Canthacur Treated Verruace Now an Ulcer

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Anyone ever treated a verrucae plantaris with canthacur and after 2-3 treatment, have it ulcerate.....? had to put in L.A. and do an emergency surgical excision of the remaining verrucae and now I am treating the patient for a small ulcer....never happened to me before - probably bad area for any treatment - posterior-plantar heel...would anyone have done this differently ?

C.F.G.

 

Hi CFG

I can't comment on canthacur as I don't think it's available in the UK.
However a few more details about the patient may help people advise whether this was a suitable treatment regime in general.

Patient age, relevent medical history, length of time between visits etc would be useful

 

Patient is a healthy 25 year old male with no known allergies and no medications - 7 days between visits...this is what is so puzzling...I suspect that the placement of the VP, combined with an untreated varus biomechanical deformity place excessive pressure on the lesion during the initial 3 treatments - Canthacur is a powerful vesicant which I only use on healthy young males ususally and so far without this happening...godd questions though...THANKS....

 

Hi CFG,

I assume Canthacur is Cantharadine, or Cantherone? Unfortunately, this is not licensed for podiatric use in the UK. I know dermatologists sometimes use if for VP`s, as it blisters and separates the dermis from the epidermis (basically an ulcer, with a roof) thereby, `cutting off` vascular supply to the VP.

As a student, I obtained some of the red`super strength` with Sal acid, for my own use...but was too chicken to use it. I gave it to a dermatologist pod to try, who informed me that it was very painful on application, (Well, it was for his wife anyway, whom he used it on) but very effective. He described the resultant blister as `a clean ulcer`.

Question:

Why only males?

Cheers,
Bel

 

Hi Canada Foot Guy,
I cannot comment specifically on Canthacur as I have never used it.

However, I note that the active ingredients are cantharadin - a vesicant and podophyllin, which disrupts viral activity by inducing local tissue necrosis.
So putting the two together we have a real block-buster of a treatment!

I am not sure what you mean by posterior plantar heel, do mean on the heel pad itself or away from the fibro fatty pad? I would certainly only apply such a drastic preparation in an area where there was plenty of fibrofatty padding and certainly not on children.

At the end of the day we have to decide, after consultation with the patient, what is the priority for the patient. If they want the VP removing then we can do that - but it may cause pain and tissue destruction which will will need to heal. So they may need time off work etc etc.

Or can they just learn to live with it and hope it spontaneously resolves?

In these days of litigation I would now tend to err on the side of caution, bearing in mind that in UK there are a significant number of "Fitness to practice" hearings have come to light concerning VP treatment.

To go back to your original question - the product did what it said on the tin, so all you need to do is heal up the ulcer and all will be fine.

regards

Catfoot

 

That is what I ended up with - a clean ulcer - but quite a bit larger than it should have been and patient responded unlike any other....I should say that I would use it on anyones feet but in my recent experience I have found that silver nitrate works pretty good on little kids, cryo on pregant women, cathacur on feet that are a little more sturdy (tissue wise)..most of the women I have seem with VP's have thinning skin and I have tried to be more conservative....

The issue with this patient now is trying to deal with a heel ulcer - what a pain for him and me..

 

I wouldn`t say it was an issue. As CF stated, it did what it was designed to do. If this fella has no underlying systemic conditions, then it should heal beautifully. Just a question of keeping it clean and offloaded until resolution occurs.

Out of curiosity, why do you think silver nitrate works well on kids?

 

Thanks Catfoot

Yes this t/t has been very effective for me...the wound is on the fibrofatty pad...

He is taking 3 days off and I will see him tomorrow again - Keeping in mind he is not compromised in anyway, I still treated the ulcer as I would any ulcer on any patient...offloading it is a bit tricky....as far as prophylaxis for infection, I have good results so far with topical iodosorb (sometimes with oral Abx - although there was no need in this case so far - will reassess tomorrow)

If you could direct me to any writings regarding 'Fitness to practice hearings and VPs', that would be appreciated....

Thanks for Responding

 

Hi Blinda,

well generally speaking, AgNO3 is pretty useless really, but it IS gentle and does work between 3-5 visits with debridement in my experience.....the kids don't seem to mind coming back and of course there is the revenue aspect of it - although I must say that if it takes much longer than this I give the parents a break on the cost....

 

Hi Canada Foot Guy,
All I can find is this one,

http://www.hpc-uk.org/complaints/hearings/index.asp?id=1090&showAll=1

you may be able to find some more back in the archives !

regards

CF

 

Thanks..this was useful to consider

 

We had a patient severely react to canthecur as he went out drinking the night of application. This is not something one should do with blistering agent on their foot. It is even on a list of c-i's

I have had minor ulceration remain at my 2 week debridement visits, especially if it is the second application. I have never felt the need to excise the vp in these cases. Usually I give a week with appropriate dressings (as it is never full thickness just erosion to the basement membrane) it heals up in a week then we go to less aggressive treatments until the skin is strong again.

Why did you need to excise it? How deep did you go?

Sarah

 

Hi Sarah,

Thanks for your feedback. Perhaps it could have been considered more of a deep debridment rather than an excision. At the level of the basement membrane, dead wart tissue was attached and hanging out of the ulceration (warty tissue was quite sizable) . I had to remove the attachment of the verrucae with a scalpel , then currettage the basement membrane to remove any visibile signs of the wart tissue. I am currently monitoring the patient every 2-3 days. There were two factors with this case. 1) the wart was quite healthy and tenacious and 2) it was in the worst possible place which makes me think in future I will offload the patient right away to let treatment go completely unencumbered by plantar pressure...CFG

 

Hi again CFG,

Any chance of posting some pics of the lesion?

Cheers,
Bel

 

sorry wish I had some ...patient cancelled appointment today and said he was 'healed'.....I told him that I want to see him next week for follow-up anyway....I acutally just started to take some pictures...I do have a lovely one of a hallux nail with some kind of fungal infection that has formed 2 black lines on the medial and lateral aspects of the nail on both halluxes.....

 

so patient has healed and is pain free - no sign of verrucae that we scraped off of the basement membrane - we will wait and see if we got it all