Preferred Method for Treating Verruca

think back to our discussion on your daughters vp ??

What did I tell you my philosophy was on the TT oil in an emollient base ??? Stops the parent smearing acids ,freezing and generally causing the child pain. By the time they have finished the pot of cream the vp's have usually resolved and by keep ing the callusing soft it is a pain free process.

Isnt that the basis of your comment

amazing that innit

cheers mate
D

 

Oh that.

Well, you know, always willing to learn from the voice of experiance.

Even if it is the SMUG voice of experiance.

Evidence can't show you the best treatment for happy patients. Someone who has been treating them for 20 years might be able to though.

Yeah keep hoping. I may have lapsed once or twice on a placebo for a condition which responds to placebos but I'm not completely bloody off reservation!!

Did I mention the cactus?

 

Hi Andre!

How's life over in Auz? All good here in Singapore...

Quick question, have a patient who developed verruca around the entire nail sulcus after bilateral NWR. Your thoughts ant treatment? Bit of a difficult site to treat.

Cheers for now,

Johan Steenkamp

 

I have not read this thread before - and I am not joining in the personal stuff towards the end - though go for it! However, I am gratified to see such common sense towards plantar warts in kids. I first suggested non-treatment in 1978 - and was villified - big time. I see now that the "common sense" qotient has come around; so very gratified to see such sensible answers from Rob Isaacs and others, who make statements such as "... would not treat ever unless painful". I left practice (apart from locums) many years ago - but at the time there was no evidence supporting treatment and a mountain-load supporting not treating. Carry on! Rob

 

Hello

I was just wondering could some one tell me the best way to apply Salicylic acid 70% to a verrcua
, how succussful they feel it has been for the patients and what interval period you use for apply the 70% acid?

Also what advise do you give the patient inbetween the appts once you apply the acid- Do they leave it one for the week or apply their own OTC acid inbwteen the podiatry appts?

Finally does anyone know the normal shelf life of a tub of Salicylic acid 70%

Thank you

 

But why would you want to? As I see it, there is no case to treat plantar warts unless painful - and even then one has to look carefully at a rationale as to why. Call mem old fashioned...... Rob

 

The plantar wart is painful? Thank you

 

Sorry i meant 60% not 70% acid ...oops! x

 

Briony,
What were you taught during your training with regard to VPs ?

regards

Catfoot

 

Didnt really cover the acids- just cryo so thats why I was asking to see what others were doing? Been looking into courses for recaps but havent really seen any?

Thank you

 

Hi Bryony,
What course did you do?

Now, please don't take this the wrong way, but I would ask yourself this question

If you haven't been taught to use a certain modality, should you using it?

If you attempt a treatment that you haven't been taught and you have an untoward outcome then your insurance won't cover you because you have been acting outside your Scope of Practice.

In Podiatry, VP treatments and orthotics are the two areas that attract most litigation.

I would suggest that you don't attempt any treatments with acids until you are familiar with them. Maybe shadow a pod somewhere?

regards

Catfoot

 

Hello catfoot,

Not taken the wrong way at all .... Im not going to be using on patients yet... i was getting advcie first anyway. Just doing some research about acids, thats why i was asking.

Yes I know and fully understand the litigation issues.

Thank you

 

Hi Briony,
Might I suggest you get in contact with which ever teaching establishment you trained at and get your answers direct from them which I would advise would be a much safer way to get the knowledge you are seeking rather than picking up a wrong interpretation on here ?

I'm at a loss as to why you were not taught the use of chemical Tx but nevertheless if you trained with a private trainer, they have a duty of care to you so should be able to assist you.
Good Luck
Cheers
D

 

Thank you

 

Agree that leaving non painful v ps alone is fine. I have had some success, after explaining about introducing the blood supply to the virus by debriding until slight bleed, then get the child to abrade with an emery board every few days to restimulate immune response.This way the patient and parent can feel they are doing something, and the vps often resolve, along with other small warts.

 

Greetings All
Nice little thread which reassures me that I am not alone with generally leaving verrucae alone...
If I am to treat I often manually debride and then advise for the patient to use a foot rasp to maintain the reduction of hyperkeratosis... along with 'diswart' (gluteraldehyde 10%) which seems to help without too much harm - if they can get it to bleed then 'a little blood won't hurt'

However I thought I might get some other opinions on a case-
I have a professional footballer who has unusual feet- bilateral trigger hallux with valgus rotation of the phalanx- which do not give him any trouble... the problem is he has a mosaic wart over the interphalangeal joint of his L hallux. It is a good size- at least 2cm in diameter. It generally does cause a problem though it does get a fissure in it (due to the high plantar pressures?)

Up to this point in time I have not touched it as I am concerned about causing problems which could cause him to miss a game and there are not too many breaks due to World Cup qualifying...

Any thoughts about possible treatment in the future??? Has laser treatment been shown to be of any use (people seem to use it for everything now)??

I guess I looking at quick recovery or low trauma options...

Many thanks

 

Craig:

Treatment with Falknor's needling technique will not cause any need for alteration to his training schedule. He should be able to be nearly 100% by the next day following the needling procedure.

Here is a short thread on the technique.

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=25720

It is interesting that now, over three years since I first described my experiences with using Falknor's needling technique to treat mosaic verrucae here on Podiatry Arena, which apparently virtually no one was aware of in the UK at the time, there are quite a number of UK podiatrists now advertising on their websites, offering "dry needling" treatment for verrucae.

Just type in "verruca needling" into Google.....the power of the internet (and Podiatry Arena) is amazing!:drinks

 

Hi Kevin
Thanks for that- I would have thought that needling would not be so well tolerated in a high load area without much fibro fatty padding beneath it???
I am still inclined to leave it alone, but I want to have options up my sleeve...

 

Hi Craig,

If you`re inclined to leave it alone and the pt isn`t bothered by the VP, then I wouldn`t treat it either. As you know, VP`s often spontaneously resolve in individuals who are not immunocompromised.

However, you mentioned that you would like to consider `quick recovery and low trauma options` for future treatments. I agree with Kevin, needling (not dry needling) under a digital ring block would not interfere with his training.

Is the VP on the plantar or dorsal aspect of the hallux?

Cheers,
Bel

 

It is plantar mainly due to the shape of his toe... On initial inspection you would think it was typical hyper keratosis on the IPJ.
I shall take a photo when I next see him!
On the subject of being immunosuppressed... Vitaman D deficiency is a huge issue here. Pretty much the whole population is deficient. Possible factor do you think?

 

Interesting. There is some evidence that Vitamin D Deficiency Suppresses Cell-Mediated Immunity, so could be a factor.

Look forward to seeing the pic.

Cheers,
Bel

 

Hi Craig

Just to echo the above- I've had a couple of patients who've run about 10k distance within a day of needling treatment (not that this was part of the post op recommendations!) with no problems, so might fit into his training fine if it does become necessary.

 

Thuja, Banana skins, duck tape, garlic, walking around a yew tree widdyshins on a full moon, we've heard them all but my personal favourite told to me by an whithered old Russian woman with a face like slate hangers nail bag ... is:

1. count how many warts there are
2. get a piece of biodegradable RED cotton thread
3. tie granny knots in a piece of cotton thread - a knot for each wart
4. get a skinny twig and wind it the knotted thread around the twig
5. plant the bound twig in a flower pot
6. water regularly
7. warts disappear withing 30 days

As far as I can tell - it works as well as anything else!

Might be accused of withcraft though!

 

Hi Leah, I am not sure what you mean by,

can you translate, just in case I am missing an important treatment modality ?

Thanks

Catfoot

 

As I said a while ago, treating verruccae is all smoke and mirrors..

 

MMMmmmm, I am sure this has all been said before - but why is one treating warts at all? OK, some hurt, and that might be a justification, but surely there is not valid rationale for treaing any other (Beneficence, Non-Maleficence etc)? Rob

 

Rob:

When you have an athlete coming to you with a painful plantar wart under their 2nd metatarsal head preventing them from training or competing in their sport, what do you tell them, "I might be justified in treating your plantar's wart only if it ispainful"? What do you recommend otherwise for treatment since you said "that might be a justification". In my mind, pain is definitely a justification to treat this condition.

I know you are retired and not treating people any more, but remember, the term "beneficence" means "The state or quality of being kind, charitable, or beneficial." How is it being kind, charitable and beneficial to an athlete in pain when you tell them that their pain "might be a justification for treatment of their medical condition". To me, this type of language between the clinician and patient who is in pain when he or she wants to participate in the activity they love indicates an uncaring and arrogant attitude in the clinician, not beneficence.

By the way, Rob, when was the last time you were in podiatric practice??

 

I am not sure how to address this personal attack, especially by a member of the profession that I have long held in high regard.

Let us take each attack one by one. I last practiced in February, and am back at work again next week. My current work, apart from being a consultant to pod schools, is in psycho-geri - the sharp end of good.

In the pure dictionary sense, beneficence means: the doing of good; active, goodness or kindness; charity (a cut and paste from Dictionary.com). However, as we both well know, in the sense of medical ethics, it simply means "do only good"; and indeed, its anti-statement, "non-maleficence" means do no harm. But you knew that.

And, as I am sure you are aware, there is literature (though I am out of date) that provides evidence that "removal" of warts in kids removes from them the immunity that they may have derived from their natural progression. Again, I come back to beneficence and non-maleficence.

you may like to note that in my first statement, I made an exception for the person in pain, which, I guess, is making me wonder what the basis is for this personal attack? While I have commented on many occassions upon the ethics of treating asymptomatic warts, I have always made exception for that are symptomatic.

While tact had never been my strong spot, I do not retract my comments.

My final word is this, and I have alluded to it before; the Nurenburg defence is, sadly becoming more and more common. It is not a valid defence, and never will be.

Puzzled, Rob

 

Rob:

No personal offense was intended and I am sorry that it came across that way especially to someone who has been a leader within the profession for so long.

I just thought that for you to say that treatment of a painful plantar wart might require treatment sounded rather like you meant that there is something else that an ethical podiatrist would otherwise consider offering this patient for this painful condition for his or her benefit and health. Since you said it only "might" require treatment, then this also means it "might" also not require treatment. I am puzzled, therefore, Rob, what are the other alternatives for the ethical podiatrist to consider for this patient in the way of treatment to try to eradicate this painful verrucae for him or her?

 

I too am puzzled, why do people get so aggressive, and so quickly online? Would you behave like that in conversation? How close to the surface is your boiling rage?

 

Whatever agression you may have seen, it is not mine. All cool, Rob

 

Just trying to keep up me image.....

http://www.chrismcdougall.com/blog/2010/02/but-what-about-glass/

 

Hi Elizabeth,

Not sure who you are addressing here, but I am genuinely pleased that you have decided to stick around. As I said before, the Arena has much to offer everyone. Personally, I have learnt a great deal from many practitioners here, which in turn has benefited my practice.

Your analogy of a conversation is a good one, presuming you mean face to face and in the same room. Now, I`m not trying to teach you anything new here, but remember that the spoken word is only a small part of effective communication. Much is conveyed through body language, gestures, facial expression, tone, etc, none of which are possible in text. I.E, when posts are written here, we do not have the luxury of inflection and short or precise posts can come across as curt, or even aggressive, when the posters only intention was to be direct. I know I`m guilty of this, probably from years of living with a South African who are notorious for their `directness` (remember Spitting Image )
I guess what I`m trying to say is that not all direct posts here should be perceived as aggressive or rude. Often the poster is being straight or maybe just short of time to construct a considered post. They may also write with the same conviction as you when you wrote;

This could be taken as a sweeping statement without evidence at best or aggressive at worst and that is not a criticism of you by me, just an observation of how posts can be misread by the beholder.

Just my thoughts and no offence intended.
Bel

 

Hi Rob,

I agree that the majority of painless VPs do not require treatment, particularly in children as evidence suggests that spontaneous resolution is relatively high in comparison to adult patients.

However, I would also consider intervention if the lesion(s) interfere with their quality of life (QOL), whether that be through pain, altered gait or even if the pt perceives their QOL to be compromised due to cosmetic embarrassment. That said, I always explicitly explain ALL treatment options, including no treatment and the risks and benefits of each.

Just my opinion, of course.

Cheers,
Bel

 

I have never said anything which differs from all the latter comments; in any of my postings - right back to the MacDonald and Kidd paper (of about 1998, admittedly not about warts, but was about the ethics of intervention), we never said "you should not"; we merely asked the question "are you sure that you should?". There in lies the differences between the reflective and the non-reflective practitioner. While Dr Kirby quite rightly points out that I am now sort-of retired, that does not mean that I have laid down. Rob

 

Dont ever do that Rob stick with the rest of us "sort of retired" folk and keep going !!

Cheers
D

 

Indeed.

And I, for one, am glad you have not been put out to pasture. You are one of the practitioners to which I referred to as learning from and improving my practice. :drinks

Cheers,
Bel

 

RW, Rob

 

Does anyone have any suggestions on treating a child with painful VP on 1st MTPJ which is very prominent? Has been around for 2 years!

 

Can I ask if anyone knows or has any experience of treating verrucas with cryo spray 59 ???

its a spray can with a long tube attached - the idea is to put semi compressed felt on the verruca, and then to apply one minute bursts of cold through the felt - six times according the the instructions

and if anyone know, or has used this product...do i have to anaesthesize the foot? ie is it too painful without