Acta Dermato-Venereologica 99-3CompleteContent | Page 29

349 SHORT COMMUNICATION Combination of Surgery and Nd:YAG Laser Therapy for Recalcitrant Viral Warts: A Successful Therapeutic Approach for Immunosuppressed Patients Andrea BACZAKO 1 , Veronika KRAUTHEIM 2 , Tilo BIEDERMANN 1 and Thomas VOLZ 1 1 Department of Dermatology and Allergology, and 2 Department of Anaesthesiology, Klinikum rechts der Isar, Technical University of Munich, Biedersteinerstraße 29, DE-80802 Munich, Germany. E-mail: [email protected] Accepted Nov 20, 2018; E-published Nov 21, 2018 Verrucae vulgares are benign epidermal tumours induced by cutaneous infection with different subtypes of human papilloma virus (HPV). Spontaneous regression can oc- cur, but treatment is usually challenging and protracted. Immunocompromised patients have a higher risk of malignant HPV-induced skin tumours and recalcitrant viral warts, which are more difficult to treat than in im- munocompetent individuals. In immunocompromised patients, complications appear more frequently and se- verely, therefore the therapeutic regime must be chosen carefully considering possible impaired wound healing or toxicity of therapeutic agents. Therapeutic approaches can be surgical, chemical or immunomodulatory or by laser, but only limited data exist on effective treatment in immunocompromised patients. CASE REPORT We report here a 68-year-old woman who had had a large number of verrucae vulgares on both hands and feet for 5 years, which were refractory to multiple attempts at topical treatment with 5-fluorura- cil, salicylic acid, cryotherapy, laser treatment or surgery alone. In addition to disfiguring skin findings, the patient experienced intense pain, limited mobility of both hands and psychological strain. The warts had proliferated due to an underlying B-cell lymphoma, repeatedly treated with chemotherapy. Despite a detectable leucopaenia (2.18 g/l, reference 4.0–9.0 g/l), the pa- tient was otherwise in good health with no other susceptibility to infection. Multiple aggregated grey nodules with hyperkeratotic disrupted surface were found on the metacarpophalangeal and interphalangeal joints, dorsa and palms of both hands and toes on both feet (Fig. 1). The extent of the lesions first required surgical reduction of all tumour masses on both hands and feet. Removal of the warts was carried out by shaving the base of the tumours until punctate bleeding from vessels of the dermal papillae could be seen. Thus, mainly intraepidermal resection was observed to prevent scarring wherever possible. In the same session we also performed laser treatment with a Nd:YAG laser (1,064 nm wavelength, 130 J/cm 2 fluence, 20 ms pulse duration). Both procedures were performed under general anaesthesia. Postoperative analgesia was achieved by an axillary brachial plexus block and oral analgesics. Infection parameters were monitored continuously under antibiotic prophy- laxis. There were no postoperative complications, and the patient was permanently free of pain. All warts showed typical histological features, apart from 1, which presented with cell dysplasia and a change in the nuclear-cytoplasmatic ratio, thus displaying histo- logical criteria of an initial squamous cell carcinoma. Genotyping revealed the presence of both low- and high-risk HPV types 1, 6, 11, 16, 18 and 31 (HPV Broad Spectrum antibody, Zytomed Systems GmbH, Berlin, Germany). All warts on the hands and feet were removed successfully, and wound healing was equally completed on all sites within 4 weeks after combined surgical and Fig. 1. Multiple verrucae vulgares on the right hand of a 68-year- old immunocompromised patient. laser-therapeutic approach (Fig. 2). As expected, several small warts returned on both hands due to the patient’s permanently redu- ced immune status, spreading by autoinoculation. However, these were responsive to treatment with 5-fluoruracil and salicylic acid. Overall, the patient showed drastic improvement in mobility in all affected fingers and toes, reported a greatly improved life quality and is now able to perform everyday activities to the full extent. Fig. 2. Right hand of the same patient 3 months after surgery and laser therapy. This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica. doi: 10.2340/00015555-3092 Acta Derm Venereol 2019; 99: 349–350