357
ORIGINAL SCIENTIFIC ARTICLE
Effectiveness and Safety of Ablative Er:YAG Laser Treatment of External Genital Warts
Juna d.o.o., Ljubljana, 
Slovenia
Correspondence/
Korespondenca:
Urška Bizjak Ogrinc, e: 
urska.bizjak-ogrinc@juna.si
Key words:
ablative laser; 
condylomata acuminata; 
laser Er:YAG; external 
genital warts; HPV
Ključne besede:
ablativni laser; kondilomi; 
laser Er:YAG; genitalne 
bradavice; HPV
Received: 17. 3. 2020
Accepted: 17. 7. 2020
eng slo element
en article-lang
10.6016/ZdravVestn.3050 doi
17.3.2020 date-received
17.7.2020 date-accepted
Human reproduction Reprodukcija človeka discipline
Original scientific article Izvirni znanstveni članek article-type
Effectiveness and safety of ablative Er:YAG 
laser treatment for external genital warts
Varnost in učinkovitost odstranjevanja genitalnih 
bradavic z ablativnim erbijevim laserjem
article-title
Effectiveness and safety of ablative Er:YAG 
laser treatment for external genital warts
Varnost in učinkovitost odstranjevanja genitalnih 
bradavic z ablativnim erbijevim laserjem
alt-title
ablative laser, condylomata acuminata, laser 
Er:YAG, external genital warts, HPV
ablativni laser, kondilomi, laser Er:YAG, genitalne 
bradavice, HPV
kwd-group
The authors declare that there are no conflicts 
of interest present.
Avtorji so izjavili, da ne obstajajo nobeni 
konkurenčni interesi.
conflict
year volume first month last month first page last page
2020 89 7 8 357 364
name surname aff email
Urška Bizjak Ogrinc 1 urska.bizjak-ogrinc@juna.si
name surname aff
Sabina Senčar 1
eng slo aff-id
Juna d.o.o., Ljubljana, Slovenia Juna d.o.o., Ljubljana, Slovenija 1
Effectiveness and safety of ablative Er:YAG 
laser treatment for external genital warts
Varnost in učinkovitost odstranjevanja genitalnih 
bradavic z ablativnim erbijevim laserjem
Urška Bizjak Ogrinc, Sabina Senčar
Abstract
Background: The aim of this study is to evaluate effectiveness and safety of the use of ablative 
Er:YAG laser for removal of external genital warts (EGW), also called condylomata acuminata (CA).
Methods: This is a retrospective cohort study performed at Gynecology Clinic Juna in Ljublja-
na, Slovenia. All patients older than 18 years that were clinically diagnosed with EGW and were 
treated with ablative Er:YAG laser between January 2012 and December 2017 were included in 
the study.
Results: A total of 133 female patients (mean age 39.6 ± 12.9 years, range: 19–80) with EGW were 
eligible to be included in this study. EGW have been present from one to seven months, with a 
mean presence of 2.1 ± 2.0 months. The majority of the warts were on the labia, major some also 
on the mons pubis. The size of the lesions was 2–8 mm. The majority of patients, who complet-
ed therapy (74 patients out of 116; 64 ) received only one treatment and 82 of the patients (n = 
95) showed complete clearance of the lesions, without recurrence observed to date of analysis. 
Complete clearance was achieved after an average of 1.33 treatment sessions. Recurrence was 
reported by 21 patients (18 ). Recorded adverse effects of laser treatment were mild and tran-
sient.
Conclusion: Er:YAG laser removal of EGW is a simple, quick and safe procedure, particularly suit-
able for large volume EGW or those that are located in anatomical sites difficult to access by other 
techniques.
Izvleček
Izhodišče: Raziskava skuša ovrednotiti učinkovitost in varnost odstranjevanja genitalnih brada-
vic (kondilomov) z ablativnim erbijevim laserjem.
Metode: Retrospektivna kohortna raziskava je vključevala vse bolnice, starejše od 18 let, pri kat-
erih smo v ginekološki ambulanti Juna v obdobju med januarjem 2012 in decembrom 2017 diag-
nosticirali genitalne bradavice in jih odstranili z ablativnim erbijevim laserjem.
Rezultati: Skupaj je bilo v raziskavo vključenih 133 bolnic (povprečna starost: 39,6 ± 12,9, raz-
pon let: 19–80). Pri bolnicah so bile genitalne bradavice prisotne od enega do sedmih mesecev, 
v povprečju 2,1 ± 2,0 meseca. Večinoma so se nahajale na velikih sramnih ustnicah, v nekaterih 
primerih tudi na nadsramju. Velikost bradavic je bila med 2 in 8 mm. Pri večini bolnic (74 od 116, 
64 %) je bil potreben le en poseg z laserjem. Pri 82 % bolnic (n = 95) je bilo zdravljenje uspešno 
in ponovnega pojava genitalnih bradavic nismo zaznali, pri čemer smo v povprečju za popolno 
Slovenian
Medical
Journal
358
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Zdrav Vestn | July – August 2020 | Volume 89 | https://doi.org/10.6016/ZdravVestn.3050
1 Introduction
Human Papillomavirus (HPV) is a 
highly contagious virus that is the cause 
of one of the most frequently transmitted 
viral infections in the world (1,2). HPV in-
fection is spread by skin-to-skin contact, 
predominately during sexual activity, and 
is therefore considered a sexually trans-
mitted infection (STI) (1). There have been 
more than 200 HPV genotypes identified, 
approximately 40 of which are capable of 
infecting the anogenital tract and are cat-
egorized as either low or high risk, based 
on their capacity of inducing malignancy 
(3,4). External genital warts (EGW), also 
called condylomata acuminata, are benign 
cellular proliferations of the anogenital 
skin and mucosa that form in response to 
viral infection with a low-risk HPV gen-
otype, usually types 6 or 11 (4,5). Pre-ex-
posure vaccination in the form of either 
bivalent, quadrivalent or 9-valent vaccine 
is one of the most effective methods for 
preventing infection and transmission of 
the virus and has been recommended by 
the WHO as part of routine vaccination 
since 2007 (6).
Most (70–90%) of HPV infections are 
asymptomatic and can resolve sponta-
neously, however, once EGW develop, the 
treatment options are directed toward re-
moval of the warts and usually do not elim-
odstranitev genitalnih bradavic potrebovali 1,33 posega. Pri 21 osebah (18 %) je prišlo do pon-
ovnega izbruha genitalnih bradavic. Opaženi stranski učinki laserskega posega so bili blagi in 
prehodni.
Zaključek: Odstranjevanje genitalnih bradavic z ablativnim erbijevim laserjem je enostavno, hit-
ro in varno, še posebej primerno pri obsežnih spremembah, ki se nahajajo na težko dostopnih 
anatomskih mestih.
Cite as/Citirajte kot: Bizjak Ogrinc U, Senčar S. Effectiveness and safety of ablative Er:YAG laser treatment for 
external genital warts. Zdrav Vestn. 2020;89(7–8):357–64.
DOI: https://doi.org/10.6016/ZdravVestn.3050
Copyright (c) 2020 Slovenian Medical Journal. This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
inate the HPV infection (4). The available 
treatments are highly variable with respect 
to their cost, side-effect profile, dosing 
schedules, treatment duration, overall ef-
fectiveness and availability to patients (4). 
They can be grouped into topical inter-
ventions and physical ablative techniques, 
including laser vaporisation (7). Laser va-
porisation is performed using ablative la-
sers, which are highly absorbed in water 
and can vaporise structures on the tissue 
surface. The most frequently used laser for 
vaporisation of EGW has been the CO2 
laser, because of its established use in gy-
naecological surgery. However, there are 
lasers that are even more highly absorbed 
in water and these could therefore present 
an even better solution for surface vapori-
sation. The Er:YAG laser has a wavelength 
of 2940 nm and has a ten times higher op-
tical absorption coefficient in tissue water 
than the CO2 laser. This results in clean-
er and more precise target tissue removal 
with minimal adjacent tissue damage (8). 
It has also been shown that the Er:YAG la-
ser plume resulting from EGW treatment 
is free of HPV DNA (9), however, the use 
of an evacuation hood is recommended 
when performing any ablative laser pro-
cedure.
Er:YAG has been widely and successful-
359
ORIGINAL SCIENTIFIC ARTICLE
Effectiveness and Safety of Ablative Er:YAG Laser Treatment of External Genital Warts
ly applied for treatment of common warts 
(10-13), however, literature describing the 
use of Er:YAG for treatment of EGW is 
scarce (11,14). The aim of this paper was 
to retrospectively analyse the effectiveness 
of Er:YAG laser vaporisation of EGW in 
cases from our clinical practice.
2 Materials and Methods
2.1 Study design and patient 
population
This was a retrospective chart review 
study that was conducted at the Gynecolo-
gy Clinic Juna, Ljubljana, Slovenia. Ethics 
approval (No. 0120–253/2019/7) was ob-
tained from the National Medical Ethics 
Committee of the Ministry of Health of 
the Republic of Slovenia and the study was 
conducted according to the Declaration of 
Helsinki. The study was registered at Clin-
icalTrials.gov (NCT04073082). The aim of 
this study was to retrospectively evaluate 
the effectiveness and safety of Er:YAG la-
ser for treatment of EGW in patients treat-
ed in our clinic during six years of clinical 
practice.
All female patients older than 18 years 
that were clinically diagnosed with EGW 
and were treated with Er:YAG laser be-
tween January 2012 and December 2017 
were included in the study. Eligible pa-
tients were followed from the initial di-
agnosis until the most recent chart entry. 
The following parameters were relevant 
for our chart review: general demographic 
data; medical history; previous treatments; 
number of laser treatments needed for le-
sion clearance; laser parameters used; and 
adverse effects of laser treatment. In all 
patients, evaluation of treated lesions was 
done two weeks following the initial laser 
treatment. In some cases where the lesions 
were extensive, more than one treatment 
was required to completely clear the pri-
mary lesion. For these patients, laser treat-
ments were performed every two weeks 
until the area was completely cleared and 
asymptomatic. An EGW episode was con-
sidered as resolved (clinical clearance) 
when no recurrence of lesions was ob-
served after six months. All adverse events 
attributable to laser treatment were noted 
and followed.
2.2 Laser procedure
EGW were removed using an abla-
tive Er:YAG laser (SP Dynamis, Fotona, 
Ljubljana, Slovenia). Treatment proto-
col was comparable in all patients. After 
routine sterilization of the area, the local 
anaesthetic was applied (EMLA Cream 
5%, Aspen Pharma Trading Ltd., Dub-
lin, Ireland). Laser parameters that were 
used were adapted to the EGW size and 
ranged from 2–4 mm spot size (full spot, 
R11 handpiece), MSP pulse duration (100 
µs), with a repetition rate of 3–5 Hz and 
fluences from 3–5 J/cm2. Depending on 
the extent of the lesion, the duration of 
treatment usually lasted between 15 and 
30 minutes. Due to potentially hazardous 
laser plumes, the practitioner wore a mask 
with a particle filter, and a fume extractor 
was used in the treated area. Post-laser 
care recommendations included careful 
washing with mild intimate washing gel 
and sexual abstinence until the treated tis-
sue was completely re-epithelialized.
2.3 Treatment evaluation
The number of treatments needed and 
possible recurrence were evaluated for 
each patient. In cases involving extensive 
lesions, the number of sessions needed to 
treat the whole area was recorded. Relapse 
time was determined in accordance with 
studies using other destructive or surgical 
approaches, such as cryosurgery and CO2 
laser (4). If the time between consecutive 
treatments was greater than 1 month, it 
was considered as a wart recurrence. The 
effectiveness of Er:YAG laser therapy was 
defined as the proportion of those patients 
who had received single treatment or mul-
tiple treatments within a period of 30 days 
(one month) and had no subsequent epi-
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sode of EGW. Patient charts were required 
to have follow-up information available 
for at least 6 months (180 days) subse-
quent to their last treatment session. Pa-
tients who did not meet this criterion are 
presented separately and their treatment is 
being considered as continued at the time 
of analysis.
2.4 Statistical analysis
Descriptive statistics were calculated 
for all study variables, including mean, 
median, standard deviation, and 95% con-
fidence interval (CI) of the mean for con-
tinuous variables. Categorical variables 
were described as absolute and relative 
frequency over the total valid values (n). 
Categorical variables were compared us-
ing the chi-square test for homogeneity 
of the groups and ANOVA was used for 
comparison of the means of continuous 
variables. The statistical analysis was per-
formed using SPSS software (SPSS ver. 23, 
IBM SPSS Statistics IBM Corp., NY).
The cumulative risk of subsequent 
EGW was calculated as the proportion of 
patients having at least one subsequent ep-
isode.
3 Results
3.1 Demographics and patient 
characteristics
A total of 133 women with EGW were 
found eligible to be included in this ret-
rospective study (Table 1). Seventeen pa-
tients had their last visit recorded within 6 
months prior to the data collection, which 
rendered their therapy incomplete at the 
time of analysis, whereas 116 patients 
completed their therapy.
The mean age of patients included in 
our retrospective chart review is presented 
in Table 1. Regarding the history of EGW, 
as reported by patients, they were present 
from 1 to 7 months, with a mean presence 
of 2.1 ± 2.0 months. The majority of the 
genital warts were situated on the labia 
majora and some on the mons pubis. Size 
of the lesions ranged from 2 to 8 mm.
Previously received treatments report-
ed by the patients were CO2 laser, cryo-
therapy, electrocautery and imiquimod 
cream.
Table 1: Description of the patient population. The table includes analysis of all patients, and 
subanalyses of patients who have either completed their therapy or their therapy is continued.
All patients
(n = 133)
Completed therapy
(n = 116)
Continued therapy
(n = 17)
Age
Mean (SD) 39.6 (12.9) 40.0 (13.0) 36.4 (11.9)
Range 19–80 19–80 21–63
Number of treat. sessions
Mean (SD) 1.59 (0.98) 1.60 (0.99) 1.53 (0.94)
Range 1–5 1–5 1–4
Follow-up from most recent Tx [months]
Mean (SD) 23.8 (14.8) 26.9 (13.1) 2.31 (1.59)
Range 0.33–60.8 6.43–60.8 0.33–5.70
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Effectiveness and Safety of Ablative Er:YAG Laser Treatment of External Genital Warts
3.2 Treatment regimen
The patients who completed their ther-
apy (Table 1) received from one to five 
treatments, with majority of them (74 pa-
tients, 64%) receiving only one treatment.
81.9% of the patients (n = 95) showed 
complete clearance of the lesions, without 
recurrence observed to date of analysis. 
Complete clearance was achieved after an 
average of 1.33 (95% CI, 1.17–1.48) treat-
ment sessions; 21 patients in this group 
(22.1%) required multiple treatment ses-
sions due to an extensive area affected by 
warts.
Recurrence was reported by 21 pa-
tients, which corresponds to cumulative 
risk of subsequent EGW of 18.1% (95% 
CI, 11.1–25.1). There have been 36 recur-
rence episodes of EGW recorded in 21 
patients. The median time to recurrence 
of the EGW was 1.9 months (IQR = 4.6). 
In majority of patients with recurrence (n 
= 15), the warts recurred in a period be-
tween 1 and 6 months.
The patients were grouped into six 
groups according to their age (Table 2). 
One-way ANOVA with post-hoc Bonfer-
roni correction for multiple comparisons 
was conducted to determine if patients 
of different age groups required different 
numbers of treatment sessions to achieve 
complete clearance. There was a heteroge-
neity of variance, as assessed by Levene’s 
test of homogeneity (p = 0.006). Data is 
presented in Table 2. The results reveal 
that the differences between age groups 
are not statistically significant F(5, 110) = 
1.182, p = 0.323.
The chi-square test of homogeneity 
revealed no statistically significant dif-
ference in the frequency of patients with 
recurrence between the determined age 
groups, nor was there any statistical dif-
ference between the groups regarding the 
percentage of patients requiring only one 
treatment.
The observed adverse events of the 
laser treatment were in some cases mild 
itching, mild bleeding and mild swelling.
4 Discussion
Public health policy in Slovenia en-
ables routine HPV immunization of all 
girls at the age of 12 years since 2009, and 
according to the NIJZ (Slovenia National 
Institute of Public Health) report, 49.8% 
of 12-year-old girls were vaccinated in 
the year 2017. According to an Australian 
overview of the epidemiological effects 
of the HPV vaccination, it has not only 
Table 2: Effectiveness (Complete Clearance (CC)) of Er:YAG laser treatment within the age groups.
Age group No. of 
patients [n]
Mean no. of treatments
(95% CI)
Patients 
requiring 
single 
treatment 
[n, (%)]
Effectiveness of treatment CC
[n, (%; 95% CI)]
Mean no. of treatments 
needed for CCb
(95% CI)
19–29 26 1.96 (1.43–2.49) 14 (54.8) 21 (80.7; 73.6–87.9) 1.62 (1.11–2.13)
30–39 35 1.63 (1.26–1.99) 24 (68.6) 27 (77.1; 79.5–84.8) 1.19 (0.94–1.43)
40–49 31 1.45 (1.15–1.75) 21 (67.7) 29 (93.5; 89.1–98.0) 1.34 (1.09–1.60)
50–59 12 1.25 (0.96–1.54) 9 (75.0) 10 (83.3; 76.6–90.1) 1.10 (0.87–1.33)
60–69 8 1.50 (1.05–1.95) 4 (50.0) 4 (50.0; 40.9–59.1) 1.00 (1.00–1.00)
70–80 4 1.50 (0.58–2.42) 2 (50.0) 4 (100; 100–100) 1.50 (0.58–2.42)
Overall 116 1.60 (1.42–1.78) 74 (63.8) 95 81.9; 74.9–88.9) 1.33 (1.17–1.48)
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been shown to have greatly reduced the 
incidence of cervical cancer but also the 
incidence of genital warts in the female 
and male population (15). Nevertheless, 
the number of patients that are burdened 
by this stigmatizing disease remains high. 
The treatment choice for EGW removal is 
typically decided after discussion between 
the clinician and the patient, and is usually 
based on the risk/benefit ratio, accessibil-
ity of the treatment, and should also take 
into consideration the patient’s immuno-
logic status (7).
Data on ablative laser techniques used 
for the treatment of EGW have been most-
ly limited to CO2 laser, which has been 
shown to be very effective in achieving 
complete clearance at the end of the treat-
ment (7). Laser therapy is significantly 
more effective than imiquimod 5% cream, 
trichloroacetic acid (TCA), cryothera-
py and combinations of those treatments 
(7). Ablative Er:YAG laser has been suc-
cessfully used for treatment of common 
warts (10,12,16-18) and some studies have 
shown that Er:YAG laser can be used for 
the treatment of EGW (11), but systemati-
cally collected published data is scarce.
The retrospective analysis of clinical 
cases from our practice has shown that 
ablative Er:YAG laser vaporisation is an 
effective and safe solution for removal 
of EGW. To our knowledge, the present 
study represents the largest series of pa-
tients with EGW that were treated with 
ablative Er:YAG laser. The effectiveness of 
the treatment (no recurrence of lesions) 
was 81.9%, demonstrating comparable ef-
fectiveness of the Er:YAG laser procedure 
to other available methods.
An 89–95% clearance rate was report-
ed for CO2 laser (19,20), which was about 
two times more effective than cryothera-
py (20) and comparable to potassium hy-
droxide (KOH) (19). The observed cumu-
lative recurrence rate of 18.1% (95% CI, 
11.1–25.1) is comparable or even lower 
than that observed with cryotherapy (re-
ported to have up to a 39% recurrence rate 
(20,21)), nitric-zinc complex (NZC, 29% 
recurrence rate) (22), and 48.5% for any 
“complete full destructive” medical inter-
vention (3). Further analysis of our results 
reveals that in only 12.9% of patients the 
EGW episode recurred within a period of 
one to six months, whereas in the remain-
ing 5.2% of patients the EGW recurred 
in a period longer that six months, which 
could be considered as a new infection (4), 
but due to the lack of HPV genotyping in 
our patients, the nature of the recurrence 
could not be determined.
Compared to cryotherapy, the Er:YAG 
laser treatment requires lower number of 
treatment sessions to achieve full clini-
cal clearance, and can be, as the CO2 la-
ser procedure (20), basically considered a 
single-session treatment option. The mean 
number of required treatments in our 
study was 1.33, which is markedly lower 
than the mean number of six to nine ses-
sions reported for cryotherapy (21).
Important factors determining the ef-
fectiveness of treatment are the extent and 
number of lesions, since they may be in-
dicative of an extent of the lesion and its 
multi-point infection. Some parts of such 
an infection may be in a latent or sub-
clinical phase and may cause recurrence 
at a later time (23). Failing to treat these 
latent and subclinical infections can lead 
to treatment failure and occurrence of le-
sions in untreated areas can be misinter-
preted as recurrence (23). Cryotherapy is 
considered as the first-line provider-ad-
ministered therapy for multifocal small 
warts (24), but treatment of wider areas 
may not be well tolerated due to pain and 
side effects of the treatment, such as local 
tissue destruction with blistering, ulcer-
ation, infection, and loss of pigmentation 
(20). The possibility of treatment of larger 
subclinical lesions in the surrounding skin 
is one of the main advantages of laser va-
porisation over cryotherapy. Nevertheless, 
some patients included in our study still 
needed multiple treatment sessions in or-
der to avoid extensive tissue ablation and 
associated discomfort and possible com-
plications.
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Effectiveness and Safety of Ablative Er:YAG Laser Treatment of External Genital Warts
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Age has been recognized as one of the 
risk factors for infection with HPV, devel-
opment of EGW, and for effectiveness of 
EGW treatment; however, our results have 
shown no statistical difference between 
different age groups regarding the effec-
tiveness of treatment.
When compared to other modalities, 
such as KOH (19), CO2 laser (19) or cryo-
therapy (20), the ablative Er:YAG laser 
treatment appears to be associated with 
lower incidence and milder adverse ef-
fects.
The main limitation of our retrospec-
tive study is the lack of HPV genotyping; 
the lack of information about patients’ 
comorbidities that may have influence on 
the effectiveness of laser treatment; and 
the relatively low number of patients in 
higher age groups.
Despite these limitations, our study 
provides long-term epidemiological infor-
mation on the frequency of EGW recur-
rence when treated with ablative Er:YAG 
laser.
Considering its non-systemic effect and 
generally mild side effects, Er:YAG laser 
therapy could be considered the treatment 
of choice for immunosuppressed patients 
with extensive lesions, who are unrespon-
sive to TCA or cryotherapy. It can be con-
sidered a single-session therapy and has 
been proven to be particularly suitable for 
EGW of a large volume or those that are 
located in anatomical sites that are diffi-
cult to access by other ablative techniques.
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HUMAN REPRODUCTION
Zdrav Vestn | July – August 2020 | Volume 89 | https://doi.org/10.6016/ZdravVestn.3050
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