon dioxide laser vaporization from 1984 through 1989 were surveyed with follow-up from 3 months to 6 years. Materials and methods, operative technique, and results were reviewed. This procedure was used as both a primary treatment as well as secondary or tertiary treatments on recalcitrant verrucae. Solitary as well as multiple or mosaic lesions were evaluated. Patients were surveyed for elimination of all verrucae, partial or complete recurrence, postoperative complications, and satisfaction. The overall success rate, considering all eight treatment categories, was 75%. Ultimate success rates ranged from 93% for solitary lesions to 62% for multiple recalcitrant lesions. The authors' findings show clinical significance in the marked differentiation of success rates in accordance with the classification scheme. That is to say, initial treatment of a solitary lesion showed a higher success rate than initial treatment of multiple lesions, and initial treatment of virgin lesions showed a higher success rate than initial treatment of recalcitrant lesions. Based on the data accumulated, the authors propose that treatment of plantar verruca be initiated early, i.e., while the lesion is solitary and has been heretofore untreated. On the other hand, those lesions having a second or third treatment by carbon dioxide laser vaporization resulted in a higher ultimate success rate than those which had only one primary treatment. The general conclusion is that carbon dioxide laser management should be considered as a viable treatment alternative in relation to other, more traditional, techniques in the treatment of plantar verruca.     

Surgical management for sciatic nerve injury

Objective:To summarize surgical treatments and their corresponding curative effects on sciatic nerve injuries.Methods:Surgical treatments on sciatic nerve injury were performed in 28 patients from January 1990 to July 2000.The treatments included neurolysis, neurolysis plus partial nerve anastomosis,nerve anastomosis and nerve transplantation.The curative effect was evaluated according to Sunderland criteria.Results:Of 28 cases, 22 patients were followed up with a follow-up period of 13 months to 5 years (average 30 months).Of 22 nerves, 7 were excellent ,5 good,7 fair and 3 poor ,with an excellence rate of 54.5%.Conclusions:The fair results of sciatic nerve injury are related to its structural character.Surgical exploration should be performed if nerve function does not recover 3 months after primary operation and if Tinel‘s sign and electromyogram show no signs of nerve regeneration.Electrophysiological monitoring in the operation is useful in electing surgical methods and predicting the results of nerve anastomosls .     

Hip arthroplasty in chronic dialysis patients

We retrospectively reviewed 15 patients (24 hips) on chronic renal dialysis who underwent hip arthroplasty between 1970 and 1990. The average age at surgery was 39 years; the average follow-up was 8 years (range, 1–19 years). All follow-up of less than 5 years relates to those patients who died. Of these 24 hips, 14 (58%) failed or were failing due to loosening; the average time to revision was 7 years (range, 1.5–14 years). A complicated course was experienced in 16 hips (66%), primarily related to medical difficulties. There was one perioperative death. The following orthopedic complications afflicted 5 hips (21%): one femur fracture during revision; one femur fracture at 2 months after revision; one dislocation during seizure; one displacement of acetabular cup requiring recementing; and late generalized septic death of one patient (with both hips involved). Within an average of 3 years (range, 15 months to 7 years) after their index surgery, 6 of the 15 patients (40%) died. The patients who lived were chronically ill, and all but three remained on long-term dialysis. The functional level of all those remaining on dialysis steadily declined, and none reached a quality of life comparable to an osteoarthritic patient. This study confirms a previously reported high mortality and morbidity rate in this population. Despite their difficulties, 22/24 primary hips were relieved of pain and increased in function; six patients returned to work. We see no better alternative for pain relief in total hip arthroplasty, particularly in view of contemporary surgical techniques and improved medical management.     

Patient-Perceived Recovery and Outcomes after Bipolar Radiofrequency Controlled Ablation with Platelet-Rich Plasma Injection for Refractory Plantar Fasciosis

Previous studies have documented persistent postoperative symptoms and limitations following plantar fasciotomy using patient-reported outcome measures (PROMs). The incomplete recovery (resolution) has been theorized to occur from altered foot biomechanics, and alternative treatment methods have continued to gained popularity for addressing refractory plantar fasciosis (RPF). The purpose of the present study was to assess patient-perceived recovery (PPR) and outcomes after bipolar radiofrequency controlled ablation (BRC) with platelet-rich plasma (PRP) injection for RPF. From July 2006 to July 2016, 43 patients (52 procedures) were enrolled. PROMS were prospectively obtained and compared between patients who perceived themselves as recovered without/residual deficits (recovered–resolved, recovered–not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure were recorded. Overall, 67.4% perceived themselves as recovered–resolved, 23.3% as recovered–not resolved, and 9.3% as not recovered. Holistic and procedure specific satisfaction were high (90.7% and 88.4%), with a mean modified Foot Function Index of 11.65, visual analog scale for pain 1.5, and failure rate of 9.3% at a median of 53 months (interquartile range 33 to 83). In the present study, outcomes with BRC with PRP injection compared favorably to the long-term outcomes reported for partial and complete plantar fasciotomy. Although 14 patients (32.6%) continued to have some postoperative symptoms, 71% indicated that they were satisfied with their symptoms, and 64% would undergo a similar procedure again. Therefore, despite the study's shortcomings, a patient's ability to cope appears to have a role in recovery from RPF.     

Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis

A retrospective review was conducted of 23 patients (26 feet) to assess operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis. Nonsurgical treatment was implemented in all patients with no relief of symptoms (average 20.8 months) prior to surgery. Using a visual analog pain scale (0-10), the average preoperative pain was 9.2 (range, 8-10). Prior to surgery, 65.2% of patients had severe limitations of activity, and 34.8% of patients had moderate limitations of activity. An average 25.3-month follow-up (range, 8-51) was performed by telephone interview. Average postoperative pain decreased to 1.7 using the same visual analog scale. Thirteen patients (57%) had no functional limitations postoperatively and nine patients (39%) had minimal functional limitations postoperatively. One patient (4%) had moderate functional limitations postoperatively. Twenty patients (87%) were completely satisfied with the surgery, two patients (9%) were satisfied with reservations, and one patient (4%) was unsatisfied with the surgery. The average period before return to work or daily activities was 1.5 months. Two patients had minor complications of partial wound dehiscence that healed uneventfully and mild dorsal midfoot pain which required temporary use of a boot walker. While the majority of patients with plantar fasciitis can be managed with nonoperative treatment, those patients with recalcitrant plantar fasciitis can be effectively treated with partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle.     

Pulsed dye laser treatment of genital warts

BACKGROUND AND OBJECTIVES: Genital warts represent benign epithelial proliferations induced by human papillomavirus. The goal of treatment is the clearance of visible warts. Different regimens are available. Flashlamp-pumped pulsed dye laser (FPDL) represents one of many treatment options for the management of viral warts (verrucae vulgares), its effectiveness being comparable with that of conventional therapies. We evaluated the effectivity of FPDL light for the treatment of genital warts. STUDY DESIGN/MATERIALS AND METHODS: A prospective study was performed to examine the efficacy of FPDL in untreated genital warts in which 22 patients were included. RESULTS: All patients showed complete remission after 1.59 (1-5) laser sessions and no scarring was observed. CONCLUSIONS: This study demonstrate that FPDL is a simple and safe, cost and time saving alternative treatment option for genital warts and should be listed in genital warts treatment guidelines.     

Hip arthroscopy for acetabular labral tears.

The purpose of this study is to better understand the history, physical examination, imaging, and outcome of arthroscopic debridement of acetabular labral tears. We performed a review of all 290 patients who underwent hip arthroscopy at our institution to identify those who have undergone arthroscopic debridement of an acetabular labral tear. Patients were assessed at follow-up by a physician visit or telephone interview and questioned as to pain, mechanical symptoms, activity level, work status, sports ability, and performance of activities of daily living. Patients were followed-up for a minimum of 1 year or until they underwent total hip arthroplasty (THA). All 28 patients meeting the study criteria were available for follow-up (mean age, 41 years; range, 14 to 70 years) at an average of 34 months after surgery (range, 13 to 100 months). Average duration of symptoms before arthroscopy was 25 months. Eighteen (64%) patients were noted to have mechanical symptoms such as clicking or locking. Ten patients were noted to have a specific inciting event that initiated their symptoms. Magnetic resonance imaging identified the labral tear in 5 of 21 (24%) cases; arthrography identified the tear in 1 of 8 (13%). Of the 28 tears identified, there were 12 radial flap, 5 degenerative, 5 bucket handle, 3 horizontal cleavage, and 3 peripheral longitudinal tears. Seventeen were located anteriorly, 7 were located posteriorly, and 4 were located superiorly. Patients were stratified into two groups based on the presence of significant joint arthritis on radiographs. Of those without arthritis, 10 of 14 (71%) had good to excellent results, and 2 patients underwent total hip arthroplasty at an average of 52 months after surgery. Of those with arthritis, 3 of 14 (21%) had good to excellent results, and 6 patients underwent THA at an average of 14 months after surgery. There were three cases of complications consisting of nerve palsies (two sciatic, one pudendal) that resolved completely without any remaining functional or sensory deficits.