Surgical treatment


Freezing warts with liquid nitrogen is a rapid method of treatment. It is contraindicated in small children, since it is frequently associated with intense pain secondary to oedema under the nail bed. Application of a surface anaesthetic cream 1-2 hours prior to therapy does not help to reduce pain in the periungual region. Hyperkeratotic warts should be pared off before treatment to permit freezing of the deeper portions of the wart. Freezing takes 10-15 seconds using cryogen spray. A 1 mm halo ring should form in the normal skin surrounding the wart. Cryosurgery should be used with caution for warts on the proximal nail fold, since nail matrix damage is a common complication, with leukonychia, Beau's lines and onychomadesis. Irreversible matrix destruction with nail atrophy has been reported after overzealous cryosurgery.

Surgical excision

Excision of periungual warts is not recommended since it produces scarring and is associated with a high frequency of recurrence.

• Electrosurgery should be avoided, since it produces considerable scarring.

• Infrared coagulation is another destructive method that is not recommended.

• Localized heating using a radiofrequency heat generator has been successfully used to treat hand warts (86% cure). This treatment is not particularly painful, but may cause scarring and does not seem suitable for periungual warts.

Laser techniques

Carbon dioxide laser: this causes thermic destruction of the wart, producing a loss of skin which heals by secondary intention. When warts extend into the nail folds or the nail bed, laser treatment should be preceded by partial or total nail avulsion. Re-epithelialization takes a long time (approximately 9 weeks) and is associated with risk of infections and pain. Some authors reported complete cures in 71% of patients with periungual warts exclusively treated with one or two sessions of CO2 laser. Temporary or permanent nail dystrophy were observed in 29% of treated patients. Pain sometimes persists after wound healing. Scarring is not rare, as well as disturbance of function. This technique is suggested only as a secondary approach for recalcitrant warts.

Pulsed dye laser: this laser acts through a selective microvascular destruction of the dilated capillaries of the warts, since the oxyhaemoglobin contained in the vessels preferentially absorbs yellow light. Healing of the wart is due both to thermic damage and to removal of the blood supply. Stimulation of a cell-mediated immune response may be another contributing factor. A few days after the procedure the wart becomes dry and black, as a result of necrosis. Since no wound is produced, patients may return to work immediately and postoperative pain is minimal. Healing occurs after 2-4 weeks. Periungual warts are less responsive to treatment than palmar or common warts. Although this technique is associated with a very low incidence of scarring, cure is achieved in only a third of cases, and usually after two to four treatments.

• Erbium:YAG laser: the erbium:ytrium-aluminium-garnet (YAG) laser produces a controlled tissue ablation with minimal thermal damage compared with the CO2 laser. This laser has been used for periungual warts with an excellent safety profile and minimal morbidity and pain.

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