Autoinoculation Therapy for the Treatment of Widespread Cutaneous Warts.

BACKGROUND: Cutaneous warts are common lesions that are often unresponsive to various therapeutic modalities. OBJECTIVE: To assess the role of autoinoculation therapy in the treatment of widespread cutaneous warts. MATERIALS AND METHODS: This interventional study included patients with widespread skin warts who did not respond to conventional treatments. Two methods were used to perform the autoinoculation therapy. The first procedure was performed by obtaining a small piece of the wart and inoculating it into a subcutaneous pocket. The second method was developed by the investigator and was performed by inserting a needle into the center of the wart toward the nearby subcutaneous tissue, with multiple forward and backward movements in several directions around the lesion. RESULTS: The prospective study included 23 patients. The illness duration ranged from 3 months to 5 years. Autoinoculation interventions revealed full recovery of all warts in 20 cases (87%) within 20 to 90 days (mean: 40.7 days). CONCLUSION: Autoinoculation procedures demonstrated effectiveness, less cost, lesser pain, less invasiveness, without leaving skin scars in comparison with other conventional therapies.

Treatment of plane warts with long pulse ND - YAG laser 532 nm.

BACKGROUND: Warts are one of the contagious viral diseases that may cause disturbing cosmetic problems. Plane warts represents a common self-limiting viral infection of the skin caused by the Human Papilloma Virus, however, those that do not disappear by themselves can be very difficult to treat with no uniformly effective treatment modality. OBJECTIVE: To assess the efficacy of long pulsed 532 nm ND:YAG  laser in the treatment of plane warts. PATIENTS AND METHODS: In this therapeutic clinical trial study, 34 patients with plane warts were enrolled. Each patient was eligible for up to three treatment sessions administrated at 2 weeks intervals with long pulsed ND:YAG  laser at a spot size 3 mm; wavelength 532 nm; pulsed duration 20 ms; and fluence 30 J/cm2 . The patients were assessed before each treatment session and at 3 months after the last treatment session. The response to treatment was graded using four points scale: Scale 1 = poor: <25%, Scale 2 = fair: 25%-50%, Scale 3 = good: 51%-75%, Scale 4 = excellent: >75%. RESULTS: Twenty-two patients only with a total of 478 lesions, completed the study; their ages ranged from (6-45) years with a mean ± SD 19.95 ± 13.142 years. Thirteen patients (59.09%) were female and nine (40.90%) were male. The results from this study showing that long pulsed ND:YAG laser 532 nm led to an excellent response in 19 patients (86.36%) in which 15 of 19 patients showed a complete response (78.94%); one patient showed a good response (4.545%), one showed a fair response (4.545%) and one showed a poor response (4.545%) at the end of three-months follow up. The difference was statistically significant; the P value at the three months follow-up was 0.002. The cumulative clearance rate after the first, second, and third treatment sessions was 58.4%, 77.7%, and 89.9% respectively. Recurrence was seen in only one patient (4.545%). Side effects were generally mild and didn't prevent normal activity. CONCLUSION: Long pulsed ND:YAG laser 532 nm appears to be an effective method for treatment of plane warts.

Clinical evidence of 595 nm pulse dye laser treatment for viral warts on hands and feet.

BACKGROUND: Viral warts, induced by infection by different HPV genotypes, are highly frequent in the general population, particularly during infancy and among adolescents. The effectiveness of the 595 nm Pulse dye-laser in treating viral warts on the hands and feet in both adults and children was investigated in this study. MATERIALS AND METHODS: A selection of 203 patients with multiple viral warts was made. All patients underwent 4-5 treatment sessions with a 595 nm pulse Dye Laser (PDL). Treatment outcome was assessed by a quartile scale: 1 indicates no or low results (0%-25% of the lesion area cleared), 2 indicates slight clearance (25%-50% of the lesion area cleared), 3 indicates moderate-good clearance (50%-75%), and 4 indicates excellent clearance (75%-100%). Patients were asked for a subjective evaluation of the perceived overall results by means of the following score: unsatisfied (1), not very satisfied (2), satisfied (3), and very satisfied (4). Possible side effects were monitored. Results obtained were judged with a photographic evaluation, immediately and at the control visit (6 months after the last laser session). RESULTS: All patients observed global improvements. Most of the lesions were completely removed after laser therapy. A total of 95% of patients achieved excellent clearance and they were very satisfied following the laser treatment. Relevant side effects were absent in all patients. CONCLUSION: PDL treatment with the study device using a wavelength of 595 nm has proven to be a tolerable and safe therapy for viral warts management.

Evaluation of combined treatment with Er:YAG laser and long-pulsed Nd:YAG laser for the treatment of recalcitrant warts: A prospective randomized controlled trial.

BACKGROUND: Viral warts are common infectious skin disease induced by human papillomavirus (HPV). Lasers have been used for warts treatment in recent years with variable success rates. OBJECTIVE: This study aimed to prospectively evaluate combined treatment with Er:YAG laser and long-pulsed Nd:YAG laser compared to Er:YAG laser for the treatment of recalcitrant warts after one session. MATERIALS AND METHODS: This study included 240 lesions from 24 patients. All the lesions were diagnosed clinically as recalcitrant warts after failure of topical treatment and cryotherapy. About 120 lesions underwent a combined therapy of Er:YAG and long-pulsed (LP) Nd:YAG lasers, and the remaining 120 lesions underwent Er:YAG laser therapy only. The clearance rate was evaluated 5 weeks after and classified by three-graded evaluation: complete response, partial response and poor response. RESULTS: The clearance rate in the combined Er:YAG + LP Nd:YAG lasers group was, statistically significant, higher than that of the Er:YAG laser group (p = 0.008). The complete response rate was 48% (58 of 120 warts) for the Er:YAG +LP Nd:YAG lasers group and only 29% (35 of 120 warts) for the Er:YAG laser group. CONCLUSION: The combination of Er:YAG and long-pulsed Nd:YAG lasers is more effective than Er:YAG laser alone in treating recalcitrant warts after single session.

Efficacy of Autoinoculation in Treatment of Multiple Viral Warts - A Single Arm Study.

OBJECTIVE: To test the effectiveness of autoinoculation of a wart in patients with multiple viral warts. STUDY DESIGN: An experimental study. PLACE AND DURATION OF STUDY: Department of Dermatology, Pak Emirates Military Hospital (PEMH), Rawalpindi, from February 2021 to February 2022. METHODOLOGY: Patients above 12 years of age, having more than 5 warts were included. Those getting any other treatment for warts were excluded. The procedure was performed on a total of 70 patients with warts on 3 sites i.e. face/neck, palmoplantar and multiple sites. The outcome was categorised into cleared (no wart), partially cleared (reduced number of warts than baseline), and no response (same or increased number of warts than baseline). RESULTS: Out of 70 patients, 54 (77.1%) patients showed complete response, 6 (8.6%) showed partial response and 10 (14.3%) showed no response at all. Out of 54 patients who showed complete response, 36 (66.6%) were cleared after only one inoculation, fifteen (27.7%) were cleared after two inoculations, and 3 (5.5%) were cleared after three inoculations. The results were statistically significant with p-value <0.05. CONCLUSION: Autoinoculation is a simple and minimally invasive procedure which proved to be very effective against all types of warts, with very promising results against palmoplantar warts. KEY WORDS: Viral warts, Multiple viral warts, Autoinoculation, Delayed hypersensitivity, Human papilloma virus (HPV), Palmoplantar warts, Immunity.

Destructive therapies for cutaneous warts: A review of the evidence.

BACKGROUND AND OBJECTIVES: Non-genital warts are benign cutaneous growths caused by infection with the human papillomavirus. Although warts can resolve spontaneously, patients might seek treatment due to discomfort or social ostracism. This review summarises high-quality studies investigating the efficacy of chemical and physical destructive wart therapies. METHOD: We performed a literature review (up to June 2021) of published articles for wart management from MEDLINE and Embase databases. We considered systematic reviews, randomised controlled trials (RCTs), cohort studies and case series. We included studies that investigated chemical or physical destructive therapies. RESULTS: Fifteen therapies were evaluated and included salicylic acid, cryotherapy, silver nitrate, phenol, cantharidin, glycolic acid, pyruvic acid, citric acid, formic acid, trichloroacetic acid, monochloroacetic acid, zinc, laser, surgery and electrocautery. Very few treatment options have been studied through RCTs. DISCUSSION: To attenuate transmission, hygienic practices need to be adopted in conjunction with any treatment. Important considerations when treating patients with warts include the location of the wart, the evidence supporting the proposed treatment and potential adverse effects of treatment.

A novel fractional solid-state 585 nm laser on facial verruca plana: A report of three cases.

A novel fractional laser system with differential-wavelength modified optically pumped semiconductor technology can produce a pure 585 nm wavelength as pulsed dye laser, which has been used to treat vascular, pigmented skin lesions. Besides, this new laser modality also showed promising results for verruca plana in our experience. In this brief report, we present three cases of facial flat warts treated by this novel 585 nm diode laser.

Sequential Use of CO2 Laser Prior to Nd:YAG and Dye Laser in the Management of Non-Facial Warts: A Retrospective Study.

Background and Objectives: Warts are benign lesions of viral etiology characterized by a hyperkeratotic appearance tending to spread across the skin surface. Various treatments have been proposed to manage this condition, such as acids, imiquimod, photodynamic therapy, cryotherapy, and various lasers. Materials and Methods: In this paper, we describe a combination protocol using CO2 laser prior to Nd:YAG laser for lesions interesting the palmoplantar areas or dye laser for lesions on other skin surfaces in the management of non-facial warts resistant to traditional therapies. In total, 34 patients with 103 warts suffering from wart infection resistant to traditional therapies treated from 1 January 2019 to 1 June 2020 were retrospectively enrolled at the Dermatological Unit of Magna Graecia University (Catanzaro, Italy). Two dermatologists measured clinical results, classifying lesions with complete resolution, partial resolution, or non-responding. Patients at four months follow-up were asked to evaluate their degree of satisfaction with a visual analog scale (VAS). Results: Almost all patients reported the complete resolution of lesions, with no patient reporting scarring. Five patients reported hypopigmentation in the treated areas. The mean satisfaction level was high. Only three patients experienced a relapse of the condition. Conclusions: Using a vascular laser following a CO2 superficial ablation of warts may help reduce the risk of scarring and decrease the incidence of relapses for lesions resistant to traditional therapies. Therefore, more extensive studies will be necessary to confirm the obtained results.

Airborne particulate concentration during non-thermal nano-pulse stimulation wart clearance is negligible compared to thermal modalities.

OBJECTIVES: As clinicians continue to implement safety protocols amid the global pandemic, considerations to mitigate potential viral transmission of airborne particulates (plume) generated from certain dermatologic procedures are of growing interest. This study intended to measure the change in airborne particulate matter using a non-thermal energy modality called nano-pulse stimulation (NPS) and compare levels of concentration to common thermal modalities (CO2 laser and electrocautery). NPS is a new non-thermal modality that applies nanosecond pulses of electrical energy to induce regulated cell death in cellular structures while sparing the surrounding acellular structure of the dermis. MATERIALS AND METHODS: The study used a Condensation Particle Counter during four types of dermatologic procedures: (1) using non-thermal NPS for the clearance of cutaneous, nongenital warts; (2) an electrocautery treatment of warts; (3) a CO2 laser for facial resurfacing; and (4) an electrocautery procedure for a facelift. Four subjects and a total of 11 warts were treated with NPS while a particle counter was used to detect the average particles per cubic centimeter once per second. The same particle counter was used, for comparison, during a wart removal procedure using electrocautery for comparison, and for control, during a skin resurfacing procedure with a CO2 laser and a facelift in which electrocautery was used. RESULTS: Only one of the 11 NPS wart procedures generated any detectable change in the particulate concentration and that change was negligible in comparison to the increase in particulate concentration measured during the CO2 laser resurfacing and the electrocautery use during a facelift procedure. CONCLUSIONS: Procedures using non-thermal NPS technology do not generate significant plume when applied to eliminate warts, suggesting it is unlikely that this new energy modality would release viral DNA into the air.

Wart removal without anesthesia using long-pulse 1064-nm Nd:YAG laser.

BACKGROUND: Warts are benign epithelial proliferations that result from human papillomavirus (HPV) infection occurring on the skin and mucosa. Patients express a significant reduction in quality of life due to this cosmetic nuisance, as well as functional problems and physical discomfort. Newer methods of wart removal include different energy-based devices, mostly lasers. Nonablative lasers such as Nd:YAG have a higher success rate and are usually used with topical or infiltrative anesthesia. The procedure may be safer without anesthesia but still tolerable with an appropriate cooling and technique. AIMS: The purpose of this study is to report on our experience over 3 years since the approach without anesthesia has been utilized. PATIENTS/METHODS: A retrospective chart review analysis of all 85 patients who underwent 1064 nm Nd:YAG wart removal without anesthesia between November 2016 and August 2019 was conducted. One of the main outcome measures was determining the number of sessions required in order to get full clearance. RESULTS: The mean number of sessions was 2.2 (range 1-7). The mean VAS pain score during the procedure was 6 (range: 2-10), and side effects were negligible. CONCLUSION: Long-pulse 1064-nm Nd:YAG laser without any chemical anesthesia is safe and effective for the treatment of warts.

Laser therapy in cutaneous and genital warts: A review article.

Traditional treatment modalities for wart require long-term treatment course and usually have high recurrence rates and unwanted side effects. In this review article, we evaluated different types of laser therapy in the treatment of warts. Published articles since 2000 up to July 2020 about laser therapy in genital and non-genital warts were searched and assessed. Fifty articles were selected for the final review, including 22 pulsed dye laser (PDL), 10 neodymium-yttrium-aluminum-garnet (Nd: YAG), 3 erbium-doped yttrium-aluminum-garnet (Er: YAG), 14 carbon dioxide (CO2 ) laser and one systematic review. Complete response rates were different in terms of laser type used (0%-100%, 9.1%-100%, 83.3%-100%, and 59.15%-100% for PDL, Nd: YAG, Er: YAG, and CO2 laser, respectively). There was no significant difference between conventional treatment modalities and laser therapy regarding efficacy and recurrence rate. Combination of lasers with keratolytic agents, immunomodulators and photodynamic therapy can be helpful especially in immunosuppressed patients, refractory, and recurrent lesions. PDL has the lowest occurrence of adverse effects relative to other types of lasers.

Cryosurgical ablation for treatment of common warts on the nasal vestibule.

BACKGROUND: Common warts rarely occur on the nasal vestibule. It should be treated more carefully than other skin lesions because scar contracture results in the narrowing of the external naris, causing nasal obstruction and reducing the patient's quality of life. In this report, we introduce our method for common warts on the nasal vestibule using handheld cryoablation devise. PATIENTS AND OPERATIVE METHODS: We performed a series of four cryosurgical ablation procedures to treat common warts on the nasal vestibule. All the procedures employed a reusable handheld cryoablation device (CRY-AC®, Brymill Cryogenic Systems, Ellington, CT). RESULT: All patients were successfully treated for four to six sessions without any adverse event. CONCLUSION: Cryotherapy for common warts on nasal vestibular is easily performed in an office setting under no anesthesia without bleeding. We believe this easy and safe procedure is suitable as the first line therapy for common wart on nasal vestibular.

Risk of Virus Contamination Through Surgical Smoke During Minimally Invasive Surgery: A Systematic Review of the Literature on a Neglected Issue Revived in the COVID-19 Pandemic Era.

CONTEXT: The coronavirus disease 2019 (COVID-19) pandemic raised concerns about the safety of laparoscopy due to the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion in surgical smoke. Although no case of SARS-CoV-2 contagion related to surgical smoke has been reported, several international surgical societies recommended caution or even discouraged the use of a laparoscopic approach. OBJECTIVE: To evaluate the risk of virus spread due to surgical smoke during surgical procedures. EVIDENCE ACQUISITION: We searched PubMed and Scopus for eligible studies, including clinical and preclinical studies assessing the presence of any virus in the surgical smoke from any surgical procedure or experimental model. EVIDENCE SYNTHESIS: We identified 24 studies. No study was found investigating SARS-CoV-2 or any other coronavirus. About other viruses, hepatitis B virus was identified in the surgical smoke collected during different laparoscopic surgeries (colorectal resections, gastrectomies, and hepatic wedge resections). Other clinical studies suggested a consistent risk of transmission for human papillomavirus (HPV) in the surgical treatments of HPV-related disease (mainly genital warts, laryngeal papillomas, or cutaneous lesions). Preclinical studies showed conflicting results, but HPV was shown to have a high risk of transmission. CONCLUSIONS: Although all the available data come from different viruses, considering that the SARS-CoV-2 virus has been shown in blood and stools, the theoretical risk of virus diffusion through surgical smoke cannot be excluded. Specific clinical studies are needed to understand the effective presence of the virus in the surgical smoke of different surgical procedures and its concentration. Meanwhile, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-19, seems mandatory. PATIENT SUMMARY: In this systematic review, we looked at the risk of virus spread from surgical smoke exposure during surgery. Although no study was found investigating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or any other coronavirus, we found that the theoretical risk of virus diffusion through surgical smoke cannot be excluded.

CO2 laser treatment for plantar warts in children: A case series.

Several types of human papillomaviruses induce warts. Warts are one of the most common infections in childhood with a reported prevalence of up to 20%. Warts are divided clinically into genital and nongenital forms. Plantar warts are common nongenital warts. In this series, five pediatric cases treated with CO2 laser for their plantar warts are presented. One patient was a known case of Hodgkin's lymphoma. Three of our patients had history of unsuccessful treatments with other modalities, while the other had received no previous treatment. CO2 laser with continuous mode (focused and defocused) was used. In our cases, only one session was enough for clearance of the warts. All the patients were visited 1 week and 3 months after treatment to assess the efficacy and any possible recurrences. Follow-up showed that all the patients remained in remission up to 3 months posttreatment with no adverse events.

Cutaneous Cryosurgery for Common Skin Conditions.

Cryosurgery is the application of freezing temperatures to achieve the destruction of tissue. Cutaneous cryosurgery has become a commonly performed outpatient procedure because of the combination of its safety, effectiveness, low cost, ease of use, lack of need for injectable anesthetic, and good cosmetic results. Cryosurgery may be performed in the outpatient setting using dipstick, spray, or cryoprobe techniques to treat a variety of benign, premalignant, and malignant skin lesions with high cure rates. Benign lesions such as common and plantar warts, anogenital condylomas, molluscum contagiosum, and seborrheic keratoses can be treated with cryotherapy. Basal and squamous cell carcinomas with low-risk features may be treated with cryosurgery. Contraindications to cryosurgery include neoplasms with indefinite margins or when pathology is desired, basal cell or squamous cell carcinomas with high-risk features, and prior adverse local reaction or hypersensitivity to cryosurgery. Potential adverse effects include bleeding, blistering, edema, paresthesia, and pain and less commonly include tendon rupture, scarring, alopecia, atrophy, and hypopigmentation.

Efficacy of Intralesional Cryosurgery in the Treatment of Multiple Extragenital Cutaneous Warts: A Randomized Controlled Study.

BACKGROUND: The efficacy of intralesional (IL) cryosurgery in the treatment of cutaneous warts has not been previously studied. OBJECTIVE: To compare the efficacy and safety of IL cryosurgery versus electrosurgery in multiple extragenital warts and investigate their effect on serum interleukin (IL)-12 and interferon-gamma (IFN-γ). MATERIALS AND METHODS: Thirty-one patients were included; 18 received IL cryosurgery, and 13 had electrosurgery. Treatment was performed for the largest or few (2-3) small warts (target) until cleared, leaving the remaining (distant) warts untreated. Clinical response of the target and distant warts and adverse effects were evaluated. Serum IL-12 and IFN-γ levels were assessed before and after treatment. RESULTS: All patients had complete clearing of the treated wart in both groups. IL cryosurgery was well tolerated; infection, ulceration, and recurrence occurred only with electrosurgery. Complete/near-complete resolution of the distant untreated warts was seen in 33.3% versus none of patients in the IL cryosurgery and electrosurgery groups, respectively (p = .003). Furthermore, IL-12 and IFN-γ levels showed a tendency to increase after IL cryosurgery, and their increase correlated with distant wart response. CONCLUSION: Intralesional cryosurgery is effective not only in clearing treated warts but also resolving untreated warts and possibly enhances human papillomavirus-directed immune response.