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Case study - VPs

Discussion in 'General Issues and Discussion Forum' started by gl72, Nov 22, 2011.

  1. gl72

    gl72 Member

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    Hi everyone,

    I am a 3rd year pod student and I am having some trouble with a female patient attending our clinics. She is a VP patient and I know that there's no specific treatment for this but I was just wondering what your thoughts were on this specific case I'm so hopelessly trying to resolve (I have been reading some other threads regarding VP treatments - loved the dead cat thing!).

    Mrs X is a 45-year-old chef that has been suffering from plantar VPs for the last 25years. She has diffused VPs on the R/F and multiple mosaic VPs on the L/F, which is in a much worse state than the R/F.

    She has a general good health, no systemic diseases and is not on any prescribed medication. She has not no known allergies and no family Hx of any immunological diseases.

    I'm currently treating with LLLT, had her 5th session with no dramatical resolution although she reports that they're feeling a lot more comfortable. I feel that that might be because of the weekly debridement. She has also started the thuja treatment a few days ago - too early to report outcomes though.

    Mrs X has also tried all of the following treatments:

    Salicylic acid
    Duct tape

    She hasn't tried silver nitrate yet, something that I might propose for the next treatment plan. I am aware of some other treatments that include injecting the sites with a chemical agent but not very sure on those?

    She has now started to get warts on her hands as well so I was wondering when and if it's a good time to reffer her for an immune check. Apparently she doesn't get sick that easy, just had 2 days off work in 2 years as she said. She is currently going through a family issue that's causing some kind of stress but given the fact that she's got them since she was 20 (very young age for the immune system not to be responding and if it was problematic wouldn't it somehow show after 25 years?), I don't think that stress solely is the problem here.

    I would feel much more better if I could reffer her for an immune check but you know NHS - and when you're in uni, you do need to justify every single thing so..

    ..thanks for reading all of my muttering, looking forward to see what you guys think.

  2. MrBen

    MrBen Active Member

  3. W J Liggins

    W J Liggins Well-Known Member

    I would refer this patient to your tutor. 25 years is too long! However, Duct tape does not work any better than placebo - see threads on this site. Salicylic acid alone will not penetrate past the superficial epidermal cells and Bazuka?, well, I suggest that you look up the constituents. Imiquimod is likewise not very penetrative since it's main indication is ano-genital warts. Your tutor may suggest cautery or excision. Mosaic VPs are notoriously difficult to resolve and the best bet may be masterly inactivity.

    All the best

    Bill Liggins
  4. blinda

    blinda MVP

    I agree that further investigation of her immune system is warranted on this occasion. That said, I have had great success with needling mosaic VP`s. Here is an example of one before, during and 8 weeks later;




    Applying a protein precipitant (silver nitrate) is just nonsensensical...... ok, I cheated and edited this into my post, no offence intended Georgia ;)

  5. Brummy Pod

    Brummy Pod Active Member

    Here are some notes from a dermatology update:

    If a patient is immuno-suppressed, you will never get rid of their warts. In a study done, of those who sought treatment, a significant number said that they would not have bothered if they knew what trouble it was going to cause. Also, 35% cleared up anyway regardless of whether they were treated or not.
    Nothing therapy: works, has a success rate of 32%, however, causes no scarring, immunity obtained from using nothing will be lifelong, painless. Any other treatment must have a success rate of 50-60%, to be able to say that you’re treatment is better than doing nothing. Salicylic acid = 62% at any concentration, cryotherapy 50-55%. With cryo, the more aggressive the freeze, the more successful it is, but more likely pain and slower healing. Warts go when they are ready.
  6. blinda

    blinda MVP

    Do you have references for the above? Not doubting you, but I`d like to read the articles where these figures are taken from.

  7. Catfoot

    Catfoot Well-Known Member

    It sounds to me like it comes from an Ivan Bristow dermatology lecture, but I couldn't say which one !


  8. gl72

    gl72 Member

    Hi all,

    thanks for your kind comments.
    I am reading the thread about needling - Kevin Kirby supports it works so I might give it a try. Problem is, do we pods do that in the UK or does it need referral to someone else? I know that we haven't done it at the uni's clinic before and I'm not sure if the NHS trusts do it also.

    Pt can't be referred to a tutor. Pts are the student's responsibilities and they expect us to make justified choices for our choice of treatment :)

    She might even tried needleling because every time I suggest another treatment she remembers she's done it... I'm definately going with immune check up if needling doesn't happen.

    Thanks again for your replies.

  9. gl72

    gl72 Member

    Forgot to mention.

    Electrosurgery or any other form of surgical excision is contraindicated due to the size of the lesions and the fact that it will take long to heal and the patient can't be off from work that long.
  10. W J Liggins

    W J Liggins Well-Known Member

    Yes, podiatrists are uniquely qualified to carry out needling as described. I don't use this technique myself, but Bel and others report good results.

    Is referral not considered a valid part of overall treatment in your school? In both pp and NHS work there are times when it is not only advisable but crucial to refer on to, for example, a diabetologist, vascular surgeon or a rheumatologist. One of the reasons, in my view, for podiatry being regarded as a 'Cinderella' profession is that we tend to soldier on alone when the patient should be referred for their own benefit and the profession would gain respect if more people did so.

    I trust that you will forgive me for being unimpressed by your reason for rejecting certain forms of treatment. If your treatment is justified, then the patient must accept it and make the relevant working arrangements. Of course, she is entitled to reject your advice, in which case she must seek treatment elsewhere. Would the same attitude appertain if she was being treated by a dermatologist or a general surgeon? As a tip for the future, both cautery and excholiation heal well and rapidly since, with skill, the pathology only is treated leaving the epidermis (generally) intact.

    I think that your plan to carry out a blood screen is a good idea. May I suggest that FBC and immunoglobulin levels should be first on the list?

    All the best

    Bill Liggins
  11. gl72

    gl72 Member

    Hi Bill,

    Thanks for the reply. Just a few points here because I might have not made myself clear on what I previously mentioned.

    Referral IS an integral part of our practice, both as qualified podiatrists and as training students. I totally agree with you, a multidisciplinary approach to a problem is many times life-saving than a "selfish" solo approach. Here at my school they teach us how important it is to know how the referring system works, that's why through our training we do referrals to GPs, diabetologists, dieticians, vascular surgeons etc and we attend several placements to see where the patients are referred to. I was specifically referring to the needling therapy, that's why I asked if I need to do a referral for it because I wasn't sure if podiatrists in the UK were to do it. My bad for not making it very clear.

    Also, the patient's foot is almost covered by mosaic verrucae that's why the contraidication for electrosurgery and also, forgive me if I'm being a bit cheeky, I believe that a holistic approach to the patient is much more better than kind of "making" them to choose something we consider good. If it's affecting my patient's wellbeing in terms of physical and emotional status then it affects me as well as a health professional. If she has got a reason that she can't get off work that considers more important than getting rid of the VPs that's fine by me. Having her to take a week of work and being miserable isn't going to help my practice very much.

    Of course, as you said, if that's my last resort for treatment and she doesn't want it then I would def not be able to provide my services to her if she doesn't want.

    Again, I don't mean to be cheeky and I understand that it's impossible to give the whole picture of the patient through a thread. Also, english is not my 1st language so bear with me :eek: still being a student carries a lot of pressure, not only from patients but from tutors as well. Forgive me for still being in the "student mode" of things, hopefully with podiatry arena's help of everyone and some experience I will get better :)

    Thanks again for your tips, I'm so glad I have podiatry arena as a learning aid.

    Best regards,
  12. W J Liggins

    W J Liggins Well-Known Member

    Well then we must disagree. If she has tried everything but excholiation or cautery (leaving needling aside for the moment), and it is your opinion that one or other of those treatments might be appropriate, then you are treating her 'holistically'. If the patient refuses the treatment that is in your opinion appropriate, then that will affect your well being and emotional status as well as hers in that she is till insisting that you continue to treat her using an unsuccessful technique. If she considers that her work is more important than getting rid of the VP, then fine, that is her choice but I suggest that the professional interface has become fractured and you should part company. The question to ask yourself is does she really want treatment? I ask again, if she was being treated by a dermatologist or a general surgeon, would her attitude be the same? If so, then fair enough, she doesn't want treatment. If not then she should expect to have the same respect for you as the other practitioner. Concerning referral, despite their reported refusal to be involved, I would include your tutors as well as outside practitioners. There may well be a paper in a case like this.

    Leaving aside the philosophy, it is usual when faced with very severe cases to treat in areas rather than the whole plantar surface. I think that the bloods will probably show up something interesting. If not, then working with a dermatologist would be a useful learning experience but be prepared, they hate VPs as much as anyone on these pages!

    All the best

    Bill Liggins

    PS. Your English is excellent
  13. gl72

    gl72 Member

    Hi again Bill,

    Thanks for the encouraging comment on my english :D

    My humble opinion as a student is that, given the Hx of the VPs, a needling treatment would benefit this patient more than cautery or excoriation. Yes, I do believe that the later could be beneficial for some patients as there's not a sole effective treatment for VPs, but given the fact that her VPs are VERY persistent, I would go with needling that stimulates the body's immune system to fight off the virus.

    I'd dare to say that the last time I proposed to reffer the patient for a full blood count and antibodies, I ended up getting told off because "it's not cost effective to send every patient with longstanding VPs for bloods". I was then told that I need to justify my choices but apparently facts weren't on my side.

    Believe it or not, this patient has been to the dermatologists and has more faith in our practice to help her.. Also, electrosurgery was considered inappropriate by most of my supervisors.

    Another point - what do you think about the fact that, after 25 years of having the virus active on her feet, she starts getting them on the hands? Would that worry you? I know you'll say that she prob got it from her feet but if that was the case wouldn't the warts on the hands appear long before? I'm really trying to find some good enough reasons to refer this patient for bloods....

    I hate VP's.
  14. blinda

    blinda MVP

    Never heard of him....does he know anything about skin?

    He would have shown the references during his lecture, so I would like to have had the opportunity to check out those figures myself, if Brummy Pod had made a note of them. Never mind, not important.

  15. gl72

    gl72 Member

    Ivan Bristow of Southampton uni is one of the lead people for podiatric dermatology in the UK ;) he has written several papers on dermatological issues of podiatry and published a couple of books as well.

    Remember the CUBED acronym for melanoma? That's Ivan Bristow too. He's published a very nice set of clinical guidelines for the recognition of malignant melanoma on the foot. Very handy.

    Bristow, I.R., de Berker, D.A.R., Acland, K. M., Turner, R.J. and Bowling, J. (2010) Clinical guidelines for the recognition of melanoma of the foot and nail unit. Journal of Foot and Ankle Research, 3:25
  16. gl72

    gl72 Member

    This is what he's got on VPs:

    Potter, M.J. and Bristow, I. (2006) The treatment and management of verrucae using caustics. Podiatry Now, 9, (3), S1-S8.

    Bristow, Ivan R. and Greenwood, Jane (2009) The management of plantar warts - a podiatric perspective. Dermatological Nursing, 8, (3)
  17. blinda

    blinda MVP

    VP stuff

    Sorry Georgia, I was being facetious:eek:. Never carries well in forum speak, I know. (Craig, we really need a tongue in cheek smiley). Ivan and Mike are good friends of mine. But thanks for posting their references, podiatric dermatology can always do with more promotion here. Cheers, Bel.
  18. gl72

    gl72 Member

    Re: VP stuff

    Good one, surely got me :D if you get in touch with them any time sooner, I'd LOVE to have the reference to that bit about VPs and immune system if you're kind enough to ask them. Would look fab in my written piece of work! :)

    Thanks again for the reply,

  19. blinda

    blinda MVP

    VP stuff

    Georgia, i'm doing some research on immunology and HPV with Ivan at the moment. If you PM me your email addy i can send you some references which you may find interesting. Cheers, Bel.
  20. Too bad there is no mention of the very effective needling technique (Falknor GW: Needling-a new technique in verruca therapy: a case report. JAPA, 59:51-52, 1969) in this article for the treatment of verrucae plantaris. It will likely take someone to publish a new article on this technique in a widely-circulated podiatric medical journal in order to correct this error of omission.
  21. W J Liggins

    W J Liggins Well-Known Member

    We await Bel's submission with interest!

    All the best

    Bill Liggins
  22. I would think you are correct on that one. And then a follow up trial with VAS discussion of treatment and recovery I would expect before it gets taught in Schools and used as 1st option re VP´s.

    For those following along and want to read the paper Kevin listed here you go.

    Attached Files:

  23. yep no pressure Bel ;)
  24. gl72

    gl72 Member

    Thank you for posting the papers everyone, I already have the old one for VPs and needling.

    Mr Kirby, as you correctly noted, yes it does underline the need for a new research on the needling therapy since so many practitioners refer to it being so effective. It is very sad that this is not even theoretically taught to us as a potential therapy for VPs - would expect that since it's so widely used. And it could turn into some potential field of interest for pods going with research in the long term.

    Special thanks to Bel for being so kind to send me references.. Thank you Mike for the papers as well, although I got them due to my excessively overloaded with VPs caseload AND my special interest in foot melanoma :)

    Sorry if I'm repeating myself but, how can I justify referring the pt for immunology tests? I had trouble justifying my decision to the tutor. I sometimes think to myself that as good as a clinical practice is in the undergraduate level, it always hides risks of depressing own initiative...

    Anyway, thanks again to everyone for being supportive.

  25. blinda

    blinda MVP

    OK, already!


    When you refer a pt for further investigation, whether it be bloods, US, X-ray, etc, you have to ask yourself how the results of such an investigation will affect your treatment plan. This is part of the justification process that your tutors are asking of you. If the results make no difference to your planned treatment, then they are unlikely to accept the referral.

    Ivan and Julia Schofield (consultant dermatologist of Herts uni) facilitated a good question and answer session at the SCP conference yesterday, during which she acknowledged that there is an increase of VP occurrence in the population today, yet the NHS Pod depts simply cannot afford to treat these, in the main, asymptomatic and self limiting lesions. In particular, transplant patients, who are required to take immunosupressant meds to prevent organ rejection, are developing viral dermatological pathologies which are proving to be challenging in effective treatment modalities. Sometimes, you just have to offer long term palliative care in the form of offloading and callus reduction.

    Good luck with your studies, and more importantly, enjoy them!

  26. gl72

    gl72 Member

    You are absolutely right on what you're saying and I totally understand that. My treatment plan would change depending on the results of those tests. It would be either referring the pt to the appropriate professional if results were positive for any immune problems OR concluding my current plan and discharging. As you said, depending on the patient's status, some kind of palliative care to relieve any symptoms of pain might be needed.

    I understand the point of immunosupressed transplant patients but, that would be already known in the pt's Hx so there would be no need to make any further tests.

    My question is still on: I understand that it is not cost effective to refer every VP patient for bloods, but WHEN do you actually do so? I am kind of confused because yes, you won't need blood for someone you already know they're immunosupressed for some (already known) reason, but when does it get you, as an experienced professional, worried? Because part of our role is to also "catch" things from early signs or manifestations.

    Apologies for keep asking these but I do need to clarify it in my head. Still blurry I'm afraid :(
  27. blinda

    blinda MVP

    Maybe the language barrier is getting in the way here but, are you saying that dependant upon the results of blood tests, you would either;

    a) refer the pt to a dermatologist/immunologist, i.e. the `appropriate professional`, which I presume you allude to, for them to deal with or,
    b) discharge the pt? (very NHS ;))

    Respectfully, I would suggest that neither of the above is an appropriate nor realistic podiatric treatment plan. In an ideal world, it would be fantastic if we could refer every pt whom, whilst in `general good health, no systemic diseases` (your initial description) to dermatologists for recalcitrant verrucae..... but it just aint gonna happen in the NHS, for the reasons I outlined before. VP`s are not regarded as high priority in the grand scheme of things, and I tend to agree with this philosophy, to a degree. That is why palliative care is often required, largely by the podiatric private practitioner, as the NHS don`t `do` VP tx.

    In answer to your question of when to refer for bloods, I would say that you have to judge each case according to its own merit. In this case, 25 years of progressive HPV manifestation could indicate immunological defects, but you do have to appreciate/respect the appropriate referral pathways and criteria and explicitly explain this to your pt.

    Hope that helps!
  28. gl72

    gl72 Member

    Funny thing, the phrase "in an ideal world..." comes up very often :p

    That has made things crystal clear now. Thanks for the clarifications Bel! I assume some things just come up with experience (trying to comfort myself here...).

    Thanks again, you've been super helpful!

    Georgia :)
  29. R.E.G

    R.E.G Active Member


    No one seems to have picked up on this thread?

    Plantar warts treated with topical adapalene 8th Nov.

    Seemed interesting to me.

    As far as needling goes one small study was published in the Society journal showing around 50% success, which is about what I got on the very few I did, so have reverted to the more conventional blunt dissection.

    I eagerly await your results.

  30. blinda

    blinda MVP

    Hi Bob,

    Yeah, interesting indeed. Problem is that whilst Adapalene and other inflammatory modifiers, such as Imiquimod, have certainly been seen to promote HPV resolution, they can only be used off label as they have not been approved for podiatric use....yet. Therefore, GP`s are VERY reluctant to prescribe these for VPs.

    50% success of needling a few (or 14) VP pts doesn`t really lend itself as a significant result to extrapolate. I`m using rather more than a few subjects, but it`s still a long way from publication at the moment.


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