Dear Editor, Verruca plana, caused by human papilloma virus types 3, 10, 28, and 41, manifests as asymptomatic, flat-topped papules. They can cause significant cosmetic concern, especially when they are numerous and present on the face. Extensive lesions are not amenable to ablative treatment modalities and show variable response to other immunomodulatory, topical, and systemic agents.1 We report a patient with recalcitrant, extensive facial verruca plana who showed complete resolution after a single session of pulsed-dye laser (PDL). A 20-year-old girl with Fitzpatrick skin type IV, presented with numerous hyperpigmented to skin colored flat-topped papules on the face for the last 12 years, which were diagnosed as plane warts Figure 1. The lesions were gradually progressive and caused significant psychosocial distress to the patient. The patient was initially treated with topical tretinoin 0.025% once daily application for 6 months with no improvement. She was subsequently treated with oral isotretinoin at a dose of 0.3 mg/kg/day for 2 years, during which there was no progression of the disease, and the lesions became flatter. But the therapeutic response plateaued after a year of treatment, and on discontinuation, there was recurrence of lesions to the baseline level. She then underwent eight sessions of intralesional measles-mumps-rubella (MMR) vaccine (0.1mL) administered at two-weekly intervals, along with oral zinc gluconate 50 mg twice a day, with no clinical response. She was then initiated on oral levamisole 150 mg twice weekly for 3 months, with no response. After 8 months of exhausting all treatment options, she underwent a single session of PDL (spot size: 5 mm, fluence: 6 J/cm2, wavelength: 585 nm, pulse duration: 0.45 ms, Cynosure multiplex Cynergy™ laser) on the plane warts on the right half of her face. Within 24 to 48 hours after the PDL session, she noticed a sudden onset of redness associated with a burning sensation on the lesions. This was followed by resolution of all the skin lesions within a month, leaving behind post-inflammatory hyperpigmentation. At 4 months of follow-up, there has been no recurrence, and the patient continues to remain in remission Figure 2.Figure 1: Pre-treatment photographs of multiple verruca plana on the face of a 20-year-old girl (a) side profile (b) front profileFigure 2: Complete resolution of verruca plana with post-inflammatory hyperpigmentation following one session of pulsed-dye laser (a) side profile (b) front profileExtensive verruca plana on the face can be a therapeutic challenge. Current treatment modalities include ablative methods like topical trichloroacetic acid application, radiofrequency ablation, cryotherapy, and pulsed-dye and Nd-YAG lasers; topical medications like retinoids, salicylic acid, 1–5% 5-fluorouracil, 5% imiquimod, intralesional immunotherapy with MMR vaccine, purified protein derivative (PPD), bleomycin, etc., and systemic agents like oral retinoids.1 The overall response to treatment is variable, and hence the need for newer modalities. Literature shows promising results with PDL in various types of warts at different locations, achieving clearance rates ranging from 50% to 100%.2-4 A study by Vargas et al.5 exclusively on facial verruca, showed resolution of lesions in all 12 patients after 1–4 sessions, undertaken 3–4 weeks apart. In a series of 4 cases of verruca plana published by Khandpur et al.,6 there was complete clearance of lesions after 2–4 sessions of PDL, each undertaken at 4–6 weekly intervals. In a retrospective review by Grillo et al.,7 the overall clearance rate was 78% in 32 patients who received 1–2 sessions of PDL 3 weeks apart. Follow-up at 1 year demonstrated minimal recurrence. PDL works on the principle of selective photothermolysis, targeting oxyhemoglobin in the blood vessels. In warts, the primary target is the superficial plexus of dermal vessels, leading to ischemic necrosis of the warty growth. Another mechanism could be non-specific thermal damage to the infected keratinocytes. Stimulation of local cell-mediated immunity may be the third and probably the main mechanism of action in our patient, which led to complete resolution of all facial verruca plana following a single PDL laser session on warts on the right side of the face.8,9 PDL carries the advantages of producing insignificant pigmentary and textural sequelae and is well-tolerated by the patients. Our patient developed post-inflammatory hyperpigmentation, which she considered cosmetically more acceptable than the verruca plana. Authors’ contributions We confirm that all authors have read and approved the manuscript for submission. All authors meet authorship criteria, and the manuscript represents honest work. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the authors without the use of artificial intelligence technologies.
Najeeb et al. (2026) studied this question.