Curettage + microneedling + topical ALA-PDT for the treatment of acral resistant warts: Our experience.

BACKGROUND

Cutaneous warts are an extremely common problem, whose eradication can be challenging. Topical PDT involves applying a porphyrin precursor, 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) to the affected area. ALA-PDT has been well documented to be successful in the treatment of recalcitrant warts. PDT has a limited role in the treatment of thicker lesions because the photosensitizer does not penetrate keratotic lesions well, though this is vehicle dependent.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of curettage + microneedling + ALA-PDT for the treatment of resistant acral warts. We hypothesized that microneedling may increase the efficacy of PDT, providing a channel to deliver the ALA to deeper areas of warts.

METHODS

Our study was carried out between November 2017 and July 2018. Eligible participants had one or more resistant plantar or palmar warts. Thirteen patients were recruited. They underwent a thorough curettage, followed by the application of 5-ALA 10% cream on the wart, and by microneedling. Later, the pricked skin was covered for three hours by an occlusive polyurethane dressing, and finally irradiated with a red-light source. Patients performed one session every three weeks for a total of three cycles.

RESULTS

After 3 treatments of curettage + microneedling + ALA-PDT, 11 patients (84.6%) showed complete remission (defined as complete disappearance of their warts). One patient (7.7%) showed partial remission (defined as greater than 50% decrease in the wart area) after 3 sessions; this patient needed other 2 sessions to achieve complete remission. The mean follow-up period after healing was 4.3 months. Adverse effects were recorded.

CONCLUSION

We have demonstrated, for the first time to our knowledge, that the combination of curettage + microneedling + topical ALA-PDT may offer an effective and safe alternative for the treatment of acral resistant warts, even when PDT alone has already been insufficient.