I treat the patient every two weeks until I can see a return of normal skin lines. In my experience, pulsed dye laser treatment typically requires five to six treatments, depending on how thick the skin is in the area being treated as well as how long the wart(s) have been present. The plantar heel area can take up to 10 treatments or more. In between treatments, I have the patients use a topical drying agent and also use oral medication if they are amenable.
The pulsed dye laser treatments are somewhat painful but brief. They also do not require any post-treatment care. The more power you can use, the quicker the resolution but you have to weigh this with patient tolerance to the treatment. You must debride the lased wart tissue before each laser treatment. Typical settings are 12 to 14 J/cm2. You may also have patients use an OTC acid topical between visits if they are willing to be adherent. If the aforementioned non-surgical treatment fails, I will then utilize cold steel or a CO2 laser. This is mostly dependent on what kind of wart I am trying to treat.
What You Should Know About Using The CO2 Laser
There are several pearls on using the CO2 laser for treatment of warts. Make sure you ablate 3 mm beyond the visual border of the lesion, just like you would do with cold steel debridement. Use a skin marker to demarcate the lesion plus the 3 mm beyond the border. The typical setting that I use is 3W of continuous power. I also like to utilize loupes when I do the procedure as you can really discern the skin lines.
I first circumscribe the entire lesion. If there is a small lesion just outside the main lesion, I include that in the demarcation instead of creating a little skin island. I then use a scribble technique back and forth in a pattern from top to bottom or side to side depending on the area. Between passes of the laser, I use a 4 mm curette to remove the lased tissue. I also use a sterile wet sponge for atraumatic debridement of the area before using the curette to debride the tissue. This makes it easier to remove the ablated tissue. I also send some of this tissue to the pathologist.
I continue this scribble and curette technique until I see only white basement membrane. Then I defocus the laser by pulling it back and cauterizing the area. Be careful here as you can easily penetrate the basement membrane and create holes that could cause unwanted scarring. Once you are finished, cover the surgical site with silver sulfadiazine, a non-adherent dressing and a sterile bandage. Have the patient change the dressing once a day. Healing takes about a month.
When Patients Do Not Respond To Conservative Methods
If lesion(s) appear to be well encapsulated and are not likely to respond to lasers due to thickness, I am more inclined to go straight to surgical treatment. I might even use the pulsed dye laser in the early healing period after surgical removal if I can see any signs of recurrence.
If the patient has failed all of the aforementioned approaches or there are too many warts to treat, I will employ the Panacos graft technique. This procedure involves taking a small piece of wart and implanting it into the foot (usually the opposite foot) in the subcutaneous layer. This will hopefully initiate the body’s own immune system to recognize this “foreign” body and mount an immune response to the viral infection. I have found this has a very high success rate. The typical time between the procedure and resolution of all warts is approximately four months. Accordingly, it is important to explain to the patient that it will take some time to see any results.