Mosaic verrucae-help with treatment

hola buenas podohugh y dr. kirby, al principio traté con ácido nítrico al 60% y vaselina salicilica al 30% en cura oclusiva y en tratamiento mixto con Homeoterapia con thuja occidentalis 30 ch en gránulos. el primer mes bien, el segundo estancamiento de la lesión hasta el tercer mes, cuando hablan de la técnica multi punch se supone que es para producir un aumento del sistema inmune o una modulación del mismo a través del traumatismo que producen las agujas?

 

Hi Menci,

I have tried to translate your previous post.... The pics are great, but I have NO idea what you are trying to convey. When you signed up for the Arena, you ticked the box which included;

That said, the lesions usually darken (inflammatory phase) prior to resolution, as shown in your pic :drinks

 

Dr. Kirby and Podohugh Hello, sorry for the issue of translation I realized I was into American forum, well what I meant was that this took 3 months trying vph tiled with 60% nitric acid and Vaseline salicylic 30% until the first month good bad bad, but the 2nd month is stalled, and the third is as before, the photos you show are from the beginning when the patient arrived, taking the history his mother told me the child, it is 12 years old, went barefoot at home and that a few months ago his brother also had one on his feet. Dr. Kirby when you talk about multi puncture technique refers to make an indent to produce a stimulation of the immune system and thus cure papillomavirus himself, he would have to perform a posterior tibial nerve block, no? Thank you and all who have been interested in this post

 

Is it legal to use cantharidin in America, indicated the use of plantar warts and, as an active ingredient of formulations?

 

any updates/feedback on needled patients? At 6 months most of mine seem to have failed........vp's have recurred....anyone else finding this?

 

Can anyone recommend a stockist of portable nitrous oxide cryo surgery equipment. What I currently use is not transportable between clinics. All suggestions great fully accepted. Sorry this is not an answer to the tread but I'm very new to this and still figuring out!!! Thanks.

 

Julian

We are also disappointed with the success rate. We have reviewed all cases and resolution is a little under 50%. (which is still reasonable)

We have re-needled some (more 'comprehensively')and will continue to monitor results.

Angus

 

I've successfully used potassium permanganate for mycosis, never knew it could be used for Rx VP's. I thought it was Formaldehyde that VP's were soaked in? I've never used it as I'd be concerned the Pt might become sensitised to it...
I've had quite a few +ve results after a short course of Cimetidine - I think there are a few threads on here about it, mainly seems to be 10-18 years old's though. Persistent VP's, particularly florid outbreaks always make me suspect some form of immunosuppression...

 

My results are also disappointing. I would agree with other posts that results are not better than other more traditional/conservative treatments. I now only use it on patients with large numbers of VPs and who have busy lives that are unable to attend regular appts. It's such a pity, it would have been so great to have a treatment modality to offer with the kind of results promised in the earlier parts of this thread.

 

I am seeing about 65-70% resolution rate at the moment - AND and rarely do Tibial Blocks now - have mastered Kevin's Ethyl chl;oride local infiltration method and use that in most cases.

 

Hi Steve
I struggle with containing the fluid where I want to to go with the fine jet spray.

I've only used it a couple of times with just a wad of gauze on my thumb to stop it running down the foot but that was a bit hit and miss with the end result.

I thought of a felt cavity pad but the absorption into that would I thought possibly increase the area of freeze.

So I've kept with ankle blocks for the time being but have an open mind on alternatives.
Any suggestions?
Cheers Fella
D

 

Hey Delboy - how's it 'anging?
Which type are you using? I use the glass bottle variety which is pretty accurate with a fine spray - held about 10-15cm away from foot perpendicular to the surface.

 

Good thanks mate and I hope you are the same ?

Yep that's what I was doing but perhaps I'm being heavy handed with the spray ( yes the glass fine jet) I just found it not very accurate and difficult to containing where I wanted it.
Just have to practice a bit more I suppose
Cheers
D

 

Ethyl chloride spray, if kept in one place on the skin during the spray, will freeze about a 1 cm square area of skin. I generally do a small circle of spray (circle diameter = approximately 5 mm) to make a little bigger area of skin freeze and not risk one smaller area of the skin getting all the spray.

The bottle must be inverted when spraying and the metal lever on top of the bottle must be pressed firmly down as far as it will go to allow the fine spray stream to occur (partial depression will squirt it sideways....watch your eyes!). I use my 4th and 5th fingers to depress the lever while my index and middle fingers grasp the bottle, holding the bottle inverted while doing so. I will bet that if you are trying to use your thumb to depress the metal lever, you will have a very difficult time controlling the spray accurately.

I never worry about the ethyl chloride run-off. I just let the excess ethyl chloride run down the foot and/or leg when using it to freeze the skin for injections. No harm is done when the ethyl chloride runs down the foot/leg but sometimes it does leave a fine whitish residue on the skin that can be cleaned later off the skin with water.

Generally one only needs a 5-7 second spray with ethyl chloride to freeze the skin so that the needle stick is not painful for the patient. I generally have my assistant use the spray but, when she is busy, I often spray with one hand and inject with the other. Just takes a little practice.

Ankle blocks seem like a whole lot of work to me. Ethyl chloride is the way to go for a busy practice. Here is the type of ethyl chloride spray I use.

Gebauer Ethyl Chloride Fine Spray, Glass Bottle

 

Thanks for that Kevin, it was the run off that was concerning me ( my thumb will thank you as well if its not getting frozen )

We have a different bottle but the same valve by the looks of it and the principle you describe is the same BUT to depress the lever fully in the unit I have floods everything so a controlled depression is what I have been using up to now.

I will go back to the drawing board and try again to perfect the technique as Steve has done
Cheers
D

 

Make sure you are using the finest spray bottle you can since you don't need a lot of spray volume to properly freeze the skin. In addition, it is actually better to spray further away from the skin than closer to the skin since the longer distance of spray will help cool, through evaporation, the ethyl chloride liquid further so that you will need to use less ethyl chloride the further you are from the skin. Spraying about 15 to 20 cm away from the skin seems to work the best.

 

Does anyone have a video of the needling procedure being performed? Preferably with the use of Ethyl chloride. Thanks

 

Paul:

I don't know of any videos. I suppose I should have one of my staff members take a video of me sometime doing the procedure, but I'm usually so busy in the office it never seems to happen.

 

As the initial one to introduce this procedure to the masses it would be very fitting if the first video showed you doing the procedure. Pus it would be extremely handy to show my boss

 

Not sure if this has clearly been answered so apologies if it has (I couldn't find it in the previous comments however with 5 or 600 I might have missed). The depth the needle is placed through the epidermis is approx. 7mm but hwo are you judging that ie. what "feeling" is it that tells you, you are at the right depth without penetrating the dermis?

 

Hi
I have treated extensive mosaic warts once only but with success. The girl had had 4 years of treatment in England and the last attempt was to soak her feet in formalin weekly and she had been doing this for the last 3 years. All it had done in her opinion was spread the virus. I was honest and told her I had not treated such a severe case and they were all over her plantar surface as well as most toes dorsally. I told her I used Monochlor acetic acid but was not sure she would be able to tolerate it given it was a large area and would take a long time. She agreed to give it a try and we would assess how things were going and review whether to continue or not.
I did not attempt to cover the whole area with monochlor acetic acid but concentrated on just the main areas which seem to be the origins. Anyway each week there seemed to be some improvement and she was tolerating it quite well. The after a month of treatment significant areas were resolving and by the end of 3 months all verrucae were gone. Initially it was slow but once it began responding it happened quite quickly. Needless to say both her and I were ecstatic with the result.
Just to add you must always suspect a weakened immune system when you come across mosaic or resistant warts but particularly mosaic warts that are extensive. Accurate history taking is vital.
Hope this helps
Cathy

 

Hi Cathy,

Thanks for the interesting case. However, I`m afraid I can`t agree with you on the above. Principally, because we should not be scare mongering our patients. They require explicit explanation of the aetiology and treatment options of HPV, but above all reassurance. There is no evidence to suggest that HPV2 (mosaic) are more indicative of immuno-suppression than any other sub-type of HPV. Moreover, whilst immune-compromised patients are obviously more at risk of contracting/manifesting any viral infection including HPV, we cannot and should not assume the vice is versa.

HPV has adapted to evade our immune systems and can be recalcitrant even in immune-competent individuals. There are a number of factors involved that contribute to the absence, or reduction, of a cellular immune response in such patients. Briefly they are;

• The epidermis is avascular
• Latent virus particles in adjacent cells are not destroyed in keratolytic treatments (Bristow & Stiles, 2011)
• HPV can alter Langerhan cell function and activate T suppressor cells (Frazer, 2009)
• Virally infected cells have no surface markers (Bergot et al, 2011)

Here is an excerpt from a presentation that I am working on that you may (or may not) find interesting;

Cheers,
Bel

 

As usual really helpful post thank you B. I have a slight problem with that - maybe you can answer a question that has been bugging me for a while -
clearly not all infected cells are damaged in the needling process so if the infected cells present no surface markers to the immune system how does the immune system know to attack them?

Seems basic and maybe I'm getting soft in the head but can you shed any light on that because it has occured to me on several occasions when I try to explain all this in lay terms to my patients.

 

Great question, Steve. I`m more than a tad tired at the moment....so I`ll make a more in-depth reply tomorrow.

Briefly, downregulation of surface makers is just one of a variety of mechanisms employed by the immune-illusive fellas. Frazer`s work suggests that it`s the increased level of cytokines produced in an immune response which can trigger the systemic response to eradicate all, or the majority, of HPV lesions. Taken from Bergot`s paper;

Bx

 

K. I now have `net access at me new workplace

A quick search found this interesting site produced by this excellent undergrad research at Davidson College, North Carolina;

http://www.bio.davidson.edu/people/sosarafova/Assets/Bio307/emmccracken/page 05.html

Taken from the above link;

So, maybe the cell surface markers are mostly reduced, rather than eliminated? Just "guess work" on my behalf, obviously.... It would, therefore, be reasonable to conclude that an increase the cytokines AKA `natural killers` brought about by a systemic response to HPV tx (whether that be by needling, or any other modality) could be responsible for addressing virus infected keratinocytes that are not directly treated.

Like I said last night, elimination of keratinocyte surface markers is just one method that this pesky virus utilises...

Does that help?

 

Very much thanks hun - and thank you for the link - i'll read that in bed tonight (in case I have trouble getting off (to sleep that is before any smart arses make any comments )

 

Hi there,
I am liking what I am reading, and am very interested in the needling treatment.
I qualified as a Chiropodist in the private sector some 13 years ago, and do not have a license to administer local anaesthetic. Can you recomend another course of treatment for mosaics, or a topical anaesthetic that I could use.
Many thanks

 

Just had an 11 year old girl in my office again today now 5 week post verrucae needling on her plantar right heel. She had 18 verrucae plantaris lesions on her right heel, with the largest lesion being a tight cluster of about 4 vps (1.0 cm diameter) on the plantar lateral heel, which is the only one I needled 5 weeks ago.

This is one I should have photographed or done a video of. After 5 weeks, the largest vp lesions that I needled have completely resolved and the other 13 smaller lesions are nearly completely gone. The mother was very impressed and happy...to say the least. The patient never had any post op pain or disability.

Very impressive.

 

Hi, and :welcome: to the Arena!

Currently, the available topical anaesthetics would not be suitable for needling VPs as the needle penetrates deeper than the anaesthtised tissue.

If you don`t have an LA license, I would advise you to stick with the keratolytic treatments as these can induce the required inflammatory response to reduce viral load. Sometimes.

Cheers,
Bel

 

Sorry Belinda - new to posting and didn't quite come out the right way. I do not scare monger the patients at all. I always explain the aetiology and various treatment options available to them and why I choose the ones I do. I do not tell them I think their immune system is compromised. I was of the belief that people with already compromised immune systems may have greater likelihood of developing extensive mosaic wart than healthy patients and just to be aware. Thankyou for your response, it was much appreciated and i apologise for the way my post came across.

 

Cathy,

Really, no need to apologise. I wasn`t accusing you personally of scare mongering. It has been suggested, by more than a few, on various forums that HPV is indicative of a compromised immune system, which is a misleading form of cognitive bias. Kinda like Representative heuristics.

Of course, you are absolutley correct in that patients with impaired immune systems are more likely to manifest/have a reduced ability to `fight` viral infections, but we should never assume that patients with recalcitrant VP are immuno-compromised. As you stated earlier; accurate (and detailed) hx is vital, as this could, in a minority of cases, reveal a warranted referral for further investigation.

Have a good weekend :drinks
Bel

 

A quick question which has probably already been asked but I cant find it if it has.

How long does it take for someone to recover from multiple puncture?

I have a dance instructor who I am considering using multiple puncture on but she needs to be back up and dancing ASAP.

 

Most pts go back to work the same day and report no discomfort whatsoever. A minority have reported `mild bruising` for a couple of hours post operatively and only when the needled lesion is on a W/B part of the foot.

 

Wot she says
Cheers
D

 

Yeah, she be quite good when it comes to skin stuff.

Thanks Belida :drinks

Hope this treatment is as good as it sounds.

 

A few questions about dry needling of verrucae.

Maybe it's just me but I see one of the major roles of the podiatrist as guardian of the integrity of the skin and subcutaneous plantar soft tissues.

Many verrucae occur on weightbearing tissues. The weightbearing plantar tissue is highly specialised. Damage resulting in scarring and/or destruction of fibrofatty padding is, in the long term (say 20 to 50 years), likely to increase the probability of the formation of pressure lesions, eg callus, corn, ulceration.

Dry needling involves stabbing the area of skin and subcutaneous soft tissue occupied by the verruca with the intention of actively damaging the infected cells and the 'normal' tissue outside the surrounding fibrous capsule.

Elsewhere in this thread it has been suggested that the verruca should be: 'stabbed'(my word 'needled' sounds too euphemistic) 100 times; needled until it is mushy; needled until it resembles a cream cheese.

That sounds like quite a bit of local damage, especially when the needle is intentionally driven into surrounding healthy tissue?

The plantar tissues heals by scarring and any destroyed fat cells are gone for good. These features alone suggest that even when the verruca has been cured there will be residual, not necessarily macroscopic, at least not in the short term, changes to the skin and subcutaneous soft tissues and these changes represent a local reduction in the tissue's capacity to tolerate applied forces and increase the probability of future pressure lesions.

Do studies of needling look at:
the position of verrucae, eg weightbearing to non-weightbearing ratio;
residual scarring/tissue damage/tissue vitality in both the short and long term;
pressure lesions occurring on sites of previous verrucae?

Bill

 

Hi Bill,

First, it`s `needling`, not `dry needling`, two very different beasts.

There are no "studies of needling", but I can confirm that none of the 45 subjects in the review of practice, that Ivan and I published, manifested scarring or reduced tissue viability. Nor have any other `needled` patients that I have reviewed in the last 3 years.

Scarring is associated with tearing or cutting of the dermis. As we are only producing pin-point bleeding the wound usually heals with complete tissue regeneration (think tattoos; multiple needle insertions heals without scarring). Thus, skin integrity is maintained, if not restored. Below is a link to a good article that I have highlighted before, which goes some way to explain how an incision, no matter how small, usually results in scar formation, whereas tattooing doesn`t. It concludes that scarring is due to altered signalling mechanisms for healing (inappropriate levels of inflammatory cells and stimulation of granulation tissue and fibroblast activity), brought about by`subtle alterations to type of injury`, but not usually observed in needle insertions.

http://rstb.royalsocietypublishing.org/content/359/1445/839.full.pdf

In my very humble opinion, needling a VP is less intrusive than many keratolytics and other tissue destruction methods (such as salicylic acid/cryotherapy which can create severe burns and scarring as they are capable of penetrating and breaking down adipose tissue/tendon damage), as the inflicted injury is a self-limited punctured wound which only requires a dressing for 24 hrs.

That said, we do need further published research on needling in the form of controlled trials.

Cheers,
Bel

 

Hi Bel,

Thanks for the link. It looks as if they are making great strides in the direction of minimal/no scar surgery.

When I am thinking about scarring and tissue vitality even minimal scarring and reduction in tissue vitality may become significant over say a thirty year period from any scarring associated with the needling of a verruca and the appearance of say a corn, ie there is likely to be a catalogue of other injuries to the same are of tissue within that period.

In the review were scarring and reduced tissue vitality recorded? Did you look for minimal changes not necessarily visible to the naked eye?

Although the comparison with tatooing has some overlap I don't think that they map sufficiently well to allow an easy comparison.

1. The regeneration/scarring response of the plantar aspect to multiple stab wounds is not necessarily comparable to those areas of skin which are normally tatooed.

2. Tatooists recognise that there can be scarring associated with tatoos and they put it down to three factors. i. Individual variation in the tendancy to scar; ii. Keeping the needle in one spot for too long; iii. The needle penetrating too deeply.

I think that i. ii. and iii above may apply to needling and increase the likelyhood of scarring.

Apparently tatooists try to deposit the ink 1/16th to 3/32nds of an inch under the skin. I think that the needle associated with needling a verruca penetrates considerably more than that.

'Cream cheese' and 'mushy'suggest keeping the needle to long in the same place.

Bill

 

I suggested some time ago that a tattoo gun could be used for needling of verrucae. Certainly in a research environment it may allow for the control and comparison of penetration depth.

 

Bill:

There is a big difference between tattooing and performing a needling technique on a foot for verrucae plantaris: when I am performing a needling technique, I am not deposing a foreign substance within their skin with each puncture as does a tattoo artist.

In the hundreds of these needling procedures I have performed over the past 15 years, I have never seen any scarring result. However, I have seen plenty of plantar scars from other verrucae treatment methods including freezing, currettement and other injection techniques.

And by the way, depth of penetration is important in the needling procedure for good treatment results, but leaving the needle in place "too long" would likely not make much difference in scarring, unless it was left so "long" that the patient walked on the needle out of my office with it.