Photodynamic therapy using methylene blue and intense pulsed light versus intense pulsed light alone in treatment of verruca: A randomized controlled study

https://doi.org/10.1016/j.pdpdt.2021.102541Get rights and content

Highlights

  • Many therapeutic modalities are available for the treatment of warts, but no single therapy is universally effective.

  • Methylene blue (MB) is a phenothiazinium dye that can be used as photosensitiser with absorption spectrum in the 550—700 nm region.

  • Intense pulsed light (IPL) plays a role in wart treatment through targeting superficial capillaries with a success rate of around 20%.

  • Photodynamic therapy using MB and IPL is an effective option for treatment of warts with a success rate of around 40%.

  • Dermoscopy rather than unaided eye examination is more sensitive monitor for response of treatment of warts.

  • Surface area of individual warts and surface area of vessels and haemorrhagic dots using imageJ software analysis are reliable markers for follow up of treatment.

  • Success rate of treatment was higher on utilizing imageJ software.

Abstract

Background

Many therapeutic modalities are available for treatment of warts, but no single therapy is universally effective. Photodynamic therapy (PDT) using intralesional methylene blue (MB) followed by intense pulsed light (IPL) could be a successful option for treatment by several mechanisms.

Methods

This prospective randomized controlled trial was carried out on eighty patients with verrucae. Patients were randomized into three groups; group A (30 patients) received MB/IPL/PDT sessions, group B (30 Patients) received IPL sessions, and group C (control). Response was assessed by clinical and dermoscopy score (0,1, 2, or 3 according to extent of clinical and dermoscopic resolution), cure rate (percent of verrucae clinically and dermoscopy cleared), and imageJ analysis (surface area of wart and haemorrhagic structures or vessels).

Results

Clinical and dermoscopic clearance was achieved in 43.3% and 20% of patients in groups A and B respectively. Cure rate was 40.9% for group A compared to 23.4% for group B. ImageJ analysis revealed more reduction of surface area in group A being 80.05 ± 27.12% for verrucae and 89.28 ± 19.19% for vessels and haemorrhagic dots compared to 48.16 ± 34.21% and 65.99 ± 30.58% in group B.

Conclusions

MB/IPL/PDT is an effective option for treatment of warts with a success rate of around 40%, based on clinical and dermoscopic assessment. The efficacy was found to be higher on using imageJ utilizing both the surface area of the wart and surface area of vessels and haemorrhagic dots with the latter being more effected by treatment.

Introduction

Warts are benign epidermal lesions caused by human papillomavirus (HPV) [1]. The National centre for Biotechnology Information (NCBI), nucleotide sequence database currently, listed more than 150 different HPV types [2]. Productive infection and induction of hyperproliferation are initiated when the virus enters proliferating basal epithelial cells [3]. Despite the relative success of papillomaviruses in evading immune responses, up to two-thirds of cutaneous warts spontaneously regress within 2 years [4].

Many therapeutic modalities are available for the treatment of warts, but no single therapy is universally effective. Warts can resolve, recur, shrink, or grow despite therapy [5]. Treatment methods are divided into the categories of home remedies, over-the-counter treatments, and office-based therapies [6]. Photodynamic therapy (PDT) is a treatment modality involving administration of a photosensitizing compound, accumulation of the sensitizer molecules in the target cells followed by selective irradiation of the lesion with visible light [7]. PDT can exert the following mechanisms which are inter-linked: direct cytotoxicity, vascular damage, inflammation, and immune host response [8].

The use of methylene blue (MB) as a photosensitizer (PS) against some viruses has been established before [9]. Also, intense pulsed light (IPL) can be used either alone or with PDT in treating warts since it can selectively destroy the superficial capillaries of the viral papillomas, as well as induce thermal damage to the human papillary virus [10].

Therefore, a combination of both would give an appropriate option for warts treatment, and hence the aim of this study was to assess the efficacy and safety of photodynamic therapy using methylene blue and IPL for the treatment of warts.

Section snippets

Patients and methods

This prospective randomized controlled trial (ClinicalTrial.gov Identifier NCT04620785) was carried out on eighty patients with clinically and dermoscopically diagnosed verrucae. Patients were recruited from the Outpatient Clinic of Dermatology, Venereology, and Andrology Department, Alexandria Main University Hospital. The study was approved by the local ethical committee in accordance with the declaration of Helsinki 1975. The age was not less than 16 years. Written informed consent was

Results

Eighty patients with clinically and dermoscopically diagnosed verrucae were included in this study. Demographic and clinical characteristics of the studied groups are shown in Table 1 while dermsocopic features of studied verrucae are shown in Table 2.

By week 8, clinical and dermoscopy score 3 was achieved in 43.3% versus 20%, score 2 in 10% versus 3.3%, score 1 in 40% versus 30%, and score 0 in 6.7% versus 46.7% in groups A and B. There was a statistically significant difference between the

Discussion

Treatment for HPV infection is generally unsatisfactory. Most rely on destruction of the affected tissue. Clinically normal skin may harbor viral DNA and, thus, it is unlikely that destroying clinically visible lesions eliminates the virus [15].

PDT can destroy HPV-infected keratinocytes and inactivates non-enveloped viral particles by the possible mechanism of binding PS molecules to the viral surface glycoproteins and inhibiting early phases of viral infection [16].

Methylene blue is a widely

References (35)

  • R.C. Kines et al.

    The initial steps leading to papillomavirus infection occur on the basement membrane prior to cell surface binding

    Proc. Natl. Acad. Sci. U. S. A.

    (2009)
  • Kirnbauer R., Lenz P. Human Papillomaviruses. In: Bolognia J, Schaffer J, Cerroni L (eds). Dermatology E-Book. 4th ed....
  • L. Leung

    Recalcitrant nongenital warts

    Aust. Fam. Physician.

    (2011)
  • J.C. Sterling et al.

    British Association of Dermatologists’ guidelines for the management of cutaneous warts 2014

    Br. J. Dermatol.

    (2014)
  • O. Ceburkov et al.

    Photodynamic therapy in dermatology

    Eur. J. Dermatol.

    (2000)
  • P. Babilas et al.

    Photodynamic therapy in dermatology: state-of-the-art

    Photodermatol. Photoimmunol. Photomed.

    (2010)
  • K. Togsverd-Bo et al.

    Paring and intense pulsed light versus paring alone for recalcitrant hand and foot warts: a randomized clinical trial with blinded outcome evaluation

    Lasers Surg. Med.

    (2010)
  • Cited by (5)

    View full text