Evaluation of Combined Treatment With Er:YAG & Nd:YAG Lasers for the Treatment of Recalcitrant Warts
Condition: Viral Wart
MeSH terms: Warts
Study type: Interventional

Summary: 
      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: The goal of this clinical trial is 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. The main question it aims to answer is:

      Does adding a treatment of long-pulsed Nd:YAG laser to Er:YAG laser in the same treatment
      session to the same wart have more curing effect than using the Er:YAG laser alone? This
      study included 240 lesions from 24 patients. All the lesions were diagnosed clinically as
      recalcitrant warts after failure of topical treatment and Cryotherapy. 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.

      Researchers will compare the 120 treated warts with the combined lasers therapy to the 120
      treated warts treated with Er:YAG laser alone to see if adding the Nd:YAG laser therapy has
      an additional curing value.
    

Detailed description: 
      Viral warts are benign epithelial proliferations, characteristically 1-20 mm in diameter,
      that develop secondary to infection of keratinocytes by human papilloma virus (HPV). HPV
      comprises a large group of approximately 120 genotypes that infect the epithelia of the skin
      or mucosa. Warts are a common dermatological complaint, with an estimated incidence of 5%-20%
      in children and adults, with peak incidence reported during teenage years. Patients often
      express a significant reduction in quality of life due to this cosmetic nuisance, as well as
      functional problems and physical discomfort when they occur on the palms of the hands and
      soles of the feet. Therefore, cutaneous warts are one of the most common pathologies treated
      by the clinical dermatologist.

      Although warts may eventually spontaneously disappear once the immune system ﬁnds a way to
      eradicate the virus, the time taken for this to occur varies and can range from months to
      years. Managing recalcitrant warts may require more than one treating session. Chemical
      destruction can be induced with salicylic acid, cantharidin, formaldehyde, or glutaraldehyde,
      among other agents. Chemotherapeutic agents include podophyllin, podophyllotoxin,
      5-fluorouracil, and bleomycin. Allergic contact agents used against recalcitrant warts
      include dinitrochlorobenzene and squaric acid dibutyl ester. More recently, immunomodulators
      such as interferon, systemic retinoids, cimetidine, and topical imiquimod have been used. The
      used methods of physical destruction include surgical excision, electrodesiccation,
      cryosurgery, and pulsed dye or carbon dioxide laser therapy.

      Most of the methods mentioned above have their drawbacks and side effects. Surgical methods
      have proven somewhat effective but have their disadvantages of pain and long recovery periods
      and may offer incomplete and superficial results leading to high recurrence rates. Topical
      management requires the application of drugs for long durations and treatment success is,
      therefore, highly dependent on patient compliance.

      Lasers are new methods of energy-based devices for treating warts. Er:YAG laser (like CO2
      laser) is an ablative laser emitting at a wavelength of 2940 nm and highly absorbed by water.
      It is considered a safe treatment for viral warts, However, in many patients, mainly those
      with plantar warts, a significant rate of relapse may occur, requiring additional therapy.
      Recently, the long-pulsed (LP) 1064 nm Nd:YAG laser has attracted attention in the treatment
      of palmoplantar warts. The mechanism of the LP Nd:YAG laser is different from the Er:YAG
      laser. It targets the dermal blood vessels that supply infected cells and destroy them via
      photothermolysis mechanism. However, the limitations of this method are that the treatment
      usually requires several sessions, and the clearance rate after one session ranges between
      14-22%.

      This prospective study evaluates the treatment efficacy of an Er:YAG laser alone compared to
      a combination of Er:YAG followed by LP Nd:YAG after one session of recalcitrant warts. The
      investigators hypothesize that combining the two mechanisms of ablating the wart and
      coagulating the blood supply may lead to a higher wart clearance rate after a sole treatment
      session.
    

Intervention name(s): Long-Pulsed Nd:YAG Laser 1064nm & Er:YAG Laser 2940nm; Er:YAG Laser 2940nm
Intervention type(s): Device; Device
Intervention description(s): Warts with this intervention treated firstly with the Er:YAG laser, followed by the Nd:YAG laser in the same session.; Warts with this intervention treated only with the Er:YAG laser.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This randomized controlled trial included 240 lesions from 24 patients diagnosed with recalcitrant warts. Each wart of the 240 was given a number and photographed. In cases when the patient had an uneven number of warts, one wart was excluded randomly. Then, the warts of each patient were randomly divided into two groups using computerized randomization and assigned to group 1 or group 2. Each group consisted of 120 warts.
Group 1: Combined Er:YAG laser and long-pulsed Nd:YAG laser group. Group 2: Er:YAG laser group.
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: viral warts; recalcitrant; treatment; Er:YAG laser; long-pulsed Nd:YAG laser