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Cutaneous Warts: An Evidence-Based Approach to Therapy

Discussion in 'General Issues and Discussion Forum' started by admin, Aug 17, 2005.

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  1. admin

    admin Administrator Staff Member


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    Cutaneous Warts: An Evidence-Based Approach to Therapy

    Full text article from American Family Physician

    Full article
     
  2. Scorpio622

    Scorpio622 Active Member

    Does anyone have experience with the stronger acids and canthrone? We were using the pulse dye laser with success but insurance companies stopped covering it. I am now considering alternatives and would love to hear about other experiences/ treatment regiments. I just ordered cantharone plus and monocloractetic acid.
    Thanks,
    Nick
     
  3. Don ESWT

    Don ESWT Active Member

    To All,
    I use a combination of Salicylic acid and Monochloroacetic acid. This method has been used for over 65 year in Wollongong by my dad and myself.
    On Friday last I removed a 15mm diameter by 10mm deep vp.
    With mosacic warts I have seen excellent results using laser. There is a Podiatrist in Charlestown using laser.

    Don Scott
    Australia
     
  4. Matt Dilnot

    Matt Dilnot Member

    What's the justification for using the combination of acids? I've always wondered how someone came up with that idea. Why not combine 4 or 5, plus some formalin and gluteraldehyde?

    Matt
     
  5. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Everyone has their favourite treatment for VP's that they have a passion about in their support of it ---- remember that law of mine? .... ""The amount of passion involved in supporting a theory and the amount of emotional attachment to a theory is inversely proportional to the amount of evidence for that theory"

    At least the article linked in first post is an attempt to review the available evidence sensibly.
     
  6. One Foot In The Grave

    One Foot In The Grave Active Member

  7. Don ESWT

    Don ESWT Active Member

    Craig & Matt,
    History on Mono 100% and Sal 66% used on warts dates back over 100 years and when William Crawford Scott M.Ch.S. my dear old dad introduced it to Wollongong in 1949. (He was also ships Medical Officer WW2)

    The combination of only TWO chemical helps to remove a vp that is up to 15mm diameter and up to 15mm deep.

    TREATMENT
    Day 1 Say Monday apply chemicals, Day 2 Friday remove vp intact no vascular involvement, Day 3 Monday final dressing patient walking normally final debridement. I have over 15,000 happy patients in the Wollongong region.

    Laser works very well on mosacic virus warts up to 75mm * 75mm * 8mm deep

    Craig, you are a uni lecturer, do you not teach students in the technique of chemical therapy for the removal of plantar warts using the above technique.

    Has research into a vaccine been implemented so that we can inject and kill the virus and then there would be no need for our hacking and slashing or has it been put into the too hard basket.


    There is no painless way to remove a plantar wart within 1 week without the use of G.A. or L.A and NO SCARRING. If anyone out there knowns a painless way let me know because I will direct people in the right direction.

    Don Scott
    Wollongong
     
  8. Don

    Merc have succesfully trialed Gardasil which is a vaccine against HPV, predominately aimed at prevention of cervical cancer (CIN I, II & III). I'm not sure how effective this would be at clearing lesions which are already established but we may see a reduction in the incidence of VP's in immunised men & women if the drug is licensed for use.

    Many years back I did a series of clinical trials to guage the effectiveness of different types of cryosurical units in the treatment of plantar verrucae. Prior to using cryosurgery, a combination of mono crystals and salicylic acid was a common preparation for selective patients, however, like many chemotherapeutic applications, the results were unpredictable and sometimes quite painful.

    In my experience, post operative chemical ablation scar formation only occurs where the treatment has been excessive and where the tissue breakdown has denuded the collagen fibre network severely. Scar formation rarely occurs with cryosurgery but usually always with vapourisation by CO2 laser.

    Mark Russell
     
  9. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    I will have to fess up and admit that I have no idea what we teach the students....I avoid that part of the course like the plague. When, on the rare occasion, that a VP turns up in a clinic I am supervising, we mostly tend to use liquid nitro.
     
  10. Don ESWT

    Don ESWT Active Member

    Mark,
    Thanks, it is about time a vaccine was available for vp treatment
    Pain is always involved with mono and Sal and I always advise the patient. As I say to them, "Short time pain but a long time gain". Without treatment and depending on location of vp it can affect gait and be debilitating.
    No scarring with the chemical therapy treatment
    Cica Care may help reduce the scarring.

    Don Scott
     
  11. Gardasil and Ceravix protect against two strains of HPV 16 and 18, which are specific in cervical intraepithelial neoplasia. There may be a positive effect for VPs however skin infections tend to be HPV-1, HPV-3 and HPV-6. Whether or not the vaccine would have any preventative effect for VPs is debateable, however it is encouraging that drug companies are researching this area in virology and who knows, maybe we'll get a specific VP vaccine at some point in the future. But at what cost? Don't discard the sal and mono just yet!

    Mark
     
  12. Kirsti

    Kirsti Welcome New Poster

    I get great results with the under 10 age group using Duct Tape therapy. The parent applies duct tape (cut just bigger than the VP) to the wart and it remains intact for 6 days. On Day 7 the parent pumices the area and reapplies the duct tape. This is continued for 4 weeks and reviewed by myself. In most cases the wart is gone in 4 weeks although in about 25% cases it takes 8 weeks. Believe it or not since introducing into our clinic two years ago I haven't had a failure in the under 10's.
     
  13. Don ESWT

    Don ESWT Active Member

    Kirsty,
    What about the rest the over 10's and the under120's

    What about the cross contamination using the pumice stone spreading the virus to other pores in the skin via micro abrasion of the skin. (the virus is only 1 nm in diameter)

    Don Scott
     
  14. Homeopathy can be very useful, especially in childen, who will respond to one of several remedies, given orally, which are indicated for warts. Adults are harder due to having a more complicated pathological 'history'. It would be best to refer them to a homeopath. Thuja tincture is widely used in the UK, applied topically, but again it tends to work better on children.
     
  15. Don ESWT

    Don ESWT Active Member

    Malcolm and all,
    Excuse my ignorance, but what is "Thuja tincture" what is its chemical makeup. Is it a base or acidic?
    The old saying, is it animal vegetable or mineral?

    Duck Tape - Previous post by Kirsty said to work well on under 10's.
    The Tape must have some type of adhesive on it therefore it has an aclusive effect. The tape is non porous therefore cutting off the oxygen supply to the outer skin. Again the chemical in the tape will react causing some maceration..

    We must tell our patients what the physical size of the vp is. They are a hard mass and in some ways could be classified as a benign tumour

    Dermatologically - they are situated in the upper 3 layers
    incubation is 1 month to 20 months
    the virus survives -25 degrees C to +55 degrees C
    the size of the virus is 1 millionth of a millimetre (only see by electron scanning microscope

    Don Scott
    Podiatrist
    ESW Therapist
    Australia

    See you in New Zealand
     
  16. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    I am already here - watch for the daily updates....

    CP
     
  17. summer

    summer Active Member

    I have had GREAT success using BLEOMYCIN recently. It generally takes only one treatment and the wart "dies" within 1 week. I have yet to have to repeat the therapy on any patient. Over the years I have tried everything from Cantherone, to Sal acid, to Phenol, to cryotherapy and lasers. I did use Aldara and duct tape for a while, and while it is effective it does take weeks to resolve wheras the BLEOMYCIN is usually a one "shot" treatment. It is injected in very dilute amounts directly into the wart. Let me know if there is any interest in trying this therapy, as I will forward the technique and dilution, and please note that a quick internet search will lead you to many articles regarding this therapy.
     
  18. Don,
    Thuja Occidentalis is an evergreen shrub, found in many gardens.
    A tincture is made from the leaves by a homeopathic pharmacy and it is this that is applied undiluted onto the wart. I am unaware of the chemical composition.
    The tincture is also diluted many times to produce a 'remedy' which can be taken orally to stimulate the immune system to reject the lesion.
    Homeopathy is said to work by treating like with like ie. any substance that produces disease can be given in highly diluted form, below the toxic level, and it will have the opposite effect, curing those symptoms which it produces in toxic doses.
    So if you ingested the undiluted Thuja tincture, you are likely to eventually produce warts, amongst other things.

    Summer,
    I am interested in your Bleomycin technique.

    Hope to see you in Christchurch.
     
  19. Mel

    Mel Welcome New Poster

    Local treatments for cutaneous warts
    S Gibbs, I Harvey, JC Sterling, R Stark
    The Cochrane Database of Systematic Reviews 2005 Issue 3

    Main results
    Fifty two trials were identified which fulfilled the criteria for inclusion in the review. The evidence provided by these studies was generally weak because of poor methodology and reporting.

    In 17 trials with placebo groups that used participants as the unit of analysis the average cure rate of placebo preparations was 30% (range 0 to 73%) after an average period of 10 weeks (range 4 to 24 weeks).

    The best available evidence was for simple topical treatments containing salicylic acid, which are clearly better than placebo. Data pooled from six placebo-controlled trials show a cure rate of 144/191 (75%) compared with 89/185 (48%) in controls, odds ratio 3.91 (95% confidence interval 2.40 to 6.36), random effects model.

    Most of the bigger trials of cryotherapy studied different regimens rather than comparing cryotherapy with other treatments or placebo. Pooled data from two small trials that included cryotherapy and placebo or no treatment, showed no significant difference in cure rates. In two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy no significant difference in efficacy was demonstrated.

    There was no consistent evidence for the effectiveness of intralesional bleomycin. Four studies, using warts rather than individuals as the unit of analysis, had widely varying results which could not be meaningfully pooled.

    There was some evidence for the efficacy of dinitrochlorobenzene, a potent contact sensitizer. Pooled data from two small studies comparing dinitrochlorobenzene with placebo showed cure rates of 32/40 (80%) and 15/40 (38%) respectively, odds ratio 6.67 (95% confidence interval 2.44 to 18.23), random effects model.

    Only limited evidence was found for the efficacy of topical 5-fluorouracil, intralesional interferons and photodynamic therapy.

    Bleomycin, dinitrochlorobenzene, 5-fluorouracil, interferons and photodynamic therapy are potentially hazardous or toxic treatments.

    Authors' conclusions
    There is a considerable lack of evidence on which to base the rational use of the local treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy and some evidence that it is only of equivalent efficacy to simpler, safer treatments. Dinitrochlorobenzene appears to be effective but there were no statistically significant differences when compared with the safer, simpler and cheaper topical treatments containing salicylic acid. The benefits and risks of 5-fluorouracil, bleomycin, interferons and photodynamic therapy remain to be determined.

    * I guess the simpler the better!
     
  20. Felicity Prentice

    Felicity Prentice Active Member

    Some very fascinating discussion going on. I will free associate a bit, and respond at random...

    I had have some experience with dinitrochlorobenzene, and for some it works, and for others it causes a godalmighty rash and reaction. Plus there is some question about carcinogenesis, so I have abandoned it.

    As for why the combination of sal acid and monochlor - I was always taught that the sal acid, being a keratolytic, disrupted and macerated the tissue (especially the hyperkeratosis associated with plantar VP's); and the mighty monochlor crystals took the opportunity to get in there and do their caustic nuisance on the tissues, including those containing the virus. The only problem is that sal acid is water soluble, so if the area isn't kept dry you can get a meltdown the size of Chernobyl.

    As to duct tape - yep, I suspect the occlusive nature of the tape is the secret of the treatment, and thus the resultant maceration is the basis of success. However, I have also had success in children using banana skin (cut to size!) and waterproof dressing. I doubt the banana skin has any therapeutic value, but it sure causes some interesting discussion.

    The suggestability of warts ("wishing them away") has a strong track record (sorry no RCT's yet!), especially in children. But I can also report the successful use of hypnotherapy in an adult to treat warts. Fellow graduates of mine from Lincoln Institute might recall the patient who attended regularly for debridement of warts that pretty much covered the entire plantar surface of both feet (not mosaic types, the full catastrophe). An attending doctor to the clinic, who had an interest in hypnotherapy, used suggestion to treat these warts. After about 6 treatments, we began to see a real and genuine reduction in the number, size and distribution of the lesions. We then lost contact with the patient, so I guess we will never know.......

    cheers,

    Felicity
     
  21. summer

    summer Active Member

    Felicity

    Interesting about wishing them away. I had heard a story years ago about that. About 10 years ago, I had a young girl who was peppered with them. On a hunch, I scheduled her for laser exicision but made sure to tell her it would be rather painful, and she would have to be put to sleep for it. She was scared to "death", but showed up at the outpatient center for removal and laser excision. Lo and behold, when I arrived in thr morning, the nurses asked me where the warts were, I couldn't believe it, but they were ALL GONE!

    We let the girl go home, but I was at a loss to explain it to the family, but did give them the only explanation I could. They got scared and ran away. Never happened to me since!
     
  22. Hylton Menz

    Hylton Menz Guest

    Re hypnotism and warts:


    Spanos NP, Stenstrom RJ, Johnston JC. Hypnosis, placebo, and suggestion in the treatment of warts. Psychosomatic Medicine 1988 May-Jun;50(3):245-60.

    Two experiments assessed the effects of psychological variables on wart regression. In Experiment 1, subjects given hypnotic suggestion exhibited more wart regression than those given either a placebo treatment or no treatment. In Experiment 2, hypnotic and nonhypnotic subjects given the same suggestions were equally likely to exhibit wart regression and more likely to show this effect than no treatment controls. In both experiments, treated subjects who lost warts reported more vivid suggested imagery than treated subjects who did not lose warts. However, hypnotizability and attribute measures of imagery propensity were unrelated to wart loss. Subjects given the suggestion that they would lose warts on only one side of the body did not show evidence of a side-specific treatment effect.​
    Spanos NP, Williams V, Gwynn MI. Effects of hypnotic, placebo, and salicylic acid treatments on wart regression. Psychosomatic Medicine 1990 Jan-Feb;52(1):109-14.

    Subjects with warts on their hands and/or feet were randomly assigned to a hypnotic suggestion, topical salicylic acid, placebo, or no treatment control condition. Subjects in the three treated groups developed equivalent expectations of treatment success. Nevertheless, at the six-week follow-up interval only the hypnotic subjects had lost significantly more warts than the no treatment controls. Theoretical implications are discussed.​
     
  23. Felicity Prentice

    Felicity Prentice Active Member

    Here's a quick question. Why do we treat warts? Are there established rates of cross contamination - are these high enough to warrant iatrogenic ulceration in an otherwise healthy patient? Granted, VP's on the plantar surface can cause discomfort...but elsewhere, are they worth treating, especially in children (where there is often spontaneous resolution).

    cheers,

    Felicity
     
  24. Angel

    Angel Member

    I know a man who had multiple warts on both hands, they disapeared overnight after using a weedkiller the day before. Could this be the next trend for the treatment of warts?
     
  25. C Bain

    C Bain Active Member

    Hi Angel,

    Yes, only if they fall off the next day, complete cure! Hands I mean not the warts!

    Regards,

    Colin.
     
  26. Angel

    Angel Member

    Hi Colin

    OK, I know, I should of said" the warts disapeared".

    But be grateful, I actually understood your post!!!!.
     
  27. C Bain

    C Bain Active Member

    Hi Angel,

    You see miracles never cease!

    Regards,

    Colin.
     
  28. podrick

    podrick Active Member

    bleomycin injection?

    hello,
    i saw bleomycin used once during my residency and read up on its efficacy.however,since it is a chemotherapy agent is there any problems with its indications for vp.
    how do you dilute it for vp injection?

    thanks
     
  29. Cameron

    Cameron Well-Known Member

    Netozens

    Sorry for coming into the discusion late. The mix of sal acid and monochloracetic acid is described in Reid's Therapeutics or Le Rosignol's Pharmacopae. Both substances have different actions and act together as an irritant to cause an epidermal blister (called breakdown in the old text). Salaculic acid breaks down the side salt linkages and traps water making the kerin pliable and unstable. Mono is a caustic which destroys the keratin. Together to focus the action specific to the wart and accelerate irritation locally. Care is required to centre the chrystal, otherwise there is indescriniate destruction of the skin (burn). When used on healthy feet the combination usually achieves a beneficial outcome.

    Most traditional chemical verrucae treatments involve encouraging separation of the infected stratum spinosum and in the case ot irritants by creating an epidermal/dermal blister. This can be done in a variety of ways both chemically and physically. Thuja and formalin are astringents and take longer to achieve an outcome.

    Little has been published on systemic antivrial treatment for warts, although some chemical compounds are thought to be antiviral eg povidone iodine.

    Cameron
     
  30. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Evidence

    Topical 5% 5-fluorouracil cream in the treatment of plantar warts: a prospective, randomized, and controlled clinical study.
    J Drugs Dermatol. 2006 May;5(5):418-24
     
  31. martinharvey

    martinharvey Active Member

    Late as usual

    Cameron

    Le Rosignol's Pharmacopae.

    I thought I was the only one on the Planet with a copy of this little red book on his surgery shelf. I think mines around 1947. Interestingly they advocate Cannabu Cannuba as a specific for heloma neurovasculare. Pass the Ganja anyone?

    Regards, Martin
     
  32. gush_horn

    gush_horn Member

    Any thoughts on this? would a better solution be to debride the verruca using scalpel? reducing chance of cross contamination

    also was wondering on thoughts for Rx of a diabetic pt with verruca? Would say the use of a lower concentration salicylic (25%) be used? Or begin with something like duct tape occlusion therapy?
     
  33. Cameron

    Cameron Well-Known Member

    gush_horn

    As far as I am aware the virus replicates in the Stratum Spinosum and the keratinous layer lies above it. Removal of the hyperkeratosis would not in the normal course of events expose the Spinosum, so the risk of cross infection by whatever means would be minimal. Especally when the skin is prepared with an antimicrobial agent. A sterile scalpel would be an added advantage.

    Since the purpose of chemical treatments with caustics is to cause a dermal/ dermal-epidermal blister usually referred to as breakdown, it would be important to ascertain whether the diabetic person has normal healing rates. Prolonging treatments with milder percentages may have no advantage, whereas a short sharp trauma to the skin more beneficial. In the event of poor healing rates, alternatives (including no treatment) would need to be found.

    toeslayer
     
  34. Don ESWT

    Don ESWT Active Member

    When using a scalpel across the surface of the wart you will alway have vascular involvement.
    If you cut into the wart you will have vascular involvement and the Kobner effect has been known to occur unless deep penetration occurs, then scarring will occur.

    Cross contamination occurs on a daily basis with the tranferance of the viral particles from person to person at pool gyms etc or how else would we be treating this virus on a daily basis so it cannot be stopped with a sterile scalpel blade?


    Toeslayer is correct with the comments in his last paragraph.

    Don Scott
     
  35. gush_horn

    gush_horn Member

    When taking an evidence based practice approach, can the use of any other treatment other than salicylic acid be supported as a front line option? (based on the Cochrane review)

    completely agree with the at risk comments. The cautious approach with compromised pts makes complete sense. Is there an issue of (spontaneous) breakdown of verruca in people with compromised vascular supply?
     
  36. perrypod

    perrypod Active Member

    Clinical hypnosis, acupuncture, local and constitutional homoeopathic prescribing even changes to diet........ a brief consideration of research indicates horses for courses. Is it luck or judgement? Do they go away, or disappear only to return in a similar fashion to cold sores? Or are they stress induced or related?
    Getting them free of pain is 9/10ths. the battle won. Or is it?
     
  37. perrypod

    perrypod Active Member

    Firstly, a simple question regarding VP's:-
    Is treating the pain 9/10ths. the battle won?
    Inter alia I have been involved with clinical hypnosis. I have been hypnotised several times myself and found it a very relaxing experiance. It is a useful modality with broad applications and can be used for treating many skin skin disorders. Also it can be used to induce analgesia. There are numerous books and articles on it's application. If used responsibly it is also safe with no detrimental side effects. I have started to use it alongside complementary and also conventional treatments.

    Remember:- Life and practice is one long trial and the jury seems forever out.
    best wishes
    Colin
     
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