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Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts Journal of the American Academy of Dermatology - Volume 32, Issue 3 (March 1995) - Copyright 1995 American Academy of Dermatology, Inc.

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Clinical and laboratory studies Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts

Hugh M. Gloster Jr. MD Randall K. Roenigk MD Rochester, Minnesota Department of Dermatology, Mayo Clinic and Mayo Foundation.

16/1/60921 Background: The documented presence of human papillomavirus DNA in the plume after carbon dioxide laser treatment of warts has raised questions about the risk of transmission of human papillomavirus to laser surgeons. Objective: We sought to define more clearly the risks to surgeons of acquiring warts from the CO2 laser plume. Methods: A comparative study was conducted between CO2 laser surgeons and two large groups of population-based control subjects (patients with warts in Olmsted County and at the Mayo Clinic from 1988 to 1992). Conclusions were drawn about the risks to surgeons of acquiring warts from the CO2 laser plume. Results: There was no significant difference ( p =0.569) between the incidence of CO2 laser surgeons with warts (5.4% ) and patients with warts in Olmsted County from 1988 to 1992 (4.9% ). There was a significant difference between the incidence of plantar ( p =0.004), nasopharyngeal ( p =0.001), and genital and perianal warts ( p =0.004) in the study group and in patients with warts treated at the Mayo Clinic from 1988 to 1992. No significant difference was found between physicians who had acquired warts and those who were wart free, on the basis of the failure to use gloves ( p =0.418), standard surgical masks ( p =0.748), laser masks ( p =0.418), smoke evacuators ( p =0.564), eye protection ( p =0.196), or full surgical gowns ( p =0.216). Finally, the incidence rates of surgeons with warts per 1000 person-years did not increase significantly ( p =0.951) as the length of time that the CO2 laser was used to treat warts increased. Conclusion: When warts are grouped together without specification of anatomic site, CO2 laser surgeons are no more likely to acquire warts than a person in the general population. However, human papillomavirus types that cause genital warts seem to have a predilection for infecting the upper airway mucosa, and laser plume containing these viruses may represent more of a hazard to the surgeon. (J A M A CAD D ERMATOL 1995;32:436-41.)

Accepted for publication Sept. 29, 1994. Reprint requests: R. K. Roenigk, MD, Department of Dermatology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905. Copyright 1995 by the American Academy of Dermatology, Inc.

The carbon dioxide laser can be used to treat various cutaneous disorders. In the defocused mode it is capable of inducing tissue temperatures higher than 100 C, which instantaneously vaporizes intracellular and extracellular water into charred tissue and plume. Many dermatologists think that CO2 laser vaporization is the treatment of choice for recalcitrant warts. Six-month cure rates of 80% to 95% have been reported for plantar and periungual warts that have been refractory to other standard treatments such as electrodesiccation and curettage, cryotherapy, and salicylic acid. [1] Several authors have suggested that viral particles in the laser plume may be transmitted to the laser surgeon. [2] [3] [4] In fact, human papillomavirus (HPV) DNA has been demonstrated in the plume after CO2 laser treatment of warts. [5] [6] The development of laryngeal papillomatosis has been documented in a surgeon who had been treating anogenital condylomas with the Nd:YAG laser. [7] Although the CO2 laser plume produced during the treatment of bovine warts has been shown to contain infectious bovine papillomavirus particles, [4] there is no reliable infectivity

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TABLE I -- Comparison of sites of HPV lesions in 31 CO2 laser surgeons and in 6124 patients examined at the Mayo Clinic No. of CO2 laser surgeons with warts (n = 31) 1 4 0 8 18 -No. of Mayo Clinic patients with warts * (n = Incidence (%) 6124) Incidence (%) 3 13 0 26 58 -1613 37 1274 --3200 26 0.6 21 ----

Anatomic site of warts Plantar surface Nasopharynx Genital/perianal area Face Hands Miscellaneous
*From 1988 to 1992.

p Value 0.004 0.001 0.004 ----

assay for HPV. Thus it has not been possible to isolate viable virus particles from the plume nor has it been demonstrated that the plume carrying this potentially infectious material can itself cause disease in human beings. [ 8] The purpose of our study was to define more clearly the risk of acquiring HPV from the plume of warts treated with the CO2 laser.

METHODS
We sent 4200 questionnaires to all members of the American Society for Laser Medicine and the American Society of

Dermatologic Surgery. The survey requested information about the length of time the surgeon had been using the CO2 laser to treat warts, the number of patients per month who had warts treated with the CO2 laser, precautions taken to prevent transmission of HPV (e.g., gloves, standard surgical masks, laser masks, smoke evacuators, eye protection, full surgical gowns), anatomic sites of the treated warts, whether the surgeon had warts that had developed since use of the CO2 laser, and the anatomic sites of such warts. After the data from the survey had been tabulated, a comparative study was done between CO2 laser surgeons and populationbased control subjects. First, the incidence of patients with warts in Olmsted County, Minnesota (Rochester, Minn., and surrounding suburbs) was compared with the incidence of CO2 laser surgeons who had warts. Second, the anatomic locations of warts in the study group and in patients treated at the Mayo Clinic for warts from 1988 to 1992 were compared. Third, an attempt was made to determine whether the omission of any of the precautionary measures listed in the questionnaire predisposed laser surgeons to the development of warts. Finally, the physicians who responded to the survey were divided into three groups on the basis of the length of time they had been using the CO2 laser to treat warts. The incidence rates of surgeons with warts in each group were then calculated to determine whether more HPV lesions were acquired with increasing exposure time to the laser plume.

RESULTS
Of the 4200 questionnaires that were sent, 570 were returned, for a response rate of 14%. This percentage was artificially low for two reasons. First, a considerable number of physicians received two copies of the questionnaire because of their membership in both the American Society for Laser Medicine and the American Society of Dermatologic Surgery. Second, those who did not use the CO2 laser were asked to discard the questionnaire. Thirty-one of the 570 respondents (overall incidence, 5.4%) thought that they had acquired warts because of exposure to the plume produced by the CO2 laser. For comparison, the incidence of patients with warts in Olmsted County during the last 5 years was computed as follows:

The difference between the incidence of CO2 laser surgeons with warts (5.4%) and patients with warts in Olmsted County from 1988 to 1992 (4.9%) was not significant (chi-square test, p =0.569).The anatomic sites of the acquired warts in CO2 laser surgeons are listed in Table I ; also, the sites of the warts and their respective incidences in the CO2 laser surgeons and the patients treated at the Mayo Clinic from 1988 to 1992 are compared. However, the Mayo Clinic records listed only separate sites with plantar, nasopharyngeal, and genital warts. All other anatomic sites (e.g., facial, periungual, hands) were lumped together in a group termed ``miscellaneous.''

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TABLE II -- Comparison of precautionary measures used by surgeons who had HPV warts and those who were wart free CO2 laser surgeons Precautionary measure Gloves Yes No Standard surgical mask 30 1 531 8 561 9 Warts (n = 31) No warts (n = 539) Total

Standard surgical mask Yes No Laser mask Yes No Smoke evacuator Yes No Eye protection Yes No Full surgical gown Yes No 8 23 183 356 191 379 25 6 473 66 498 72 31 0 533 6 564 6 18 13 342 197 360 210 10 21 169 370 179 391

Consequently, our data had to be arranged in a similar manner so that accurate comparisons could be made. There was a significant difference between the incidence of warts at each of the sites examined (plantar, nasopharyngeal, and genital and perianal) in both groups (chi-square test, p 0.05 for each site).

The precautions taken by CO2 laser surgeons to prevent the transmission of HPV were arranged in 22 contingency tables and listed in Table II . The difference between physicians who had acquired warts and those who were wart free on the basis of the failure to use gloves ( p =0.418), standard surgical masks ( p =0.748), laser masks ( p =0.418), smoke evacuators ( p =0.564), eye protection ( p =0.196), or full surgical gowns ( p =0.216) was not significant (chi-square test). The percentages and incidence rates of CO2 laser surgeons with acquired warts in relation to the duration of exposure to the laser plume are listed in Table III . After increasing slightly when the 1- to 3-year group (4.6%) was compared with the 3- to 5year group (5.8%), the percentage of CO2 laser surgeons with warts decreased to 5.5% for physicians who had been using the laser for 5 to 10 years. There was no significant difference between the incidence

TABLE III -- Incidence rate per 1000 person-years of CO2 laser surgeons with warts compared with duration of exposure to plume Duration of exposure to plume (yr) 1-3 (mean, 2) 3-5 (mean, 4) 5-10 (mean, 7.5) No. of CO2 laser surgeons 64 103 403 CO2 laser surgeons with warts No. 3 6 22 % 4.6 5.8 5.5 Incidence rate per 1000 person years* 23.4 14.6 7.3

rates per 1000 person-years of CO2 laser surgeons with warts in any of the three groups ( p =0.951).

DISCUSSION
We have attempted to define more clearly the risk to laser surgeons of acquiring HPV from the plume produced by the CO2 laser in the treatment of warts. This was not an easy task because of the difficulty in obtaining an adequate control group matched for age and sex. To circumvent this problem partly, a comparative study was conducted in which certain variables in the study group (e.g., incidence rates, anatomic sites of warts, and precautionary measures) were compared with the same variables in two large populations of patients (Olmsted County, Minn., and the Mayo Clinic). After determining whether differences between the two groups were statistically significant, conclusions were made about the risk to surgeons of acquiring warts from the CO2 laser plume. We acknowledge that the patients in Olmsted County and at the Mayo Clinic do not represent ideal control subjects. This study is further limited by several potential biases that may exist among both study groups, such as a selection bias among the 14% of surgeons who responded tothe survey, recall bias and opinion bias by the surgeons, and diagnostic access or ``desire for diagnosis'' bias among the Olmsted County population. Nevertheless, we believe that useful clinical information can be gained by determining whether statistically significant differences exist between the two groups. The overall incidence of CO2 laser surgeons with

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acquired warts (5.4%) was not significantly different from the incidence of patients with warts in Olmsted County, Minn., from 1988 to 1992 (4.9%). Furthermore, several surveys involving pediatric and adult populations have reported warts in 3.5% to 5% of patients. [9] The similarity between the incidence of warts in our study group and that in several different patient populations indicates that CO2 laser surgeons are at no more risk of acquiring warts than the general population. This conclusion is supported by data of Lobraico et al., [10] who sent questionnaires to CO2 laser surgeons in all medical specialties and reported that the overall incidence of acquired warts was 2.8%. The highest number of acquired warts reported by CO2 laser surgeons occurred on the hands (Table I) , with an incidence of 58%. Warts on the face occurred less frequently (26%) and were followed, in order of decreasing frequency, by nasopharyngeal lesions (13%), plantar warts (3%), and condylomata acuminata (0%). Table I lists the distribution of warts by anatomic site in both CO2 laser surgeons and patients who were treated at the Mayo Clinic from 1988 to 1992. As mentioned previously, Mayo Clinic records specified only the anatomic site with plantar, nasopharyngeal, and genital and perianal warts. All other anatomic locations were lumped together in a miscellaneous category, which was not used either for comparison or for statistical analysis because it could not be determined precisely which sites had been included in this miscellaneous group. There was a statistically significant difference between the incidence of plantar, nasopharyngeal, and genital and perianal warts in both groups, which implies that CO2 laser surgeons, in comparison with the Mayo Clinic patient group, had a greater risk of acquiring nasopharyngeal lesions but were less likely to acquire plantar, genital, and perianal warts. The presence of a significantly higher incidence of nasopharyngeal lesions in our study group in conjunction with the fact that inhalation of the laser plume is a likely means by which HPV can be transmitted to the upper airway indicates that CO2 laser surgeons are at increased risk of acquiring nasopharyngeal warts through inhalation of the laser plume. All four physicians who had nasopharyngeal warts used smoke evacuators, laser masks, and gloves. Even with these precautions, it is conceivable that the plume could be inhaled through openings between the sides of the laser mask and the skin. The risk would be enhanced if the surgeon's assistant carelessly held the distal end of the smoke evacuator more than 2 cm from the irradiated site, which would result in the escape of a considerable amount of the plume into the operating suite. [11] It could be argued that the laser surgeons acquired the nasopharyngeal warts by direct contact with patients and subsequently spread the virus to the nasopharynx by hand rather than by inhalation of laser plume. Lobraico et al. [12] found a higher incidence of acquired hand lesions among dermatologists using the CO2 laser who did not wear gloves and postulated that other sites of the body (e.g., face and neck) were infected by the examiner's contaminated hands rather than by the laser plume.

It is more likely that the plume was the cause of nasopharyngeal warts in our study group because all four physicians used gloves and masks. Furthermore, three of these four physicians used the CO2 laser to treat genital warts. Laser surgeons treating genital warts would be at the greatest risk of acquiring lesions in the upper airway because HPV types 6 and 11, which are most frequently found in genital warts, are often isolated from patients with respiratory papillomatosis. [13] [14] However, we acknowledge that the nasopharyngeal warts present in the CO2 laser surgeons in our study were not analyzed for HPV type, so it is possible that the plume produced in the treatment of plantar, hand, or facial warts could have caused the nasopharyngeal lesions. The precautionary measures used by most surgeons exposed to laser plume included gloves, face masks, smoke evacuators, operating gowns, and goggles. The precautions that were taken and those which were omitted by surgeons who had acquired warts and by those who were wart free are listed in Table II . Statistical analysis of the data did not indicate that the failure to use any one of the precautionary measures predisposed surgeons to acquiring warts. Therefore in all likelihood the use of precautionary measures did not artificially lower the actual incidence of CO2 laser surgeons with warts to a level similar to that of people with warts in the general population. However, it is important to note that the number of physicians who did not use gloves or smoke evacuators was so small that the chi-square test might have been invalid, which would prevent making sound conclusions about the risk to CO2 laser surgeons of acquiring warts when gloves and smoke evacuators were not used. Therefore until more conclusive data are available, surgeons should err on the side of caution and continue to exercise

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standard precautions to prevent the spread of potentially infectious material in the plume. The incidence rates of surgeons with warts per 1000 person-years did not increase significantly with an increase in the length of time that the CO2 laser was used to treat warts (Table III) , indicating no cumulative effect of exposure time to plume on the incidence of acquired warts. Because the incidence of warts in CO2 laser surgeons should increase with longer exposure time if the plume indeed had infectious potential, our data imply that the risk of airborne transmission of HPV to the laser surgeon by the plume is not significant. In support of this conclusion, the percentage of surgeons with warts in all three time groups (4.6% for 1 to 3 years, 5.8% for 3 to 5 years, and 5.5% for 5 to 10 years) was similar to the reported incidences mentioned for people in the general population who had warts (3.5% to 5%). This is not surprising because warts in general are not highly contagious. For example, although dermatologists examine warts without wearing gloves, the incidence of hand warts in this group is not unusually high. In summary, our results indicate that when warts are grouped without specification of anatomic site, CO2 laser surgeons are no more likely to acquire warts than persons in the general population. Thus the plume does not possess enough infectious potential either to produce a significantly greater amount of warts in CO2 laser surgeons in comparison with population-based control subjects or to cause an increase in the incidence of acquired warts with increasing exposure time. However, when the incidences of warts are compared by site, CO2 laser surgeons have a higher risk of acquiring nasopharyngeal lesions, especially when they treat genital warts. This implies that the plume does indeed carry infectious viral particles that can cause disease in human beings and that different HPV types have varying degrees of contagiousness, depending on their individual biologic characteristics and the anatomic site exposed to the laser plume. In addition, the data imply that the infectious potential of most HPV types carried in the plume is very low. However, the increased incidence of CO2 laser surgeons with nasopharyngeal warts together with the fact that HPV types 6 and 11 are often isolated in patients with respiratory papillomas indicates that HPV-6 and -11 have a predilection for infecting the upper airway mucosa and that laser plume containing these viruses after the treatment of genital warts may cause disease in surgeons by inhalation. Nevertheless, because nasopharyngeal warts constituted such a small fraction of the different types of warts acquired in our study group, the overall incidence of CO2 laser surgeons with warts was not increased greater than the incidence of people in the general population who have warts. Surgeons who treat genital warts with the CO2 laser should take care to wear tight-fitting laser masks and to hold the smoke evacuator tube no more than 2 cm from the lesion, to minimize the dispersion of plume into the operating suite. It is important to recognize that the risk that the surgeon, through the laser plume, will acquire warts caused by HPV types other than those in genital lesions is comparable to that of the population as a whole. Still, standard precautionary measures should be used when all warts are treated, to minimize any potential hazard that might occur. We express our gratitude to Dr. Peter C. O'Brien and Ruth H. Cha, Mayo Clinic Section of Biostatistics, for their assistance in data analysis.

REFERENCES

1. Street 2. Andre

ML, Roenigk RK. Recalcitrant periungual verrucae: the role of carbon dioxide laser vaporization. J A M A CAD D ERMATOL 1990;23:115-20. P, Orth G, Evenou P, et al. Risk of papillomavirus infection in carbon dioxide laser treatment of genital lesions. J A M A CAD D ERMATOL

1990;22:131-2.
3. Garden

JM, O'Banion MK, Shelnitz LS, et al. Papillomavirus in the vapor of carbon dioxide laser-treated verrucae. JAMA 1988;259:1199-202.

4. Sawchuk

WS, Weber PJ, Lowy DR, et al. Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J A M A CAD D ERMATOL 1989;21:41-9.
5. Ferenczy

A, Bergeron C, Richart RM. Carbon dioxide laser energy disperses human papillomavirus deoxyribonucleic acid onto treatment fields. Am J Obstet Gynecol 1990;163:1271-4.
6. Ferenczy

A, Bergeron C, Richart RM. Human papillomavirus DNA in CO2 laser-generated plume of smoke and its consequences to the surgeon.

Obstet Gynecol 1990; 75:114-8.

7. Hallmo

P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol 1991;248:425-7.
8. Abramson

AL, DiLorenzo T P, Steinberg BM. Is papillomavirus detectable in the plume of laser-treated laryngeal papilloma? Arch Otolaryngol Head Neck Surg 1990; 116:604-7.
9. Beutner

KR, Becker T M, Stone KM. Epidemiology of human papillomavirus infections. Dermatol Clin 1991; 9:211-8. R, Schifano M, Brader K. A retrospective study on the hazards of the carbon dioxide laser plume. J Laser Appl 1988;1:6.

10. Lobraico

441

11. T revor

M. Presence of virus in CO2 laser plumes raises infection concern. Hosp Infect Control 1987;166-7. RV, Schifano MJ, Brader KR. Acquired HPV lesions compared in laser and nonlaser users. J Gynecol Surg 1989;5:77-85.

12. Lobraico 13. Mounts

P, Shah KV, Kashima H. Viral etiology of juvenile- and adult-onset squamous papilloma of the larynx. Proc Natl Acad Sci U S A 1982;79:5425-9.
14. Gissmann

L, Wolnik L, Ikenberg H, et al. Human papillomavirus types 6 and 11 DNA sequences in genital and laryngeal papillomas and in some cervical cancers. Proc Natl Acad Sci U S A 1983;80:560-3.

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