Neurovascular helomas

Members do not see these Ads. Sign Up.

Hi, I have recentlybeen visited by a female patient with a neuro' corn. My predecessor kept it under control with bi-weekly visits. However this does not seem like a practical treatment plan to me. I have actually been fortionate enough to never have been faced withone before and wanted some advice. I have read about using caustics but would love some experience based advice. Thanks a lot for your time, James.

 

I've had trouble with these as well. To date, I've been using 40% pyrogallol and offloading with orthotics.

Good timing for this post, as I've just come back from a conference where the keynote, Dr G Dockery DPM, gave lectures on using 4% Ethyl alcohol mixed with marcaine to sclerose the nerve and eventually the keratotic lesion (requires 3 - 7 weekly injections directly into the lesion).

He did mention that this is controversial, so I'm curious to see everyone's responses.

 

Hi, thanks. How long do you leave the 40% pyrogallol on for??

 

I cover with fleecy web and advise them to keep it on for 4 days. It often allows me to stretch out the time between visits.

 

Hi thanks very much for your help, its been v. useful Cheers

 

Sole_Man

Much depends on the site and past history of the lesion. If it is a neurovascular corn with a conical centre (nucleus) then it is simple a hard corn complicated with dermal protrusions. Exposed blood vessels made it bleed easily and trapped nerve endings cause reflex similar to chewing silver paper when passing stainless steel blades across the nerve ending trapped in the skin. So these lesions are tricky to work with.

Use of local anaethesia infiltration will reduce the discomfort make then easier to treat but unless the lesion is reduced and the corn enucleated, then the lesion remains chronic. Most practitioners will err on under treatment. Treatment with pyrogallol has certain advantages and disadvantages. Pyrogallic acid is a reducing agent and removes oxygen from the kertain layer. This helps breakdown keratinous mass and will leave the Startum corneum layer, hydrated (white macerated appearance). Pyro has a direct sedative effect on the superficial nerve ending which helps reduce pain between visits. The acid has a cumulative action which builds up with repeated applications and can prove toxix to tissues. Hence many restrict the application to no more than three before suspending treatment in preference to another approach. Pyro may slip across the skin and can cause painful burns

I prefer using silver nitrate soln (75-90% soln) in the form of a styptic pencil. Once you identify the key area of neurological protrusion apply styptic pencil to the skin (wet end first then dry with cotton wool), AgNo3 acts as a protein precipitant and will form a self barrier to penetration in the form of an eschar. (turns black in the presence of light.) Repeated application after reduction encourages reabsorption of nerve and blood vessels. This makes working with the lesion much easier in ensuing treatments. Once the dermal protrusions are no longeer evident then suspend the caustic. Continued attention to minute disection with the scalpel will alleviate the general discomfort associated with a painful corn.

There are simple non caustic and non anaestheitc ways to proceed from here so let me know if you want to know more.

Cheers
Cameron

 

Thanks for that advice. I too have ioted for silver nitrate on the last two visits as it seemed like a natural course of action. There has been a mild improvement since but it is good to hear that somebody else has had good results. Thanks again!! James.

 

James

If you have a skin indentation after enuncleation use cured medical grade silicone putty to fill in the dent. Flatten it to the skin surface (like filling a plaster crack on a wall). Either leave , cover with a pad, or airstrip. For a short time the viscoelsatic will act as an isobaric medium and spread GRF over the cavity. As the skin replaces itself the plug is pushed out but the first 24 hours seem critical. Review the patient in accordance with symptoms and you may find the lesion improves. Suspend the AGNo3 once you can safely and painlesslessly reduce the overlying callus then start to reduce the frequency of visits. In almost all cases of chronic cases i.e. fortnighly frequent flyers, can go up to six weeks painfree when torrelances are built up over six month period. The lesion is recalcitrant and will return to its original state if left uncared for but the length of painfree time can be extended and the ease of working with neurovascular surface improved with good scalpel technique and bland surface silicone plugs.

As a record I cast the skin surface (enucleated surface) with the same silicone medium. This provides good biofeedback to the client.

Cheers
Cameron

 

You can also prescribe something like keralac or aldara.Have the patient apply it to the corn and tell them to apply a pad to make sure the medicine does not go on "good skin".In other words,almost deal with this like a wart.To debride the thing is very painful and does require local anesthesia such as lidocaine or marcaine.

 

I encountered a neurovascular corn in my final year (14 years ago) and haven't come up against another until just recently. At uni, I remember using phenol (same concentration as for nail procedures) on the advice of my tutor. I can't remember how many applications, duration of application, duration of treatment or anything other than using phenol.

Can anyone out there tell me is phenol still an option or is this treatment outdated? What are the risks, how long to treat...

Many thanks

Rebecca

 

I've had some success with using phenol after aggressive debridement.
I think that the two key things are offloading and debridement. Given how painful debridement can be its worth thinking about whether is is worth doing it aggressively every 4 weeks under LA rather than taking as much as the patient will let you every 2. Depends on the patient.

Like Cameron i've also had good results with silicon or other occlusive methods.

I once used liquid nitrogen cryo. Patient yelled a bit but had a good 6 months of comfort from a lesion which usually became intolerable after 3 weeks.

Hope this helps

Robert

 

I do not use phenol for that.I like debridement and padding.

 

Robert, what was your treatment plan in this case - ie how many cryo sessions did you do? did you debride as well? did the patient also have offloading padding/insole?
Cryo seems like a less "messy" treatment option than using pyrogallol, and 6 months relief is not a bad result.
Adam

 

Asher

>Can anyone out there tell me is phenol still an option or is this treatment outdated? What are the risks, how long to treat...

Its pretty outdated because of its potential to do damage the surrounding skin and with safer alternatives avialable. less popular now. There is mention in the older therapeutics books of such as Reid. The safew paractice would entail protecting the surrounding skin and ensure the resultant "burn" , ulceration is healed. The wound would be no different to treating post phenolisation. Anoter caustic which was used in the dark and dim past was nitric acid (not recommended) but did have analgesic properties apparently.

Cryo surgery was popular technique a few decades back. Creating a subdermal blister would have the effect of lifting the lesion from the skin. If it was done well then it would require one treatment only (like a wart), but the problem was high reoccurance rates (unlike a wart).

Much of the traditonal "acid" treatments (salicylic acid and pyro) had very little to do with getting rid of the lesion and was more to help the practitioner reduce the overlying callus. Vascular lesions bled easily and prevented the operator from seeing the field and neurlogical tufts were emneshed into the keratin and would render the lesion painful (like toothache). It also caused an involuntary reflex arc when the steel blade came across the surface.

Silver nitrate stick 75-90% (a styptic pencil) was sometimes used to create a eschar by preciptating skin protiens. In the old text this was often described as encouraging the dermis to reabsorb small nerve ending trapped in the keratin. Not sure if it did but certainly the eschar made reduction easier seven days later.

Cheers
Cameron

 

Berms

The plan was fairly simple; debrided first so that the ice ball penetrated to an even depth around the lesion, 45 seconds of liquid nitrogen (accompanied by not a little yelling, screaming and gnashing of teeth)* and lots and lots and lots of SCF padding (because i'm only mildly sadistic). As Cameron said it basically lifts the lesion atop a blister and it takes a while for the wiggly fiberous bits (and that is the actual technical name for them) which you can never 100% get at with a blade to grow back. One session only.

If i was doing it again i'd do a tibial block.

Hope this helps

Robert

* the patient made a fuss as well!

 

Hi everyone
In all my practice I have just encouterd one case of heloma neurovascular and I debrided and applied a hydrocolloid bandage normaly used in diabetic patients, because it keeps the area without pressure and promotes healing of the leasion. The result ? The patient lasted 1 year whithout pain, after which it came back again to repeat the treatment.

André

 

Hi there.
I have just encountered my first N.V fibrous corn. The lady was in extreme pain and it became pustulant and infected. I asked her G.P to prescribe Flucloxicillin, then I used L.A to debride and applied 75% AgNO3 stick. I reviewed her a few days later but she is still in pain. How many time can I use this procedure to be deemed as clinically safe? I am reluctant to use stronger caustics because of their implications, plus she is quite a difficult patient in the sense that she will not let me near it, but wants someting done about it!

 

If she's not keen on being hurt you could try macerating it to death. Debride as far as she will let you, mask around with that hydrocolloid dressing (granuflex is good) with a hole in the middle, fill the hole with something like flexitol (20% urea) another layer of hydrocolloid over the top of that (with no hole), then pad with scf around it to deflect. Replace each week for a month or two debriding each time. Should get easier to debride with less pain as the skin gets ever softer.

Or there is always marigold.

Regards
Robert

 

I saw a patient a few months back who had two very very sore NV HDs. I suggested using LA to numb the foot so I could enucleate aggressively. She consented. First time I did a local infiltration around the 1st MPJ (where the HD was). It worked but in all honesty the injection wasn't that much less painful than the treatment would have been. I then got the surgeon at my local trust to train me up on Tibial blocks (relatively easy i thought, 2 injections supervised and as long as you can show you are adequately trained and have passed your OSCE (or equivalent) it is fine... my biggest problem was volunteers so I had to do the injections on myself...).

The patient found that the Tibial block injection was much more tolerable and then gave me the opportunity to enucleate the corn fully, apply caustic, pad and send her home. A little tender the next day but she had long periods after treatment being pain free (whereas before it was only reduced pain). And she was very happy all told.

Regards,

Sam

 

Thank you for your advice and help. Its so useful
Cheers:drinks

 

Hello,

Does anybody know of any studies that have looked at the efficacy of different treatments for neurovascular H.D's? I am having difficulty in locating any recent (within last 10 years) studies. Any help would be appreciated.

Thank you

Moosepod

 

Is the corn on a digit or plantar surface?

It may be benefitial for an ottoform/deflective padding if around a digit, or possibly carrying out a biomechanical assessment to see why the corn is there in the first place as well as the palliative care.

another option (although not great for private practice) may be an electrosurgery or laser therapy. The electrosurgery will reduce the HD in size, reduce pain and has a only a small percentage chance of reoccuring.

Sparklytootsies83

 

Hi
This is my first post and no longer being a practicing Podiatrist after an unfortunate eye accident, I would concur with anDRe with regards to the efficacy of using hydrocolloid (Granulex) dressings after careful enuncleation. I first used this treatment in the mid 80's and found it effective in terms of ease of use, length the dressing stayed in place and above all the relief felt by the patient. I passed this anecdotal treament on to many Podiatrist here in Scotland and many have found this extremely effective in their practice.

Regards

Martin

 

Thanks so much, I am new to the forum and adapting to the rules and regulations here in Germany . You mentioned that you have non chemical solutions to effective treating and I would like to know more about your experience.

Kind regards
Liz

 

Hi Guys,

I'm used to just debriding and enucleating till the patient allows me, and then off loading for more comfort.
There have been many treatments mentioned (most mentioned in the quoted text) I'm mostly curious about the AgNO3 and the silicone putty, could you back your theories with some research or studies? I have been looking for articles and haven't been able to find one...

Thanks!

Matt