Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 117-120
http://dx.doi.org/10.4236/jcdsa.2013.31017 Published Online March 2013 (http://www.scirp.org/journal/jcdsa)
117
Treatment of Recalcitrant Viral Warts with Photodynamic
Therapy with Mal and Red Light
Montserrat Fernández Guarino*, Antonio Harto, Pedro Jaén
Dermatology Departament, Hospital Universitario Ramón y Cajal, Madrid, Spain.
Received January 21st, 2013; revised February 23rd, 2013; accepted March 4th, 2013
ABSTRACT
Background: Photodynamic therapy (PDT) is a treatment for non-melanoma skin cancer. In recent years, its use has
expanded to new indications. Viral warts (VW) are some of the most promising. Methods: A retrospective, descriptive,
observational study was carried out. Patients who did not respond to cryotherapy were selected and were occluded with
methyl aminolevulinate (MAL) for three hours and they were illuminated with red light. Tolerance to treatment was
evaluated using a visual analog scale for pain (from 0 to 10). Results: A total of 15 patients with 134 VW were treated.
A complete response was obtained in 13 of 15 patients (87%) and in 127 of 134 lesions (95%). The mean number of
sessions was 3.1 (range 1 to 6) and the average pain score was 3.1 (range 0 to 8). Conclusions: PDT is a treatment that
offers good results in the treatment of VW that are resistant to routine treatment. The treatment was well tolerated in our
patient group.
Keywords: Photodynamic Therapy; Viral Warts; Red Light
1. Background
Photodynamic therapy (PDT) is a technique that is
increasingly being used for off-label indications. Viral
warts (VW) are one of the most promising indications.
Previous studies indicate clearances of between 42% -
92% of lesions with aminolevulinic acid (ALA) and
different incoherent light sources [1,2]. The primary li-
mitation of this treatment is pain.
2. Objective
The purpose of our study was to evaluate the results of
PDT in the treatment of VW with methyl aminole-vu-
linate (MAL) and red light and to evaluate treatment
tolerance.
3. Material and Methods
A retrospective, descriptive, observational study was
carried out. Patients who did not respond to at least one
correctly-applied routine treatment, always including
cryotherapy, were selected. After curettage of the lesions,
MAL was occluded for 3 hours and illuminated with red
light (Aktilite®, 630 nm, 37 J/cm2, 8 minutes). Three
sessions were applied, once per week for three weeks.
The patient rested for three-week and another three-week
cycle was applied (once per week) until a response was
obtained. Afterwards, patients were subjected to quar-
terly follow-up for one year without treatment. Pain was
measured after each session using a visual analog scale
of 0 to 10.
4. Results
A total of 15 patients with 134 VW were treated (Table 1)
A complete response was obtained in 13 of 15 patients
(87%) and in 127 of 134 lesions (95%), see Figures 1
and 2. The mean number of sessions was 3.1 (range 1 to
6) and the average pain score was 3.1 (range 0 to 8).
5. Discussion
VW is a common pathology that is treated with kera-
tolytics, cryotherapy, electrocoagulation and antimitotic
agents (podophyllin, bleomycin, retinoids). More re-
cently, new therapeutic approximations have been used
with immunomodulators such as imiquimod cream, laser
or PDT. Cryotherapy continues to be the most widely
used treatment due to its simplicity, safety, speed, effi-
cacy and low cost. However, it is not uncommon to en-
counter persistent VWs despite multiple cryotherapy ses-
sions.
There are several mechanisms of action that explain
the antiviral properties of PDe HPV-infected T. First, th
*Corresponding author.

Treatment of Recalcitrant Viral Warts with Photodynamic Therapy with Mal and Red Light 118
Table 1. Results of the treatment.
NUMBER OF
PATIENTS
NUMBER OF
LESIONS
COMPLETE
RESPONSE/PATIENT
COMPLETE
RESPONSE/LESION
NUMBER OF
SESIONS (RANGE)
PAIN
(RANGE)
15
134
-3 sole
-7 periungual
-123 hands
13/15
87%
127/134
95%
46/15
3.1
(1 - 6)
39/15
2.6
(0 - 8)
Table 2. Published studies on PDT for verruca vulgaris.
AUTHOR/
YEAR
NO.
VW PS
OCCLUSI
ON
(hours)
LIGHT
SOURCE
LIGHT
DOSAGE
(J/cm2)
NO. OF
SESSIONS
RESPONSE
(%) COMMENTS
Stender
1999 250 ALA 5 White, blue or red 40 3 73-42-28% -White light is more effective
Stender
2000 232 ALA 4 Waldman 590 - 700 nm 70 2 - 5 56% -Statistically significant compared to placebo
Fabbrocini
2001 64 ALA 5 Tunsten 400 - 700 nm 50 Maximum of 975% -Curettage and keratolytics
Schroeter
2005 48 ALA 4-8 Versalight 400 -720 nm 100 1 - 7 (mean 2.3) 88%
Ziolkowski
2006 18 ALA 4 Waldman 400 - 700 nm 70 1 - 6 67% -Previous treatment with 3% azone -Group without azone had a 37% response
Schroeter
2007 40 ALA 5 Versalight 400 - 720 nm 100 1 - 13 (mean 4.5) 90% -No recurrences at 6 months
Wang 2007 12 ALA 4 Waldman
400 - 700 nm 50 2 - 4 (mean 3.6) 42% -4/12 severe pain persisted for 24 hours
Yoo 2009 40 MAL 3 Aktilite 630 nm 50 1 - 3
(mean 2.2) 90% -Uses first CO2 laser
Lu 2010 18* ALA 4 635 nm laser 120 Maximum 394% -Flat warts
Fernandez-
Guarino
2010
235 MAL 3 PDL 395 nm 7mm
9 J/cm2
Maximum of 6
(mean 5.25)53% -No incomplete responses obtained -Response per patient: 26%
NO.: number; VW: Viral wart; PAC: patients; PS: photosensitizer; PDL: Pulsed dye laser; *: Number of patients with flat warts.
Figure 1. Image of a plantar wart previous to treatment
with photodynamic therapy.
cells proliferate more rapidly than normal circulating
cells. This leads to selective accumulation of the pho-
tosensitizer [3]. On the other hand, PDT has been shown
to destroy infected keratinocytes and inactivate viral
Figure 2. Image of the same plantar wart after five sessions
of treatment with photodynamic therapy (MAL, red light,
630 nm, 37 J/cm2, 8 minutes).
Replication [4]. Giomi, in an interesting recently publi-
shed study, studied the immunological response of PDT
on genital warts [5]. He found a progressive increase in

Treatment of Recalcitrant Viral Warts with Photodynamic Therapy with Mal and Red Light 119
perilesional CD4 T-lymphocytes during the first month.
These findings appear to suggest that there is an ability
of PDT to induce a specific immune response.
There are several published studies on the use of PDT
in VW (see Table 2) [2,6-14]. These studies found an
efficacy of 42% - 90%. The first studies were by Stender
[6,7] ALA and found that white light is more effective
than red or blue. The majority of studies use ALA as the
photosensitizer and long wave light sources and red
surroundings in order to achieve greater penetration. One
of the studies uses a diode laser with a very good res-
ponse in flat warts (94%) [13] and another uses a pulsed
dye laser in verruca vulgaris with a more moderate res-
ponse [14]. All used repeated sessions in order to achieve
a response in the lesions and all noted that the use of
ablative methods prior to PDT (keratolytics, azone, CO2
laser) increases the response to treatment by favoring
penetration of the photosensitizer and the light source.
[10,11,14] Few studies had a long patient follow-up.
Only one evaluated the response at 6 months [2]. Our
results are good if we compare them to the published
literature, though our study included a small patient series.
Without a doubt, the most limiting factor for treating
VWs with PDT is the pain, which occurs in all treatment
modalities, and leads to discontinuing the session in up to
20% of patients. [15] The pain is characteristically in-
tense and persists for up to 24 hours after treatment. It is
very notable that patients tolerated the pain well in [16]
our study (mean pain of 3.1) versus previous publications.
When we begin to apply PDT in the treatment of VW,
we select laser as the light source in order to try and
improve tolerance to treatment [14]. However, we have
achieved better tolerance with red light.
PDT with MAL and red light is a promising treatment
that is well tolerated in the management of VWs that are
resistant to standard treatments. Nevertheless, there are
few studies of adequate sample size and design that sup-
port its scientific evidence, so new studies on this subject
are needed.
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