Mosaic verrucae-help with treatment

6 week post-needling follow up: Pt. noted discomfort over last week. Callus overyling area.

pic. 1. Pre-debridement.

Pic. 2. Post- debridement.

Further review: 2 weeks.

 

Hi Twirly

I am having difficulty keeping up now- the thread is so long, and without trawling back through the list, I am not sure whether there is an improvement in this patient? Could you confirm that the VP is in fact smaller?

Not trying to teach granny to suck eggs, but does your camera have a macro setting?

Regards

Cornmerchant

 

The plane of focus for the lens of the camera was at the back of the treatment room, not on the plantar foot,which is the reason why the photos are out of focus.

Here is a little primer on how a lens in a camera focuses on subjects and makes images inside the camera for those of you who are "photographically challenged".:drinks
How Cameras Work

 

Many thanks Kevin,

Love it.

So kind when you could have been quite brutal. :sinking:

I have a phobia about any technology more advanced than the Box Brownie.

I will try though.

Honest.

 

Patient 1. Slight reduction in actual size/area of V/P at 6 weeks (more evident post debridement). Real change is in depth of lesion. Each time it is debrided (2 week intervals at present) The appearance is that the lesion is more shallow & although tender for a day or so after t/x the patient notices an improvement over all.

Thanks Corn'. Problem isn't with camera it's a 'me' thing! The on/off button had me flummoxed for a while. I intend doing some swotting up on Kevins suggestions before the next one. I also think the poster who used the scalpel with measurements on it utilised a really great idea. Will use that too in future.

Regards,

Mandy.

 

I've been watching these posts with great interest over the last few months and I have a patient who has a large VP on each foot, one for over 10 years. She is fit and healthy and I think a good candidate.

I have a couple of questions:-

1. How much are you charging for the treatment? Are you charging for a normal 30 minute appt and then a further charge for follow up appointment?

2. How many have used just local infiltration for anaesthesia?

Kind Regards

 

Hi Cambs,

For the two I have treated so far (& the one booked later this week) I have charged the same as I would for a single nail surgery. In the same price I have included the assessment, treatment & 3 follow up appointments. I intend to review the pricing in time. For me this is a very new treatment modality & I have explained this to patients. I feel confident in the procedure & the reason I currently do not intend charging for follow ups is for the benefit of follow up evidence of this particular treatment.

Only my opinion, I currently book these patients in to the last morning appointment. If the block takes longer to act I am not pressurised in any way as my scheduled break is the only loss. The next patient I have booked to block slightly earlier. My reason for this is to perform the block (very large plantar calc' V/P so I have selected a tibial block as opposed to local infiltration). I intend to block the pt., re-sit him in the waiting area with his foot elevated, reading a magazine while I treat the last booked morning patient. I'm allowing this extra time for the block to work & resist the urge to test too early. Patient calm & comfortable. Me occupied, but on hand should I need to check the patient for any reason.

The last 2 were both tib' blocks (2nd one was slow to go off so I topped up locally too).

Kind regards,

Mandy.

 

Thanks Mandy.

Patrick Lineham
Aliped Podiatry
Brington, Huntingdon
CAMBS

 

Hi

What percentage salycilic acid were you using and what concentrate/mg iron tablets per day? I would love to try the needling but where I studied in UK we didn't exactly focus on ankle or post tibial blocks..so am not too confident with the block!!

 

Sorry, slip of the tongue...zinc was what I was meant to say!!

 

Hi Footsteps,

Most (if not all?) NHS UK Podiatric surgeons & their teams perform tibial blocks on a regular basis. Only a suggestion. Why not contact your local NHS Podiatry Surgery team lead for permission to spend some time with them. It can't hurt to ask.

You do not mention your location? Our local Society Branch (South Yorkshire) all showed an interest in the needling technique during our most recent meeting. Certainly most have not performed a tibial block in some time, indeed some had never performed one. The practitioners who were interested are considering holding some practical sessions performing the blocks on each other. Personally I think this to be a good way to refresh your skills & utilise the qualifications you hold to their full potential.

Please PM me if you are in the Yorkshire area & I will be more than happy to keep you in the loop.

Kind regards,

Mandy.

 

Hi footsteps2,
just like to mention that i recently attended a LA update course run by the NUIG (university galway)and our tutor was a university of huddersfield podiatry lecturer and podiatry surgeon. absolutely brilliant course involving theory and a practical session which involved injecting foam/ silicone dummy feet and toes with LA, a great hands on experience, which has helped me as like you, ankle blocks, were not a high priority when i was training. if you would like to PM me i will give you the contact details of the tutors involved.

 

Sorry to be a spoil-sport for those of you who love giving posterior tibial nerve blocks. However, I have never used a posterior tibial nerve block when performing the needling technique for verrucae plantaris on any of my patients. All of my needling techniques are done utilizing direct infiltration of local anesthetic deep or proximal to the needling site, along with judicious use of ethyl chloride spray to temporarily freeze the skin in the area of needle puncture and injection. Direct infiltration of local anesthetic into the plantar foot is simply not that painful when done correctly and certainly is less painful and less risky than accidentally stabbing the posterior tibial nerve with a needle, which may occur with any posterior tibial nerve block. In addition, posterior tibial nerve blocks may take as much as 15-20 minutes to reach full effect and are not as predictable in achieving good anesthesia as is direct infiltration to the site of needling.

 

Kevin, Can you explain how you locally infiltrate th VP??

 

Lauren:

When doing the needling technique, my technique for local anesthetic infiltration will all depend on where the verrucae plantaris (VP) is located on the plantar foot. I always use a 25 gauge 1.5" needle with a 5 cc syringe and prefer using 2-4 cc of 0.5% Marcaine plain. If I can manage it, I will inject from dorsal, or from medial or lateral to avoid the more sensitive and thick plantar skin, and always use ethyl chloride spray (about 5-10 seconds) to temporarily numb the skin. My goal is to put about 2-3 cc of the Marcaine into the subcutaneous tissue directly plantar to the VP so that the VP starts to blanch and become more convex and indurated plantarly, indicating the Marcaine is being deposited into the subcutaneous fat just below the dermal layer of the VP lesion. I may need to use more Marcaine and sometimes use 3-4 cc, but more commonly 2-3 cc are used. The needling procedure can generally be started within 1-2 minutes of finishing the infiltration, with the needling procedure taking a total of about 2-3 minutes. From what I am hearing from the others regarding their propensity for using posterior tibial nerve blocks for such procedures, I would estimate that they could probably cut their procedure time by 1/2 to 1/3 if they used the procedure I described above, and with no more discomfort for their patients. Since I see 25-40 patients on a full day, I need to work efficiently in order to keep my appointment wait time to a minimum for my new and returning patients.

Hope this helps.

 

I have found it difficult to locally infilatrate to the central heel without significant discomfort.
So have then opted for a post tib block.

Any suggestions on angles?

 

In the central heel, I go directly plantar with lots of cold spray unless I can reach the central heel with my 1.5" needle from posterior, medial or lateral.

 

Thought I'd share my statistically meaningless experience.

Had a patient with a loooong history of recalcitrant VPS. Assorted lesion on assorted sites which had resisted pretty much everything, Cryo, Caustics, debridement etc. In the end the largest lesions were destroyed with electrodessication which worked, but caused the patient a certain amount of distress during the op (she found the LA procedure and the post op very painful). This also caused an unfortunate amount of scarring including a nasty bit on the heel which I suspect I shall learn to loath in years to come.

She developed a new lesion, around 5mm d and painful. Much upset.

On the basis that we had little to lose and that everything else we had tried had failed in the past, I did the needling thing.

For those into the fine detail I used hypnosis (Esdaile state if anyone is using that as well), a local infiltration LA then about 80 punctures to the area. Lots of bleeding. Dressed, Padded with 7mm SCF, woke the patient up (heartily delighted that she'd missed the whole thing) and sent her off on her merry way.

She reported a moderate - mild amount of pain lasting just over a week and a certain amount of bruising. She described it as somewhat less painful afterward than Cryo, but lasting longer.

Saw her today, 4 weeks to the day. Verruca completely resolved. Pt ecstatic to have avoided another bout of electrodessication.

Obviously one treatment is not proof but I shall certainly be adding this one to my treatment options for VPs! Thanks to all who have shared their experiences.

Regards
Robert

 

Hi Robert,

Has to look this up Esdaile's mesmirism:

You had you pt. wear only a loin cloth!!

Also good for scrotal drainage :wacko::

I would love to know where you learned this technique Robert. -nus the funny loin cloth & scrotal type injections of course. (Gosh that sounds rude)! Not intentional I assure you. :empathy:

Many thanks,

Mand'

 

Oh twirls you do paint a picture!

Sorry to dissappoint you but I only mentioned the Esdaile STATE not the esdaile METHOD. :empathy: . I was fully clothed throughout, as was the patient.

Esdaile himself never used hypnosis per say. He was, however one of the early loonies (sorry pioneers) who stumbled across its phenomina by accident. Like Mesmer himself and any amount of "tribal medicine" he had very little understanding of what he was doing or how it worked so went though some extraordinary palava to acheive the desired effect. However acheive it he did.

By the by, the whole passing hands thing sounds a lot like reiki to me. We've not advanced so very far.

The Esdaile STATE is simple the deepest level of Hypnosis also referred to as the coma state. In a lighter state, Somnambulism, one can manipulate sensations of pain by direct suggestion. In the coma state this is not needful and indeed surgery has been carried out in this state with no chemical anesthetic at all . Not sure I'd fancy that myself.

Hypnosis is a lot like biomechanics. At base its a very simple concept, however people who understood it poorly have wrapped it in lots of superfluosity, called it a "method" and sworn that the "method" is the reality. Many authors also spend most of their time critisizing other "methods". Which is sad because used judiciously its quick, easy and can make an otherwise unpleasant experiance far more palatable for the patient.

If anyone fancies a good read on it I'd recommend this book http://www.amazon.co.uk/Hypnotherapy-Dave-Elman/dp/0930298047

Dave Elman was a queer old bird, but his practice was almost entirely based on teaching hypnosis to medics and dentists for use as adjunct to their practice. Some of it has dated poorly, especially some of the inductions but there are some real nuggets of genius there also.

But this is off topic.

Regards
Robert

 

We didn't learn this one in school. I'm going to discuss with colleagues at the school (I'm an instructor) and perhaps introduce it into clinical education Sometimes oldies are goodies. Maybe a masters for me in it too??? hmmm.....

I realize this is going way back but stick with the hypodermic needles. I found a picture of the TB Tine Tester, which is probably similar to the Schick test device. This is different from Mantoux, which injects measured amounts of TB antigen subQ. The tines are coated with TB antigen at manufacture. Even if it were clean/sterile, the device looks pretty useless for our purposes. It's designed for skin of the forearm, the plantar skin is much thicker, and the needles are placed far apart in a ring.

http://www.irememberjfk.com/mt/2007/09/getting_tested_for_tb.php

I had this type of TB test done myself in 1984ish prior to major surgery and swear I remember that the nurse re-used the same one on every kiddie in the room, then proceeded to draw a happy face right over the pinpricks in ink pen she fished from her dirty pocket even while I screamed for her to stop drawing on my injured skin! She thought I was a weirdo for not wanting pen on my arm, everyone else liked it. We've come a long way with infection control protocol.

 

LEFT]

Hi Poppet

Have you sent your patient for a blood test to check for white blood cell count ( immunity high or low) weak immune systems encourage VP growth
also can soak VP's in Treatments containing chemicals such as formaldehyde, glutaraldehyde and podophyllin can be used to remove warts. These are poisonous to skin cells, and are dabbed onto the warts in order to kill the skin cells there.

co inside these treatments with the dermatologists

hope this helps



British Medical Journal (August 2002) said the safest and most effective treatments were those containing salicylic acid. This acid is applied to the wart to disintegrate the viral cells and has a cure rate of 75%.

 

Mosaic verrucae went missing??

Craig:

Did we lose the classic mosaic verrucae thread with all those nice pre and post op photos??

 

Re: Mosaic verrucae went missing??

Not great news because I posted some great pics of a successful one the other day
shame
Anyway I wanted to mention a couple of things so I'll post them here and repost when the thread comes back up

Question for Kevin
Kevin - any chance needling a verruca could instigate an attack of gout? - Saw a chap 2 days ago who has a hx of gout in r ankle (although at the time I thought the diagnosis was a bit iffy. Anyway 2 days after needling his vp he has developed a painful warm effusion of the ankle of the foot in question - difficult to walk on - doesnt appear to be an infection but will monitor over next 2/7

Another Question for Kevin or anyone else who wants to pitch in

Would you do one on the hand? - I have a patient who had a vp on the apex of her r4th and a wart on thenar eminence of her r hand
Needled the toe - vp resolved but wart remains - she is now badgering me to needle the hand - I am somewhat familiar with the local anatomy

 

Re: Mosaic verrucae went missing??

Hey Steve,

They are not completely lost - I saw them the other day on Pod Answers.

Nice work fella

Ian

 

Re: Mosaic verrucae went missing??

I have never seen the needling procedure cause any type of untoward reaction other than about a day's worth of mild pain in the area of the needling procedure. I have never seen an acute gouty attack be caused by the needling procedure and think that your case of gout is a coincidence. Maybe your patient went on a drinking and purine eating binge after your needling procedure?

With a wart on the hand, here in the US of A, a podiatrist can not directly treat a skin lesion on the hand. My advice is to refer her to a dermatologist or general practitioner and let them deal with it. I am very familiar with a lot of "local anatomy" .....but that doesn't give me the legal right to treat problems on that "local anatomy" as a podiatrist.:drinks

 

Re: Mosaic verrucae went missing??

Yes that's what I figured - there is a little leeway in the uk when treating warts on a hand with caustics but I thought maybe needling on the hand was a step too far - she will be disappointed!!

Thanks for your input - I think my first few needling failures were due to poor technique - getting muh better results now - hope you get the see the latest one when the thread comes back up


Cheers

Steve:drinks

 

Re: Mosaic verrucae went missing??

Hi Steve,

May I ask what you changed about your technique?

Many thanks,

Mandy.

 

Re: Mosaic verrucae went missing??

Steve and Colleagues:

I had already looked at your beautiful pre- and post-op photos of your verrucae needling procedure you just posted a few days ago before the thead went missing on us. All of you who are wanting to publish a paper or show PowerPoint slides regarding the needling procedure should take note of the quality of Steve's photos. They are excellent. What type of camera and any special settings/flash types you use to achieve such nice clinical photos, Steve? I think that if others wanted to reproduce these types of quality images on their own patients, it might be helpful for them to know what type of camera equipment you are using and how far your lens is from the foot, etc. to improve their clinical photography.

 

Re: Mosaic verrucae went missing??

Hi Twirls - how are you doing?
The thing that changed was instigated by Steve Arbes - Thanks Steve - he mentioned in one of his threads the he needled until he felt little or no resistance from the tissue. I am sure that I did NOT do this at the beginning I just counted (daft really because the bigger the lesion the more punctures) Anyway after focusing on the tissue resistance I have got much more consistent results (and two crates of beer from one patient!!!!)
The thing to note is if you are working on a large lesion work it in stages to make sure to cover the area properly. For really large lesions I would probably only needle part of it but make sure that the part I needle is completely obliterated (for want of a better word). As Kevin said it looks like ground beef afterwards. I clean mine with saline (irriclens) to remove the blood staining and the vp looks a pearly white opaque colour (see my last post if you ever get a chance the one needled was on the L1 pmp.)

Hope this helps - you seem to have done a few but if anyone reading this is close enough and wants a demonstration I would always be happy to oblige (PM me) provided my patient is happy with it.

Steve

 

Re: Mosaic verrucae went missing??

You are too kind Sir!!!
My camera is a (now old) Sony digital camera with a 5.1 megapixel resolution - nothing too flash there are much higher res cameras now. I always have the macro setting on ( I have found that when taking pics of the foot you are often around the cut off point for close focus when set to normal) with the flash set to auto - i sometimes find i have to retake the shot if i get flash reflection from the skin. using the flash ensures no camera shake. The focus is set to spot focus (i have noticed a few pics on the thread that were focused on the background behind the foot). I have the camera set to take the highest resolution photos and i think this is what makes the difference - it makes large size photos and takes up more memory but before posting i reduce the size to the max allowed by the forum. When viewing in Windows viewer etc I have found that the zoom function can show incredibly good detail of the skin. I always download my photos to the PC immediately so that I dont run out of memory on the camera.A bad shot is no good to anyone so I always check the shots on the PC before finishing with the patient. i have even used this technique to shoot through a dermoscope with excellent results. Rocket science it ain't - just take care and always read your camera manual to familiarise yourself with your equipment. Like I say its not a particularly special camera by todays standards but it was quite a good one when i bought it - probably has got a good lens in it and that always makes a difference. Check this out - I took this through a dermoscope with both the scope and the camera handheld!!

Hope this helps

http://www.podiatry-arena.com/podiatry-forum/attachment.php?attachmentid=1528&stc=1&d=1248381987

 

Re: Mosaic verrucae went missing??

Thanks Steve for those useful tips. I have taken them on board and will employ when my stolen camera is replaced!

Also thanks, Ian for pointing out that Steve`s latest photos are on Pod Answers, I have now added a few of Steve Arbes pics, with his kind permission, on that thread for people to see whilst we are waiting for the resurrection of the original thread here.

Cheers,
Bel

 

Thanks for that, Craig. You never know how important some of the threads on Podiatry Arena are until one of them goes missing for a while. We all sincerely appreciate all the herculean efforts you do for the international podiatry community. Now go and give Mimi a big hug and kiss from me and Pam.:drinks

 

Thank you Craig for your hard work. I notice that Steve Wells` latest shots are not there, but he has asked me to re post them as I have resized copies too;












Cheers,
Bel

 

I have been contacted privately by a few podiatrists who want to learn how to do the verrucae plantaris (vp) needling technique. Since it has been a few months ago since I first wrote about the technique (and six pages back in the thread), I thought it might be worthwhile to describe it more completely for those who have not yet attempted the technique.

I will generally use 5 ccs of 0.5% Marcaine plain, in a 5 cc syringe with a 25 gauge 1.5" needle to anesthetize the area of the vp lesion. If it is a mosaic verrucae or multiple verrucae, I will only anesthetize the largest and thickest vp to perform the needling technique on.

Using ethyl chloride spray, held about 9 - 12" above the intended anesthetic needle injection site, I will spray the foot for about 5-10 seconds, or until a white "frost" appears on the skin then give the injection. The Marcaine is injected into the subcutaneous fat just deep to the vp lesion, trying to inject as close to the dermis-subcutaneous fat junction as possible with the local anesthetic. The plantar skin will blanch in color and a large wheal will be raised plantarly which will include the vp lesion, if the injection is done correctly. 3.0 - 5.0 cc of local anesthetic is generally used. The initial needle puncture is not felt by the patient, but the slow infiltration of local anesthetic into the foot is somewhat painful. I tell the patients that the injection is no more painful than getting a local anesthetic injection from a dentist and most patients have no problem with the injection, even though the injection is often done through the plantar skin.

I have my assistant then scrub the foot with a povidone-iodine solution in the area around the vp and place the foot onto a sterile drape-barrier. If the injection is done correctly, the needling technique may be started within a minute after the completion of the local anesthetic injection. Using a 25 gauge 1.5" hypodermic needle, the vp is punctured to the level of the subcutaneous fat (see illustration below). The correct depth of needle puncture is about 6 - 8 mm. The correct depth may also be appreciated by a slight decrease in manual force required to advance the needle deeper into the foot, indicating that the dermis-subcutaneous fat junction has been penetrated. The total number of needle punctures should amount to about 100-200 depending on the size of the lesion. The whole vp looks like "ground beef" when the procedure is completed. I do the needling with one hand and have a 4 x 4 gauze in the other hand to occasionally dab the blood from the needling site. If each needle puncture does not produce a small drop of blood, then this indicates the the depth of needle penetration has been too shallow. The needle must get into the subcutaneous fat to push the microscopic viral particles deeply enough to stimulate the desired autoimmune response. The needling procedure itself should take about 5 minutes and should be painless to the patient. Estimated blood loss with the procedure is approximately 1.0 ccs.

The wound is finally dabbed dry with a sterile 4 x 4 gauze and then dressed with only a single 2 x 2" or 4 x 4" sterile gauze pad with self-adhesive elastic wrap (e.g. Coban) to hold it in place. The patient is instructed to keep the dressing on until the next morning, remove the dressing before they shower and then to wash the area with soap and water. No band-aid/bandage is generally necessary the next day since the needling procedure only bleeds for about an hour after the procedure is completed. There is no special wound care for the patient after the procedure otherwise. Patients generally report little to no pain in the foot the next day from the procedure, and it is rare to have a patient say they have pain two days after the procedure.

I will have the patient return to me in one week post-op for a wound inspection, to make sure there are no problems. I will then see them again at four and eight weeks post-op to possibly lightly debride any remaining thickened skin over the vp needling site. A darkened area at the vp needling site will appear at one week post-op and most patients have complete clearing of the vp with 8 weeks. I estimate that I get a 90% cure rate of not only the vp I have treated but also of the other vp lesions on both the treated foot and the untreated contralateral foot. I have seen no infections or other sequellae from the needling procedure.

I hope this rather detailed description of Falknor's needling procedure (Falknor GW: Needling--a new technique in verruca therapy. JAPA, 59:51-52, 1969.) allows more of you to feel confident enough to try this very gratifying procedure on your own patients for their painful vp lesions.

 

Thank you Kevin, that post is most helpful and will allow me to put this treatment to my boss and hopefully he will give me the green light to use on a number of patients with VP's. Thank you again.