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13 year old with multiple vp

Discussion in 'General Issues and Discussion Forum' started by Spod:), Feb 12, 2013.

  1. Spod:)

    Spod:) Member

    Members do not see these Ads. Sign Up.
    Hi all. Just wondering if any of you have any thoughts on a 13 year old boy with multiple vp both feet. Am thinking of recommending Thuja tablets. Planning on accompanying this with monthly debridement.

    Does anyone know if thuja tablets are safe to use with children this age? Is there anything else or an alternative treatment you think would be more effective?

    Regards :dizzy:
  2. blinda

    blinda MVP

    To quote my honourable colleague;
  3. I wouldn't deny this patient effective treatment. Try Falknor's needling procedure. It works quite well for mosaic or multiple verrucae.

    Mosaic Verrucae - Help With Treatment
  4. Orthican

    Orthican Active Member

    Have not been around for a while. Apologies.

    I had a question for the forum regarding VP. I have read here that the dry needling procedure works quite well. So my question is are there any practitioners doing this procedure in Canada? More specifically Alberta?
  5. Spod:)

    Spod:) Member

  6. Rob Kidd

    Rob Kidd Well-Known Member

    Look guys, I have been quoted here - and I am entirely happy to have been, but I do not seem to be allowed a right of reply. All I ask is this.

    Why are you treating warts? If they hurt, well, there is a reasonable case. If they are painless, inside basic medical ethics there is no case. But this is not new; it is over 30 years since I (at the time radically) suggested that warts should not be treated routinely. There has for years been clear evidence that the (routine) treatment of warts does not comply with basic medical ethics. We must never forget maleficence, and non-maleficence. Routine wart treatment does not comply with this. I emphasise "routine" wart treatment. Rob
  7. Spod:)

    Spod:) Member

    Thank you Rob. The warts do hurt. I take on board the issue of 'routine' treatment.

  8. blinda

    blinda MVP


    Please take the compliment as it was intended. I quoted you because I rather like the phrase "a tincture of time", which you coined, in addition to agreeing with this sentiment in some, but not all, cases. It is well documented that spontaneous regression is high in children and young adults, hence my suggestion that no treatment could be the best option here.

    However, I would not entirely agree that painful verrucae are just "a reasonable case" as these lesions can greatly effect a patients quality of life (QOL), alter gait through pain avoidance and, in some rare instances, cause damage to underlying tissue in a similar vein as corns, particularly the HPV1 sub-type.

    Verrucae are usually harmless and with a relatively good chance of natural resolution, it can be argued that they are best left untreated, and for some patients this may be preferential, for the most part where the verruca is not symptomatic. However, in adulthood they may persist for many years can be associated with significant morbidity (Ciconte et al,2003), including perceived cosmetic disfigurement and physical pain. This morbidity of discomfort and/or embarrassment of unsightly appearance is frequently underestimated and dismissed, in my opinion.

    In a nutshell, I would consider intervention if the lesions interfere with their QOL, whether that is through pain, altered gait or even if the pt perceives their QOL to be compromised due to appearance and stigma associated with a viral infection.

    I agree with Kevin; needling verrucae appears to be particularly effective in the treatment of mosaic (HPV2) and multiple (HPV4) lesions. That said, I always explicitly explain all treatment options, including no treatment and the risks and benefits of each.


    Ref Linky: Warts are not merely blemishes on the skin: A study on the morbidity associated with having viral cutaneous warts.
    Last edited: Feb 13, 2013
  9. Why don't you, Rob, try running that statement past the Dermatology Grand Rounds at Stanford Hospital (that I attended weekly during my surgical residency at the VA in Palo Alto). I'm sure you would be very popular making a statement such as this.;)
  10. This issue of "medical ethics" that Rob brings up in the treatment of a dermatological condition, is really, to me, a non-factor and is simply not a mainstream medical view.

    There are whole medical professions that conservatively and surgically treat non-painful conditions and these medical professionals are never called "unethical" for treating these non-painful medical entities. Do we call a plastic surgeon "unethical" for performing a breast augmentation or a breast reduction procedure for a female patient that desires a different body shape? No.

    Therefore, it would also be myopic to then claim that the treatment of any non-painful dermatological condition is medically unethical.
  11. blinda

    blinda MVP

    I agree.

    The majority of dermatological conditions are not physically painful but are nonetheless treated because they are recognised as debilitating and often lead to physical and psychological distress.

    With regard to the principles of maleficence and non-maleficence, we should also consider beneficence in addition to respecting a patients` autonomy, ie; they do have an active role in decision making about their treatment plans. Many patients presenting with verrucae desperately want us to treat them. In my view, unless there is medical contraindication, it would be unethical to deny them of this.
  12. Rob Kidd

    Rob Kidd Well-Known Member

    You miss my point. It is not a question of treating non-painful lesions. It is a question of: does the treatment harm the patient? There is a school of thought that suggests that treatment of warts leads to a situation where the patients may not develop the resitance to them - the resistance that they would develop should they be allowed to resolve of their own accord. That is the point. IE non-maleficence: is the treatment doing harm. I have never heard it suggested that treating psoriasis is doing any harm.
  13. And I have never heard it suggested, by any authority on the subject, that treating verrucae plantaris lesions is doing any harm.
  14. blinda

    blinda MVP

    Resistance, or immunological memory, is difficult to predict as HPV resolution is brought about by a cellular immune response (without the aid of antibodies) only when, and if enough, cytokines are produced to destroy all virally infected keratinocytes. Recent research on treatments has been aiming toward creating an enhanced systemic immune response specifically directed against early viral proteins to eradicate the virus. Whether this provides life-long immunity remains to be seen.

    Even if verrucae are left to self resolve, they often recur as the localised cell-mediated response did not produce enough cytokines to destroy latent viral particles in adjacent cells.

    There is no evidence to suggest that treatment hinders immunity, unless you can prove otherwise?

  15. Spod:)

    Spod:) Member

    Turns out the young male in question plays football at national level and being that the vp are painful I feel there is no option but to treat. Previous treatments of acid and cryo have failed. Am keen to use the needling technique. This does not seem to be very popular in the part of the UK where I practise (Northern Ireland). As such I am struggling to find someone to refer to in the short term. In the long term I would like to become proficient in this technique. Can anyone recommend a workshop which I can attend to learn this technique please? Does one require a certificate of competence or can any pod give it a go?

    Regards :D
  16. blinda

    blinda MVP

    I am unaware of any `workshops` on the needling technique, but that doesn`t mean there aren`t any.

    It`s not really a case of `giving it a go`, I would recommend that you shadow a proficient practitioner who is willing to mentor you and oversee your first treatments. I would also recommend ensuring that your LA techniques are up to date, as this would differ according to the site and sub-type of the lesion.

  17. This lad would be a perfect candidate for the needling procedure. For the young soccer players I see, you can do the needling procedure one afternoon and then have them practice or play a game the next day with very little pain, if any. If you go through the thread I mentioned, you will find, in the first few pages, that I describe the procedure in a detailed fashion. Would love to visit Ireland again....would do the procedure for free if I could get up there again.....but my patients here in Northern California don't want me to leave for another vacation.:rolleyes:
  18. mej.gillies

    mej.gillies Welcome New Poster

    Hi Spod

    I might be able to offer some supervision, I visit NI quite frequently. I've sent you a PM.

  19. blinda

    blinda MVP

    Nice one, Michael :drinks
  20. Spod:)

    Spod:) Member

    Thank you, your thread is very interesting and informative! Perhaps you could have a 'working' holiday in Ireland and run a workshop lol :eek:
  21. Ian Linane

    Ian Linane Well-Known Member

    Great offer from Michael there Spod:). I know Michael and am sure it will be a worthwhile experience.
  22. Spod:)

    Spod:) Member

    Very kind offer indeed! Have explained to Michael i Am operating a Dom clinic at present as have recently relocated. I think I will need a premises before I can practise this technique. In the short term I will refer this patient to another practitioner.

    Am in awe of how helpful all you fellow pods are! This site is very useful :eek:
  23. Rob Kidd

    Rob Kidd Well-Known Member

    For now, please refer to Cochrane: http://summaries.cochrane.org/CD001781/topical-treatments-for-skin-warts

    I know that in the dim and distant past I was in the audience at a presentation where my thoughts to you earlier were presented. Give me time, I will find them - it was 30 years ago.

    All I ask is that we do no harm

  24. We do harm when we withhold or do not offer good treatments for young people with dermatological conditions that can be treated quite successfully with these treatments by assuming that by withholding our treatment it is in the best interest of the patient. Solution? Refer the patient to someone with more clinical success at treating these conditions.
  25. blinda

    blinda MVP

    Hi Rob,

    That latest Cochrane review evaluated the efficacy of only 85 randomised controlled trials and there was a wide range of different treatments and a variety of trial designs. The authors` conclusions were;
    It is true that aggressive cryotherapy was associated with increased adverse effects such as pain, blistering and scarring. Which is why I, personally, do not offer cryo. However, nowhere in the review does it suggest any risk of impaired immunity by treating verrucae.

    A review by Lipke (2006) also states that there is a lack of high quality research;
    Lipke also stated that lack of robust evidence of a therapy which has not been subjected to rigorous scientific testing, does not mean that it is not worth knowing about nor worthy of use in practice, particularly when a specific treatment has been utilised and reported with a reasonably high clinical success rate. It has been stated that the ultimate verrucae treatment should result in resolution of all or a great percentage of warts, be painless, need only one or a part of a lesion treated and create no scarring. In my clinical experience, needling appears to achieve this, in many cases.

    As I intimated in my last post, research into HPV has moved on in the last 30 years. A particularly good paper by Frazer, 2008 (attached) succinctly explains the relationship between HPV and the innate and adaptive immune systems. He stated that successful treatment should stimulate or enhance both the innate immune system and the cellular arm of acquired immunity.

    That said, we obviously do need more robust, high quality trials on treating specific HPV subtypes 1,2 & 4, but I am certainly not harming patients by successfully and painlessly treating their verrucae.


    Ref; Lipke M: An Armamentarium of Wart Treatments. Clinical medicine and research 2006, 4(4):273-293.
    An Armamentarium of Wart Treatments
  26. Rob Kidd

    Rob Kidd Well-Known Member


    I am grateful to you for your thoughtful, and very well informed reply. It may well be that I am out of date. I am referring back to the late 70's and early 80's, where at several presentations it was "more than intimated" that there was evidence that the essential pattern we had of warts being commmon in kids and relatively rare in adults was changing as a result of treatment. And that the incidence of adult warts, so to speak, was increasing. If I am out of date, I will happily capitulate, but just suppose that I am right: would you then agree with me?

    You are clearly well informed about matters dermatological, and I am not - I was a mechanical/anatomical/primatological podiatrist. I have listened hard to your opinion.

    Where in the UK are you? I am due over next year with long suffering wife: buy you a beer?

  27. blinda

    blinda MVP


    I am always open to being corrected, if there is compelling evidence, as indeed I am always open to accepting a beer.

    I'm in Winchester, Hampshire and would love to meet one of own mentors', previous mentor.

  28. Rob Kidd

    Rob Kidd Well-Known Member

    MMMmmm. To Whom are you referring?. Well, there was a lad at Northampton that went on to big things, dermatologically speaking. Did I hear Ivan? He is a good boy................
    Last edited: Feb 17, 2013
  29. blinda

    blinda MVP

    The very same.

    He's not too shabby.
  30. Ian Linane

    Ian Linane Well-Known Member

    Rob, our Bel is good company and does know her beer so good conversation on many levels.
  31. I'm getting a little jealous here...I thought Bel was my groupie!:rolleyes:
  32. blinda

    blinda MVP

    Only 1/3 of me, the other 2/3 belong to Simon `n Joe.

    She danced a while and drank some wine
    Before she rolled her eyes at me
    I picked them up and I rolled them back
    And then we swam into the sea

    She`s alright
  33. I guess I'm just gonna havta learn to share....;)

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