Australas J. Dermatol 1992; 33: 87-91
CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS J.T.E. LIM AND C.L. GOH Singapore SUMMARY
This is a restrospective 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 JO 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 tine 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. Key words: Electrocautery, cryotherapy, liquid nitrogen, recalcitrant warts. INTRODUCTION
M E T H O D S AND MATERIALS
Periungual and subungual viral warts are treated by both medical and surgical methods. These include keratolytic and cytotoxic agents, immunotherapy with dinitrochlorobenzene,' chemotherapy with bleomycin,^ cryotherapy,' electrocautery and laser vapourisation.''' No single therapy has been established as the best and recurrences are common. In the National Skin Centre, Singapore subungual and periungual warts are usually treated by cryotherapy, electrocautery or carbon dioxide vapourisation or a combination of these. This is a retrospective study on the cure rate of carbon dioxide laser vapourisation treatment of recakitrant subungual and periungual warts that had failed treatment with conventional treatment including electrocautery and cryotherapy. Dr J.T.E. Lim, MBBS(Mal), MRCP (Ire), Senior Registrar. Dr C.L. Goh, FAMS, MMed(Singapore), MRCP(UK), Senior
Forty patients with periungual and subungual viral warts treated by carbon dioxide laser vapourisation in the National Skin Centre, Singapore were reviewed retrospectively. Viral warts were diagnosed clinically by their localised filiform appearance. Peringual warts were warts affecting the nail folds as well as the surrounding tissues. Subungual warts were those affecting the nail beds only. All patients were treated during a 2-year period from February 1990 till February 1992 and had 2-24 months of follow-up. They either had electrocautery, cryotherapy or both, prior to laser vapourisation treatment, Liquid nitrogen was used in cryotherapy. Cotton wool swabs were dipped into the liquid ^^^ ^^^^^^^ ^^^^^^^^ ^^ ^^^ ^^^^^ ^^^^^ ^ ^^^ f^g^^e was obtained. The procedure was repeated a second time. Nails were trimmed as far back ^s possible to expose the warts. The patients were
NarnirsTin^cr^tnga^'r^-
- - ^ ^ weekly intervals and cryotherapy repeated
Address for Correspondence: Dr Joyce Lim, National Skin Centre, 1 Mandalay Rd, Singapore 1130.
until clearance Occurred, or until the procedures were abandoned for failed response.
87
J.T.E. LlM AND C.L. GOH
Electrocautery was done using the Bireher Hyfrecator (Bireher Medieal System, USA) or Ellman Surgitron FFPF (Ellman International Manufacturing Ine, USA). The wart was first pared and then cauterised using power settings from 1 to low. The charred tissue was pared and any remaining wart cauterised. This was repeated until no obvious wart tissue remained. CO2 laser vapourisation was done using the Sharplan 1050 carbon dioxide laser (Sharplan Lasers, Ine. Israel) with a hand piece lens with a focused spot size of 0.08mm and a focal distance of 50mm. The continuous pulse mode was used. The beam was defocused to approximately 2.0mm, and power settings ranged from 3 to 15W, depending on the thickness of the lesion. The warts were vapourised completely until the presence of dermatoglyphic lines along
the nail fold was seen. When possible, the matrix was left intact (without incompletely treating the lesion) so that nail regrowth could occur. The type and frequency of treatments prior to laser vapourisation were noted. The outcome after laser vapourisation was recorded. The rate of recurrence, the type and frequency of treatments after recurrence and the final outcome were also noted. Recurrence was defined as warts that had cleared completely at the end of the treatment but reappeared during subsequent follow-up. Data were collected from the casenotes. Further follow-up information was obtained from telephone communication. The characteristics of the patients were summarised in Table 1 and 2. x^ test was used for statistical analysis. P value of -^0.05 was considered significant.
TABLE 1
Patient Number
Patient profile, type of treatments and outcome after first carbon dioxide laser vapourisation Type and requency of Treatment prior to CO2 laser Outcome after CO2 laser Site of Lesions Age/ Recurrence Electrocautery None Clear Sex Cryotherapy (in months) Periungual Subungual
1 2
33/M 12/M
LI RI LI
_ —
3 4 5 6 7
8/M
Rl, 3
24/M 32/M 34/M 29/M
— RI R3 —
8
18/M
RI, IV
—
—
+ +
—
I 2
— R4 — — Rl LI —
27 — 10 5 9
1 1 — 3 —
— — — — —
+ + — — —
— — 2 2 1
12
3
—
—
2
— —
11 4
— 1
— —
— +
1 —
RIV, V — —
4 — — 5 22
— — —
— + + — —
+
— — — — 3
— 3 — — — 30
— — — 1 — —
LI 9 10
23/M 13/M
11 12 13
32/F 18/F 42/M
14
23/F
15 16 17 18 19 20
10/F 16/F 29/F 29/M 34/F 30/F
Total FOOTNOTE:
R3, 4 Rl, 3 L3 — RII, Rl RI LIV R2 LI Rl LIV, V RI, 3, 5 R3 RI — 29
R = Right L = Left
— — — — — — RI, 4 L3
+ —
+ — + —
+ +
+ — + — + +
+ —
— 1 — — — 5
8 Roman Numericals 1 = big toe IMV = 2nci to 5th toes
88
Arabic Numericals 1 = thumb 2 = index 3 = middie
4 = ring 5 = little finger
CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS
were given per lesion. Twenty lesions were treated with carbon dioxide laser vapourisation without other prior treatments. Table 3 shows the cure rates following carbon dioxide laser vapourisation, after a ten month follow-up period. 42.6% (29/68) of the lesions recurred with the majority (82.7%) recurring within 3 months. Three lesions recurred at 5 months and the remaining 2 lesions at 10 months. Figure 1 compares the cure rates of the warts treated with carbon dioxide laser vapourisation as a first line treatment and those treated with carbon dioxide laser vapourisation after failed previous conventional treatment. Those who had laser treatment alone had a higher cure rate of 80.0% (16/20) compared with those who had failed other treatments prior to laser treatment (47.9% or 23/48), p value = 0.043. Subungual warts responded slightly better with a cure rate of 64.7% compared to periungual warts (54.9%) (ns). Various treatment modalities were done to the
RESULTS
Forty patients (27 males and 13 females) with a total of 68 lesions, were included in the study. Their ages ranged from 3 years to 79 years with a mean of 26.3 years. Three of them were below 12 years. Thirty eight patients were Chinese and the remaining 2 were Indians. Thirty seven of the patients had their viral warts for more than a year. Nineteen patients had a single lesion each, 15 had 2 lesions, 5 had 3 lesions and 1 had 4 lesions. There was a total of 68 lesions; 51 periungual and 17 subungual lesions. 77.9% of the lesions (53/68) were on the fingers with 49.1% (26/53) on the thumbs. Of the 15 lesions on the toes, 53.3% (8/15) were on the big toes. Forty-eight lesions had previously failed conventional therapy. 56.2% (27/48) had failed cryotherapy, 6.3% (3/48) had failed electrocautery and 37.5% (18/48) had failed both treatments. The frequency of cryotherapy treatments varied from 3 to 30 with a median of 9 treatments. One to three electrocautery treatments
TABLE 2
Patient Number
Patient profile, type of treatments and outcome after first carbon dioxide laser vapourisation Type and requency of Treatment Site of ^esions prior to CO2 laser Outcome after CO2 laser Age/ Recurrence Sex Periungual Subungual Cryotherapy Electrocautery None Clear (in months)
21 22 23 24 25 26 27 28 29
79/F 32/M 18/M 20/M 32/M 39/F 24/M 38/M 19/M
30 31 32 33 34 35 36 37
10/M 26/M 23/M 51/M 22/F 36/M 61/F
38 39 40
18/M 19/M 24/F
Total FOOTNOTE:
3/M
19 14 14 7 6 — 19 —
1 — — I — 1 — — —
— _ — — — — + — +
+ + — — — + +
1 — — 10 3 3 — — —
R3, 4
Rl — — LI —
— 22 — 6 — 4 6 11
— — — 1 — — — 2
+ — + — + — — —
+ + + — + — + +
— — — 2 — 1 — —
LI Rl Rl LI
— — —
— 3 5
— — 2
+ — —
— + +
1 — —
LI L4 —
L2, 3 R4
LI, 2 LI, 4 LI Rl LI — Rl — — Rl
R3, 4 —
51
R = Right L = Left
— L2 — — — —
Rl, 2, 3 — Rl —
Rl, 4
+
17
Roman Numericals I = big toe Il-IV = 2nd to 5th toes
89
Arabic Numericals 1 = thumb 2 = index 3 = middle
4 = ring 5 = little finger
J.T.E. LiM AND C.L. GOH lesions that recurred (Table 4). Fifteen lesions had a second carbon dioxide laser vapourisation treatment. 73.3% (11/15) of recurrent warts were cured with the laser treatment but 26.7% (4/15) recurred within 5 months. Four lesions cleared with cryotherapy alone and 2 cleared with a combination of cryotherapy and electrocautery. Two recurrent verrucae treated with electrocautery recurred again at 2 and 3 months. Four patients (6 lesions) preferred to leave their verrucae alone.
study, lesions treated with carbon dioxide laser vapourisation alone had a higher cure rate compared with those who had laser treatment after failed cryotherapy, electrocautery or both. This indicates that periungual and subungual warts can be more effectively eradicated by carbon dioxide laser vapourisation compared to cryotherapy or electrocautery. With a single carbon dioxide laser treatment all the warts cleared immediately and 57.4% (39/68) of these remained cleared on follow-up (up to 10 months). After a second laser treatment 73.5% (50/68) of the recurrent lesions were cleared. Laser treatment appeared to be an effective form of therapy for such warts. Repeat treatment offered further cure and should be considered.
DISCUSSION
Periungual and subungual warts are difficult to eradicate. However, they cannot be left alone as they are disfiguring and if the nail matrix is involved can be destructive too. Therefore, it is important to seek an effective treatment. In our
TABLE 3 Recurrence of verrucae after first carbon dioxide laser vapourisation Number of lesions recurred at
Number of Lesions Cleared
1 month
2 months
3 months
Periungual 28 (54.9%)
9
7
5
Subungual tt (64.7%)
2
1
Total 39 (57.4%)
11 (16.2%)
8 (11.8%)
5 months
10 months
Total Lesions Recurred
2
23 (45.1%)
3 5 (7.4%)
6 (35.3%)
3 (4.4%)
2 (2.9%)
29 (42.6%)
TABLE 4 Treatment and outcome for verrucae that recurred after the first carbon dioxide laser vapourisation Duration Outcome Treatment of follow-up from 1st Patient Number Recurrence CO2 laser Cleared 2nd CO2 laser Number Electrocautery Cryotherapy (months) of Lesions (months) 1 2 5
9 14 16 20 21 24 25 26 33 35 38
1 2 1 1 2 3 2 2 2 3 1 2 1 2 1 2 1
Total
29
24 24 24 20 20 20 19 17 16 15 15 13 12 11 II 7 7
7 1 9
+ -I-
17
90
CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS
Therefore laser therapy for perinugual and subungual warts is recommended as a first line therapy, as it is safe, effective and convenient. However it should only be performed by persons familiar with the procedure to minimise hazards and complications.
Many of the warts were treated with repeated cryotherapy or electrocautery, some even up to 30 treatments with no success. It would appear that laser therapy could be considered the therapy of first choice. Many lesions were cleared with a single or at most two treatments. The advantages of laser vapourisation are (1) it is time-saving for the patient; the warts can be vapourised in one sitting whereas patients need to attend weekly or fortnightly for cryotherapy, (2) less risk of bleeding and infection and (3) less post-operative swelling. A hazard of carbon dioxide laser vapourisation includes infection of the surgeon from laser plumes. Fumes from destroyed tissue have been reported to contain virus particles' and there have been reports of layngeal papillomas occuring from inhalation of such laser plumes. This risk can be reduced by appropriate care with exhaust pumps, filters and masks.' Some authors discourage surgical treatments for peringual or subungual warts for fear of causing damage to the matrix or causing considerable scarring." Others recommend a combination of intra-lesional bleomycin and cryotherapy as the most successful treatment for such warts.' However, this treatment causes severe pain, nail dystrophy'" and cutaneous toxicity." None of our patients had problems with pain and if pain occurred it was tolerable even among our paediatric patients, the youngest being three years old. The scarring that occurred was also acceptable. Subungual and peringual warts can also cause severe nail dystrophy and nail bed disfigurement if left untreated.
REFERENCES Dunagin WG, Millikan LE. Dinitrochlorobenzene immunotherapy for verrucae resistant to standard treatment modalities. J Am Acad Dermatol 1982; 6: 40-5. Shumer SM, O'Keefe EJ. Bleomycin in the treatment of recalcitrant warts. J Am Acad Dermatol 1983; 9: 91-6. Kuflif EG. Crysurgical treatment of peringual warts. J Dermatol Surg Oncol 1984; 10; 673-6. McBurney El, Rosen DA. Carbon dioxide laser treatment of verrucae vulgaris. J Dermatol Surg Oncol 1984; 1045-8. Street ML, Roenigk RK. Recalcitrant peringual verrucae: The role of carbon dioxide laser vapourisation. J Am Acad Dermalol 1990; 23; 115-20. Garden JM, O'Banion MK, Shelnitz LS et al. Papillomavirus in the vapour of carbon dioxide laser treated verrueae. JAMA 1988; 259; 199-202. Sawchuk WS, Weber PJ, Lowy DR et al. Infectious papilloma-virus in the vapour of warts treated with carbon dioxide laser or electrocoagulation; detection and protection. J Am Acad Dermatol 1989; 21; 41-9. Baran R, Barth, Dawber. Nail Disorders. Comtnon Presenting Signs, Differential Diagnosis and Treatment. UK: Martin Dumitz, 1991; 107. Norton LA, Scher and Daniel. Nail; Therapy, Diagnosis, Surgery. Philadelphia; WB Saunders, 1990: 203. Miller RA. Nail dystrophy following intralesional injections of bleomycin for a periungual wart. Arch Dermatol 1984; 120; 963-4. Urbina Gonzalez F, Cristobal Gil MC, Aquilar Martinez A, et al. Cutaneous toxicity of intralesional bleomycin administration in the treatment of periungual warts. Arch Dermatol 1986; 122; 974-5.
91
CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS J.T.E. LIM AND C.L. GOH Singapore SUMMARY
This is a restrospective 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 JO 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 tine 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. Key words: Electrocautery, cryotherapy, liquid nitrogen, recalcitrant warts. INTRODUCTION
M E T H O D S AND MATERIALS
Periungual and subungual viral warts are treated by both medical and surgical methods. These include keratolytic and cytotoxic agents, immunotherapy with dinitrochlorobenzene,' chemotherapy with bleomycin,^ cryotherapy,' electrocautery and laser vapourisation.''' No single therapy has been established as the best and recurrences are common. In the National Skin Centre, Singapore subungual and periungual warts are usually treated by cryotherapy, electrocautery or carbon dioxide vapourisation or a combination of these. This is a retrospective study on the cure rate of carbon dioxide laser vapourisation treatment of recakitrant subungual and periungual warts that had failed treatment with conventional treatment including electrocautery and cryotherapy. Dr J.T.E. Lim, MBBS(Mal), MRCP (Ire), Senior Registrar. Dr C.L. Goh, FAMS, MMed(Singapore), MRCP(UK), Senior
Forty patients with periungual and subungual viral warts treated by carbon dioxide laser vapourisation in the National Skin Centre, Singapore were reviewed retrospectively. Viral warts were diagnosed clinically by their localised filiform appearance. Peringual warts were warts affecting the nail folds as well as the surrounding tissues. Subungual warts were those affecting the nail beds only. All patients were treated during a 2-year period from February 1990 till February 1992 and had 2-24 months of follow-up. They either had electrocautery, cryotherapy or both, prior to laser vapourisation treatment, Liquid nitrogen was used in cryotherapy. Cotton wool swabs were dipped into the liquid ^^^ ^^^^^^^ ^^^^^^^^ ^^ ^^^ ^^^^^ ^^^^^ ^ ^^^ f^g^^e was obtained. The procedure was repeated a second time. Nails were trimmed as far back ^s possible to expose the warts. The patients were
NarnirsTin^cr^tnga^'r^-
- - ^ ^ weekly intervals and cryotherapy repeated
Address for Correspondence: Dr Joyce Lim, National Skin Centre, 1 Mandalay Rd, Singapore 1130.
until clearance Occurred, or until the procedures were abandoned for failed response.
87
J.T.E. LlM AND C.L. GOH
Electrocautery was done using the Bireher Hyfrecator (Bireher Medieal System, USA) or Ellman Surgitron FFPF (Ellman International Manufacturing Ine, USA). The wart was first pared and then cauterised using power settings from 1 to low. The charred tissue was pared and any remaining wart cauterised. This was repeated until no obvious wart tissue remained. CO2 laser vapourisation was done using the Sharplan 1050 carbon dioxide laser (Sharplan Lasers, Ine. Israel) with a hand piece lens with a focused spot size of 0.08mm and a focal distance of 50mm. The continuous pulse mode was used. The beam was defocused to approximately 2.0mm, and power settings ranged from 3 to 15W, depending on the thickness of the lesion. The warts were vapourised completely until the presence of dermatoglyphic lines along
the nail fold was seen. When possible, the matrix was left intact (without incompletely treating the lesion) so that nail regrowth could occur. The type and frequency of treatments prior to laser vapourisation were noted. The outcome after laser vapourisation was recorded. The rate of recurrence, the type and frequency of treatments after recurrence and the final outcome were also noted. Recurrence was defined as warts that had cleared completely at the end of the treatment but reappeared during subsequent follow-up. Data were collected from the casenotes. Further follow-up information was obtained from telephone communication. The characteristics of the patients were summarised in Table 1 and 2. x^ test was used for statistical analysis. P value of -^0.05 was considered significant.
TABLE 1
Patient Number
Patient profile, type of treatments and outcome after first carbon dioxide laser vapourisation Type and requency of Treatment prior to CO2 laser Outcome after CO2 laser Site of Lesions Age/ Recurrence Electrocautery None Clear Sex Cryotherapy (in months) Periungual Subungual
1 2
33/M 12/M
LI RI LI
_ —
3 4 5 6 7
8/M
Rl, 3
24/M 32/M 34/M 29/M
— RI R3 —
8
18/M
RI, IV
—
—
+ +
—
I 2
— R4 — — Rl LI —
27 — 10 5 9
1 1 — 3 —
— — — — —
+ + — — —
— — 2 2 1
12
3
—
—
2
— —
11 4
— 1
— —
— +
1 —
RIV, V — —
4 — — 5 22
— — —
— + + — —
+
— — — — 3
— 3 — — — 30
— — — 1 — —
LI 9 10
23/M 13/M
11 12 13
32/F 18/F 42/M
14
23/F
15 16 17 18 19 20
10/F 16/F 29/F 29/M 34/F 30/F
Total FOOTNOTE:
R3, 4 Rl, 3 L3 — RII, Rl RI LIV R2 LI Rl LIV, V RI, 3, 5 R3 RI — 29
R = Right L = Left
— — — — — — RI, 4 L3
+ —
+ — + —
+ +
+ — + — + +
+ —
— 1 — — — 5
8 Roman Numericals 1 = big toe IMV = 2nci to 5th toes
88
Arabic Numericals 1 = thumb 2 = index 3 = middie
4 = ring 5 = little finger
CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS
were given per lesion. Twenty lesions were treated with carbon dioxide laser vapourisation without other prior treatments. Table 3 shows the cure rates following carbon dioxide laser vapourisation, after a ten month follow-up period. 42.6% (29/68) of the lesions recurred with the majority (82.7%) recurring within 3 months. Three lesions recurred at 5 months and the remaining 2 lesions at 10 months. Figure 1 compares the cure rates of the warts treated with carbon dioxide laser vapourisation as a first line treatment and those treated with carbon dioxide laser vapourisation after failed previous conventional treatment. Those who had laser treatment alone had a higher cure rate of 80.0% (16/20) compared with those who had failed other treatments prior to laser treatment (47.9% or 23/48), p value = 0.043. Subungual warts responded slightly better with a cure rate of 64.7% compared to periungual warts (54.9%) (ns). Various treatment modalities were done to the
RESULTS
Forty patients (27 males and 13 females) with a total of 68 lesions, were included in the study. Their ages ranged from 3 years to 79 years with a mean of 26.3 years. Three of them were below 12 years. Thirty eight patients were Chinese and the remaining 2 were Indians. Thirty seven of the patients had their viral warts for more than a year. Nineteen patients had a single lesion each, 15 had 2 lesions, 5 had 3 lesions and 1 had 4 lesions. There was a total of 68 lesions; 51 periungual and 17 subungual lesions. 77.9% of the lesions (53/68) were on the fingers with 49.1% (26/53) on the thumbs. Of the 15 lesions on the toes, 53.3% (8/15) were on the big toes. Forty-eight lesions had previously failed conventional therapy. 56.2% (27/48) had failed cryotherapy, 6.3% (3/48) had failed electrocautery and 37.5% (18/48) had failed both treatments. The frequency of cryotherapy treatments varied from 3 to 30 with a median of 9 treatments. One to three electrocautery treatments
TABLE 2
Patient Number
Patient profile, type of treatments and outcome after first carbon dioxide laser vapourisation Type and requency of Treatment Site of ^esions prior to CO2 laser Outcome after CO2 laser Age/ Recurrence Sex Periungual Subungual Cryotherapy Electrocautery None Clear (in months)
21 22 23 24 25 26 27 28 29
79/F 32/M 18/M 20/M 32/M 39/F 24/M 38/M 19/M
30 31 32 33 34 35 36 37
10/M 26/M 23/M 51/M 22/F 36/M 61/F
38 39 40
18/M 19/M 24/F
Total FOOTNOTE:
3/M
19 14 14 7 6 — 19 —
1 — — I — 1 — — —
— _ — — — — + — +
+ + — — — + +
1 — — 10 3 3 — — —
R3, 4
Rl — — LI —
— 22 — 6 — 4 6 11
— — — 1 — — — 2
+ — + — + — — —
+ + + — + — + +
— — — 2 — 1 — —
LI Rl Rl LI
— — —
— 3 5
— — 2
+ — —
— + +
1 — —
LI L4 —
L2, 3 R4
LI, 2 LI, 4 LI Rl LI — Rl — — Rl
R3, 4 —
51
R = Right L = Left
— L2 — — — —
Rl, 2, 3 — Rl —
Rl, 4
+
17
Roman Numericals I = big toe Il-IV = 2nd to 5th toes
89
Arabic Numericals 1 = thumb 2 = index 3 = middle
4 = ring 5 = little finger
J.T.E. LiM AND C.L. GOH lesions that recurred (Table 4). Fifteen lesions had a second carbon dioxide laser vapourisation treatment. 73.3% (11/15) of recurrent warts were cured with the laser treatment but 26.7% (4/15) recurred within 5 months. Four lesions cleared with cryotherapy alone and 2 cleared with a combination of cryotherapy and electrocautery. Two recurrent verrucae treated with electrocautery recurred again at 2 and 3 months. Four patients (6 lesions) preferred to leave their verrucae alone.
study, lesions treated with carbon dioxide laser vapourisation alone had a higher cure rate compared with those who had laser treatment after failed cryotherapy, electrocautery or both. This indicates that periungual and subungual warts can be more effectively eradicated by carbon dioxide laser vapourisation compared to cryotherapy or electrocautery. With a single carbon dioxide laser treatment all the warts cleared immediately and 57.4% (39/68) of these remained cleared on follow-up (up to 10 months). After a second laser treatment 73.5% (50/68) of the recurrent lesions were cleared. Laser treatment appeared to be an effective form of therapy for such warts. Repeat treatment offered further cure and should be considered.
DISCUSSION
Periungual and subungual warts are difficult to eradicate. However, they cannot be left alone as they are disfiguring and if the nail matrix is involved can be destructive too. Therefore, it is important to seek an effective treatment. In our
TABLE 3 Recurrence of verrucae after first carbon dioxide laser vapourisation Number of lesions recurred at
Number of Lesions Cleared
1 month
2 months
3 months
Periungual 28 (54.9%)
9
7
5
Subungual tt (64.7%)
2
1
Total 39 (57.4%)
11 (16.2%)
8 (11.8%)
5 months
10 months
Total Lesions Recurred
2
23 (45.1%)
3 5 (7.4%)
6 (35.3%)
3 (4.4%)
2 (2.9%)
29 (42.6%)
TABLE 4 Treatment and outcome for verrucae that recurred after the first carbon dioxide laser vapourisation Duration Outcome Treatment of follow-up from 1st Patient Number Recurrence CO2 laser Cleared 2nd CO2 laser Number Electrocautery Cryotherapy (months) of Lesions (months) 1 2 5
9 14 16 20 21 24 25 26 33 35 38
1 2 1 1 2 3 2 2 2 3 1 2 1 2 1 2 1
Total
29
24 24 24 20 20 20 19 17 16 15 15 13 12 11 II 7 7
7 1 9
+ -I-
17
90
CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS
Therefore laser therapy for perinugual and subungual warts is recommended as a first line therapy, as it is safe, effective and convenient. However it should only be performed by persons familiar with the procedure to minimise hazards and complications.
Many of the warts were treated with repeated cryotherapy or electrocautery, some even up to 30 treatments with no success. It would appear that laser therapy could be considered the therapy of first choice. Many lesions were cleared with a single or at most two treatments. The advantages of laser vapourisation are (1) it is time-saving for the patient; the warts can be vapourised in one sitting whereas patients need to attend weekly or fortnightly for cryotherapy, (2) less risk of bleeding and infection and (3) less post-operative swelling. A hazard of carbon dioxide laser vapourisation includes infection of the surgeon from laser plumes. Fumes from destroyed tissue have been reported to contain virus particles' and there have been reports of layngeal papillomas occuring from inhalation of such laser plumes. This risk can be reduced by appropriate care with exhaust pumps, filters and masks.' Some authors discourage surgical treatments for peringual or subungual warts for fear of causing damage to the matrix or causing considerable scarring." Others recommend a combination of intra-lesional bleomycin and cryotherapy as the most successful treatment for such warts.' However, this treatment causes severe pain, nail dystrophy'" and cutaneous toxicity." None of our patients had problems with pain and if pain occurred it was tolerable even among our paediatric patients, the youngest being three years old. The scarring that occurred was also acceptable. Subungual and peringual warts can also cause severe nail dystrophy and nail bed disfigurement if left untreated.
REFERENCES Dunagin WG, Millikan LE. Dinitrochlorobenzene immunotherapy for verrucae resistant to standard treatment modalities. J Am Acad Dermatol 1982; 6: 40-5. Shumer SM, O'Keefe EJ. Bleomycin in the treatment of recalcitrant warts. J Am Acad Dermatol 1983; 9: 91-6. Kuflif EG. Crysurgical treatment of peringual warts. J Dermatol Surg Oncol 1984; 10; 673-6. McBurney El, Rosen DA. Carbon dioxide laser treatment of verrucae vulgaris. J Dermatol Surg Oncol 1984; 1045-8. Street ML, Roenigk RK. Recalcitrant peringual verrucae: The role of carbon dioxide laser vapourisation. J Am Acad Dermalol 1990; 23; 115-20. Garden JM, O'Banion MK, Shelnitz LS et al. Papillomavirus in the vapour of carbon dioxide laser treated verrueae. JAMA 1988; 259; 199-202. Sawchuk WS, Weber PJ, Lowy DR et al. Infectious papilloma-virus in the vapour of warts treated with carbon dioxide laser or electrocoagulation; detection and protection. J Am Acad Dermatol 1989; 21; 41-9. Baran R, Barth, Dawber. Nail Disorders. Comtnon Presenting Signs, Differential Diagnosis and Treatment. UK: Martin Dumitz, 1991; 107. Norton LA, Scher and Daniel. Nail; Therapy, Diagnosis, Surgery. Philadelphia; WB Saunders, 1990: 203. Miller RA. Nail dystrophy following intralesional injections of bleomycin for a periungual wart. Arch Dermatol 1984; 120; 963-4. Urbina Gonzalez F, Cristobal Gil MC, Aquilar Martinez A, et al. Cutaneous toxicity of intralesional bleomycin administration in the treatment of periungual warts. Arch Dermatol 1986; 122; 974-5.
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