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Mosaic verrucae-help with treatment

Discussion in 'General Issues and Discussion Forum' started by poppet, Feb 27, 2009.

  1. blinda

    blinda MVP

    Crickey, Bill. I probably won`t be around in 30 years to review the tissue vitality of those I`ve needled, according by my `lifestyle`;).... K, I get what you`re saying and I agree that WB areas will be subjected to micro-trauma and thus a catalogue of other injuries and indeed subequent infections in the form of bacterial, viral and fungal as the epidermis is compromised.

    Yes, they were recorded. No, I don`t have a dermascope, but if you know of any companies who are willing to donate a high quality one for research purposes, you know where to send them.

    Yes, tattooing was only offered as a means to explain how needle insertions generally do not produce scarring. Obviously, a minority of tats do scar, mostly due to poor tattooist technique or susceptibility to scarring, the latter also applies to all other VP treatments. Many of us have seen scarring from cryo, sal A and laser tx in pts.

    With regard to depth and duration of needling, penetration is quick and to just below the dermis, where there is an abundance of immune regulators present. Personally, I won`t needle a lesion overlying vulnerable/superficial structures such as the achilles tendon or joints, etc.


    Does that help?
     
  2. blinda

    blinda MVP

    I agree, it would in a research environment. Apparently not private practice. One for the SCP feedback.

    Hate it when that happens.
     
  3. I needled an 11 y/o girl with 18 verrucae plantaris lesions on her plantar heel on May 3, 2013. She came in today with her mother for her final followup. None of the painful verrucae are present any more and we had to look very close to see any evidence of them ever being on her plantar heel, now 2 months after needling. Her mother says she is sending all her friends with children with plantar's warts to me and was very pleased.

    I should have taken photos of this one. Very dramatic!
     
  4. Paul Bowles

    Paul Bowles Well-Known Member

    Could also have been spontaneous resolution Kevin. Don't shoot the messenger i'm just pointing out the flip side of the argument. :morning: In any instance the result was achieved.
     
  5. Could have been a coincidence? Yeah, right. From 18 verrucae that had been on her foot for over a year to no evidence of any verrucae after 8 weeks of needling.

    How many of your laser fungal toenail "treatment successes" do you believe are due to "spontaneous resolutions"?
     
  6. Paul Bowles

    Paul Bowles Well-Known Member

    I don't think onycomycoses responds to immune system stimulation - so none. Spontaneous resolution of VPs is documented in the literature. I'm not being critical, rather being transparent. Don't shoot the messenger...again :)
     
  7. Paul:

    No podiatrist that I know and respect, that had also seen every single one of these 18 verrucae plantaris lesions respond as rapidly as I did after needling just one of her verrucae plantaris lesions, would think that this treatment result was due to "spontaneous resolution". That would not be a reasonable assumption, in my opinion.

    BTW, I'm not the one doing the shooting.
     
  8. Paul Bowles

    Paul Bowles Well-Known Member

    As I stated above I am merely making an observation which is noted in the literature. I didnt see the lesions. Even if I had it wouldnt have made any difference. Spontaneous resolution or not the outcome is still the same, correct?

    I'm NOT criticising your management plan here or the steps you took to resolve the patients issue - I have too much respect for you - you know that! I am merely pointing out the bleeding obvious.

    :butcher:
     
  9. Paul:

    I was only trying to provide a clinical case to those who have been following this thread on Podiatry Arena and who are also interested in the needling technique as yet another way to help rid individuals of resistant and painful verrucae plantaris lesions. Nothing more, nothing less.

    In the future, I will strongly consider not taking the extra time out of my busy days to provide such cases here.....it's simply not worth the headaches.
     
  10. Zac

    Zac Active Member

    Please never stop posting Kevin (unless some non-wireless connected tropical island beckons you in retirement) :)

    Could you or others go back over the depth of penetration of the needle in treating a VP? Is there a consistent depth that the needle is inserted or what "exactly" are you feeling too know what depth to go too???
     
  11. Paul Bowles

    Paul Bowles Well-Known Member

    C'mon Kevin - if I had a dollar for everytime you said that i'd be retired!

    Your comment, my observation on your comment. Case closed.

    :rolleyes:
     
  12. wdd

    wdd Well-Known Member

    Keep taking the time Kevin. Your positive influence speads way beyond the immediate respondants and will always be of great value to the silent majority.

    Bill
     
  13. blinda

    blinda MVP

    I would respectfully disagree with you there, Paul. AMP`s, part of our immune system, play a considerable role in susceptability and ability to fight bacterial, viral and fungal infections. There is much research in looking at bottling and boosting `em;

    http://jac.oxfordjournals.org/content/57/1/94.full.pdf

    http://www.ncbi.nlm.nih.gov/pubmed/15761415

    However, I make you right on the documented increased incidence of spontaneous regression of HPV in children, but needling does appear to boost cell-mediated immunity, IMO.

    http://www.ncbi.nlm.nih.gov/pubmed/11167676.

    Chapman, C.; Visaya, G. Treatment of multiple verrucae by triggering cell-mediated immunity—A clinical trial. Br. J. Podiatry 1998, 1, 89–90.
     
  14. blinda

    blinda MVP

    Hi Zac,

    It is difficult to ascertain the exact depth, other than the needle needs to puncture through the lesion to the subcutaneous tissue. Kevins` illustration demonstrates this beautifully;

    [​IMG]

    Taken from the review;
    Hope that helps!

    Bel
     
  15. Zac

    Zac Active Member

    Bel, how deep would you need to penetrate to reach the subcutaneous fat? Sorry to harp on but just trying to minimise mistakes/risks.
     
  16. blinda

    blinda MVP

    Zac, I can`t provide an accurate measurement as depth of penetration will vary according to site of the lesion. The thickness of the epidermis, dermis and subcutaneous layers varies throughout the body and from person to person and even on different aspects of the plantar surface. For example, the heel can be approx 4mm thick and the base of the mets just 1.5mm. So, you would penetrate to a depth of approx 5mm on the heel and approx 2mm on the base of the mets.

    Basically you just have to produce pin-point bleeding until there is no more resistance. This is probably the break-down of collagen, elastic fibers, and extrafibrillar matrix found in the dermis, so that the viral particles can reach the subcutaneous tissue that houses larger blood vessels (and immune regulators) and nerves. Obviously, you wouldn`t go any deeper as you could cause damage to other structures.
     
  17. Paul Bowles

    Paul Bowles Well-Known Member

    I think you may have misunderstood my point. How do I as a Podiatrist clinically stimulate an immune system response to sub ungual onycomycoses? I mean its not as easy as dry needling is it? Or is it? The mind ponders.....

    Kevin was merely having a "crack" at the photos i've produced regarding the OM thread on Podiatry Arena - I know that. I hope he doesn't think i'm in bed with any of the OM laser companies - which I have clearly stated that I am not. My response to Kevin above wasn't to point out any flaws in the needling technique it was merely to provide an alternate theory of proposition to the resolution. The glass is always half full, and as I said above - if the problem is resolved does it really matter? Probably not.

    Regarding needling "boosting" cell mediated responses - I never said it didn't ;)
     
  18. blinda

    blinda MVP

    You're alright, Paul. I was being a pedant, guess I find AMPs fascinating :eek:..must get a life. Wouldn't it be great if it were as simple as just finding a simple stimulus to tackle all manner of infections?

    As I said before, I appreciate your pics 'n posts on OM and never thought for one moment that you were in bed with anyone. I do understand Kevin's scepticism as it would appear that more than a few less scrupulous practitioners are making rather outlandish claims about what laser tx can achieve, not to mention a tidy profit. However, I'm watching the laser thread with great interest.

    With regards to needling, I'm not precious about it. In fact I think the future of effective tx lays in sub-type specific anti-viral therapy and that keratolytic and tissue destructive methods will eventually pale into insignificance.
     
  19. Paul Bowles

    Paul Bowles Well-Known Member

    Belinda do you think we could drive sub ungual OM into the dermis like needling to generate a system wide immune response? Has anyone ever tried it? Does anyone has any incidental data on pts with sub ungual OM and PNA procedures with resolution following? Wrong thread I know...but similar topic!
     
  20. wdd

    wdd Well-Known Member

    Hi Blinda,

    No, I don`t have a dermascope, but if you know of any companies who are willing to donate a high quality one for research purposes, you know where to send them.

    It's a shame you don't have one as a dermascope seems like an absolute must for that type of research. Would taking high resolution digital pictures that could be magnified to a certain extent to show detail be a stopgap possibility?


    Obviously, a minority of tats do scar, mostly due to poor tattooist technique or susceptibility to scarring, the latter also applies to all other VP treatments.

    It seems that those factors which constitute 'poor technique' for a tatooist, ie inserting the needle below the dermis and inserting the needle frequently in a small area are necessary features of good needling technique. So it is likely that there will be more 'scarring' with needling than tatooing if the competence profiles of the practitioners of needling and tatooing are similar.

    Many of us have seen scarring from cryo, sal A and laser tx in pts.

    That seems reasonable. The tissue damage associated with needling is measured and focused whereas the techniques you highlight above are blunderbus techniques. Given the cure rate, the focused tissue trauma (and associated minimal scarring) and minimal discomfort associated with needling it sounds as if it should be the current treatment of choice?

    Why do you think that the above techniques don't produce an immune response similar to needling?



    Does that help?

    Yep. Thanks.

    Bill

    PS By 'leaving the needle in place for too long' I meant in a dynamic sense and not a static sense, ie a relatively large number os stab wounds within a relatively small area.
     
  21. blinda

    blinda MVP

    `tis a shame indeed. But as a sole practitioner in the private sector, I have to fund my own research and I cannot justify the expense. You`re looking at the best part of 600-700 squid for a dermatascope of the appropriate quality for research (Private practitioners are also incredibly restricted in the type research they are permitted to undertake and, more frustratingly, publish). I do take high res pics, but without the express written permission of each pt, I cannot publish these on a forum, or anywhere else for that matter.

    True, as with all podiatric procedures, an incompetent practitioner will cause harm.

    Needling certainly has its benefits, such as; reasonably high resolution rate, minimal discomfort & dressings, precision etc as you highlighted, but it isn`t suitable for everyone. Predominantly those with even the slightest needle phobia do not make good candidates, in addition to those who have had a reaction/intolerance to anaesthesia. I don`t think it`s the utopia of HPV treatments, but it is currently at the top of my list....until specific HPV-type therapy becomes the standard.

    It has been suggested (Bristow & Stiles, 2011) that the viral particles remaining in adjacent cells are often missed when using tissue destruction methods, such as salicylic acid and cryotherapy. The hypothesis is that exposing the virus to the dermis and subcutaneous layer, there is an increased production of cytokines and subsequent cell-mediated immune response.

    Thanks for the clarification and I understand your query, but all I can say is; I haven`t seen any scarring from the hundreds of needling procedures that I have carried out....at least thus far;)

    Cheers,
    Bel

    ref;
    Bristow, I.R.; Stiles, C.J., The treatment of stubborn plantar warts using topical 5% imiquimod cream Podiatry Now 2011, 14, 14-16
     
  22. blinda

    blinda MVP

    Interesting idea. It is reasonable to suggest an increased inflammatory response associated with wound healing could produce more cytokines, but whether that would include enough specific anti-fungal AMPs it is impossible to say. Besides which, dermatophytes do not evade the immune system, unlike HPV, as they `feed` on keratin whereas HPV invades keratinocytes. Also, dermatophytes/tinea in an open wound has been documented as a factor responsible for delayed healing, so I wouldn`t want to be introducing fungus to the deeper tissues, IMO.

    Like your thinking though.
     
  23. wdd

    wdd Well-Known Member

    Bel.,

    Thanks for your reply and for the reference.

    Bill
     
  24. wdd

    wdd Well-Known Member

    Undoubtedly it could have been and I was hoping someone with a working knowledge of probability would respond and give some idea of the probability but no one has.

    So I though I would make what is almost certain to be a laughable stab at it but it might stimulate someone more knowledgeable to put me right.

    There used to be a little formula the accuracy of which I cannot vouch for but at least it gives us something to go on.

    The formula (does not differentiate with respect to age or anything else) goes:

    50% of VPs resolve spontaneously within the first six months;
    50% of the remainder resolve within the next six month;
    and so on adfinitum or to absurdity.

    So lets assume that there is a 50% (1/2) chance of the verruca disappearing over a six month period.

    The young girl in question was seen over a two month period so lets assume that spontaneous resolution took place over say a one month period.

    Therefore the chance of spontanous resolution within a one month period, ie somewhere within the two month period she was under the care of the podiatrist, would be 1/2 x1/6 = 1/12.

    So the chance of the verruca disappearing in any month is 1/12.

    However in this case the spontaneous resolution of the verruca must coincide with the time that the verruca was under the care of the podiatrist. Assuming that the verruca took one month to resolve the podiatrist had a 1/12 chance that spontaneous resolution would coincide with her visit in any year.

    Therefore with my, I am certain, shaky calculations the probability of the verruca resolving spontanously while she was visiting the podiatrist would be 1/12x1/12 = 1/144 which is less than a 1% chance.

    Unless you know better?

    Bill
     
  25. Paul Bowles

    Paul Bowles Well-Known Member

    Regardless of the figures (and how accurate or inaccurate they may be) there is still a chance. You are also possibly not accounting for the fact that the autoimmune response could well and truly have been underway when she went to the Podiatrist in the first place.

    Why are we still talking about this? It was a simple observation on disease progression - something we all do on a daily basis.

    Reminds of the movie dumb and dumber where the beautiful Laurel Holly is asked the odds on her and Jim Cary getting together she replies "ONE IN A MILLION" and he replies:

    "So there is still a chance.......yes!"

    :)
     
  26. wdd

    wdd Well-Known Member

    Paul Bowles;311282]

    Why are we still talking about this?

    Because it is a good question. What is the probability that spontaneous resolution of a verruca and podiatric treatment are synchronous?


    It was a simple observation on disease progression - something we all do on a daily basis.

    Trying to quantify the 'observation' makes it hopefully a little more valuable and useful?

    If we were talking about the probability of developing breast cancer or prostate cancer the value of trying to calculate the probability would more obvious. Think Angelina Jolie.


    I think that apart from anything else my calculation is way too high and that the probability of spontaneous resolution coinciding with treatment is considerably less than 1%.

    If 50% of verrucae disappear within the first 6mths and 50% of the remainder in the next 6 months that means that it would take about 2 years before we can be about 95% certain that the verruca will have disappeared spontaneously.

    My calculation would than become: 1/12x 1/24 = 1/288.

    So that's a 1 in 288 (0.35%] chance that the verruca resolved spontaneously.

    Taking other factors into account, eg spontaneous resolution had already started before the patient began treatment makes the probability of the coincidence of resolution and treatment even smaller, I think.

    Bill
     
  27. Paul Bowles

    Paul Bowles Well-Known Member

    But there is still a chance!!!!

    CLICK HERE TO FIND OUT!

    For the one individual in question since we do not know whether they were already undergoing an autoimmune response or not we can assume that they had a chance of self resolution. Just as they had a chance of resolution due to intervention. So the facts here are simple - could they have resolved with intervention (according to Blindas peer reviewed/published article/research and Kevins expertise) YES they could have. Could they have spontaneously resolved (according to peer reviewed research) YES they could have. The numbers themselves are irrelevant for the individual. The outcome itself is actually irrelevant as in the patients experience it was a positive one.

    The Angelina Jolie "phenomenon" has its own statistical flaws - which is a whole other argument, suffice to say it doesn't really apply here.....
     
  28. You should probably go to the literature to find controlled trials in which the control was "no treatment" and extract the spontaneous resolution rates from these.
     
  29. wdd

    wdd Well-Known Member

    CLICK HERE TO FIND OUT!
    Loved the clip although I think that it's highly probable that she got the probability wrong, so to speak, but that's part of the biological con trick.

    YES they could have.

    Of course the answer is YES but after that I'm not sure why it even needed mentioning unless you thought that people had forgotten that there is a chance of spontaneous resolution? But having mentioned it, it is interesting to have some measure of thing.

    I'm off for a short walk now, unless I can't get the front door to open or I fall and break my leg before I get outside or someone comes to see me or a meteorite falls on my head or my wife tells me to wash the dishes, etc . They and a million other things are possible but I they usually remain tacit even though the probability of some of them arising is relatively high.


    The Angelina Jolie "phenomenon" has its own statistical flaws - which is a whole other argument, suffice to say it doesn't really apply here.....

    Yeh but it creates a pleasant image.

    Best wishes,

    ill. OOps I missed out the B. Do you think it might be a Freudian slip? Possibly I am trying to tell myself something? Whatever, I think I'll ignore the voice for today at least.
     
  30. Paul Bowles

    Paul Bowles Well-Known Member


    Keep telling yourself "there is still a chance Bill, there is still a chance....."

    :)
     
  31. wdd

    wdd Well-Known Member

    Good idea Simon. I don't have any acces to literature apart from things I can find online but I will give it a go.



    You are absolutely right there Paul.


    Thanks.

    Bill
     
  32. wdd

    wdd Well-Known Member

    The only signifcant refernce I have found online so far is:

    Sterling JC, Handfield-Jones S, Hudson PM; British Association of Dermatologists. Guidelinesfor the management of cutaneous warts. Br J Dermatol 2001; 114;4 -11.

    I'm not sure if genital warts are included but it certainly included hands and feet and didn't differentiate with respect to age, sex or anything else.

    Approximately 23% regress within 2mths
    30% regress within 3mths
    65%<78% regress within 2yrs.

    They also suggest that: "Spontaneous regression of warts must be considered in researching the effectiveness of treatment". But it doesn't seem to be?

    Bill
     
  33. blinda

    blinda MVP

    Bill,

    PM me your email addy.

    Bel
     
  34. Paul Bowles

    Paul Bowles Well-Known Member

    Going back my original posting on the topic........*cough* ;)
     
  35. It's now been 5.5 years since Falknor's needling technique was first mentioned here on Podiatry Arena (post #2) in this thread. Good to see that this thread may been at least partially responsible for stimulating research on this very effective technique. Now, in addition to Belinda Longhurst's excellent paper, there is now is a new article out in JAPMA comparing the treatment of verrucae plantaris between needling and cryotherapy.

     
  36. karen parry

    karen parry Welcome New Poster

    Hi,
    I recently heard of a lady who had had a VP for over 10 year and was under a oncologist for a malignant melanoma. The oncologist was generally chatting when my patient told her about the VP and she gave her a cream to put on it that is used for lessor skin cancer types and the VP has gone after only 3 applications.
    The oncologist said it isn't licensed for the use on V,P that is why it is not in general use. Anyone else heard of this??
     
  37. blinda

    blinda MVP

    Probably this;
    http://www.bad.org.uk/for-the-public/patient-information-leaflets/imiquimod-cream#.U-nfQGP8CTI

    There has been some limited research on its use for HPV, but as you say, it is off license.

    Bristow IR, Stiles CJ: The treatment of stubborn plantar warts using topical 5% imiquimod cream Podiatry Now 2011, 14(10):14-16

    Cheers,
    Bel
     
  38. karen parry

    karen parry Welcome New Poster

    Thanks Bel, I couldn't remember the name.
    Interesting, Ive read the article now, I wonder if
    it will becomes licensed :pigs:
     
  39. blinda

    blinda MVP

    Good article on Therapeutic HPV Vaccines.

    These new vaccines are not just prophylactic; the antigen (subtype) specific action now targets existing HPV infected epithelial cells. Another step in the right direction of producing a simple vaccine for our benign friends.:cool:

    http://www.mdpi.com/2077-0383/4/4/614
     
  40. Don ESWT

    Don ESWT Active Member

    Maybe it is time to contact Dr Ian Fraser to start work on podiatry trails to eradicate wart for our patients

    Don Scott
    Grafton
     
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