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Help with a larger plantar VP

Discussion in 'General Issues and Discussion Forum' started by walkwell, Aug 25, 2010.

  1. walkwell

    walkwell Member

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    Hi guys,

    I need help!

    I have a lady visit the clinic on a regular basis to have her verruca treated, she first visited the clinic in May 2009 presenting with a large plantar verruca on the Right 3rd metatarsal head.
    The verruca has been present for several years prior to her visit and became very painful to walk on. I have been using cryosurgery to treat the verruca.

    After several weeks of treatment with the cryo the verrca began to decrease in size however, this was very slow.

    In November 2009 the patient found a clot in her politeal artery in the right leg, and subsequently now takes warfrin.

    After January 2010 the patient did not return to the clinic until August 2010 after suffering another clot however in the femoral artery on that occasion. Her INR levels fluctuate on a daily basis from 1.5 to 4.

    After such a long gap between visits you can imagine that the verruca has doubled in size, I have measured it - 2cm x 1.5cm, it has become very painful and is very hard to treat. Removing the callous alone is extremely painful for the patient and after 5 cryo treatments the verruca still appears to be the same size if not getting larger.

    Has anyone got any suggestions into this matter?:wacko:

  2. Hi Vicky have you read this thread about needling tech for VP´s ?

    Might be something to consider, I guess an important question if around the problem with clots and blood supply and if the needling technique is a good idea, maybe a discussion with her GP or specialists ?
  3. Some photos would help. Needling should still be possible.

    The other thing, given the history, how certain are you it IS a vp?
  4. twirly

    twirly Well-Known Member

    Hi Vicky,

    For my take, given the history of previous arterial blockage (& potential for complications) I would be inclined to refer on to dermatology.

    Their arsenal of available treatments (& insurance cover) is greater than mine.

    Just my thoughts.


    Kind regards,

  5. walkwell

    walkwell Member

    Hi all,

    Thank you for your replies. We do perform dry needling for verrucas but were wary in this case because of the tendency of the lady to have thrombosis and also because of her anti-coagulant therapy.
    The lady is due to return to the clinic next week and we will take a photo and post it for all to see although we are sure the lesion is a verruca.
    I think you made a good point about referral to a dermatologist Mandy and that may possibly be the best course of action, however, I would like to see if we can sort it out if possible .

  6. Paul Bowles

    Paul Bowles Well-Known Member

    Vicki have you considered oral tagamet? (Cimetidine)

    300mg a day for 3-4 months may assist if you have concerns about other more invasive therapies.
  7. walkwell

    walkwell Member

    Hi Paul,

    Thank you for the suggestion, I hadn't considered tagamet as it is a presription only medicine here.

    This is the first verruca that I have come across where cryotherapy has not treated or at least showed signs of treating the verruca.

    I think not before too long I will consider referring this patient on, I just want to explore all avenues before doing this.

  8. Paul Bowles

    Paul Bowles Well-Known Member


    get your local GP to write a script for your patient - its an S4 available on PBS in Australia as well and our local GPs have no issue helping out writing scripts for it. Its a decent last resort for a large VP you don't want to or cannot:

    a) stimulate a good enough immune response with localized cryo/acid therapies

    b) surgically remove via sharp/blunt curettage.

    Good luck!
  9. blinda

    blinda MVP

    I agree with Paul,

    One pt I had presented with extensive mosaic VP of 10 year+ duration did not respond to initial needling tx. She then had a second bash along with oral Cimetidine.

    This combination therapy worked, but interestingly the lesion/area which resolved first was the one which I needled. Resolution of both feet followed thereafter.

  10. chs

    chs Welcome New Poster


    Just happened to see this. Have you thought about marigold Therapy? Very effective, painless can take awhile.

  11. DaVinci

    DaVinci Well-Known Member

    You can't be serious? Placebos take a while to.
  12. Julian Head

    Julian Head Active Member

    I would give needling go - you can use old fashioned ferric chloride to stem any bleeds but in my experience warfarin patients are fine with needling and do not need to rest (reducing the dvt problem). Kaltostat seems to mess it up and set like concrete.....
  13. Nina

    Nina Active Member

    The only trouble with Marigold Rx is that you need to go on one of their courses to be able to obtain it.

    I was using it very successfully in the 1990's after no more training than a lecture at a one day conference, it works very well on intransigent mosaic vp's.
    I used to work in a hospital where the dematologist refered me the pt's who didn't respond to his Rx and gave him grief, the 'buck' stopped with me, so if the cryo the'd been refered for didn't work I could try what ever I liked.

    After 10yrs of working part time or not at all due to child rearing, I returned to full time work in private practice to discover I could no longer obtain the Marigold treatments with out undertaking their course. The cost in time and travel doesn't make it ecconomically viable.

    I do find needling very satisfying and when it works it's brilliant. Probably not suitable for a Pt on anticoagulants. Have you tried Thuja? that's another homeopathic remedy that I've had success with in the past. I don't care if it's mumbo jumbo witchcraft or good old placebo, if it works you get the credit.

    There's an old saying 'The art of medicine is in occupying the patient whilst nature takes care of everything'

    Good luck

  14. walkwell

    walkwell Member

    Thank you for all of the replies, this patient is due to attend the clinic tomorrow. I will take some pictures and post them for you all to see (consent permitting).

    I will talk to her about the homeopathic remedies, we do not have any experience with marigold treatments or any other homeopathic remedies. I will definitely look in to them though.

    I have treated it 3 times with cryotherapy so it will be interesting to see if there has been any difference made on this occasion as the last 2 visits the verruca seemed to be growing in size rather than decreasing.

    Thank you all again for your suggestions.

    Julian, I am fascinated to hear of your experience of dry needling patients taking warfarin, we have not been performing dry needling on patients long and have chosen patients with no medical complaints. I am now tempted to consider dry needling based on your experiences.

  15. I would not think twice about performing a needling procedure on someone on anticoagulant therapy. Just put on a few extra 4 x 4's with a compression bandage to the needling site and have them leave this on for 12 hours, and this should minimize any bleeding. Remember that when someone is on anticoagulants this doesn't also mean they won't clot....it just takes longer to clot.
  16. Michfoot

    Michfoot Welcome New Poster

    Hi vicky

    3rd year podiatry student here. Just to let you know that we have been notified that dermatologists will no longer treat any form of verruca and ask that we do not refer any cases on to them.

    Have you thought about duct tape? I understand that it has to cover the lesion for 6 weeks to be effective. I know I am not qualified but have read that it can be effective. It worked on my friend's son when I applied the duct tape to his verruca on the dorsal aspect of his left third for a week.

    Good luck

  17. DaVinci

    DaVinci Well-Known Member

  18. walkwell

    walkwell Member

    Hi Kevin, thanks for your post. That is really encouraging and gives me more confidence to try needling after all.
  19. walkwell

    walkwell Member

    Thanks Michele, useful to know dermatologists have given up on VPs.
    Never had any VP resolutions from duct tape, but obviously it worked for you.
    After Kevin Kirby's post will probably try needling, will post how we get on.
  20. toughspiders

    toughspiders Active Member

    Hi Blinda

    I note you say combine needling with oral cimetidine, are you using an LA for the needling? Or are you needling and then asking the patient to take afterwards. I was under the impression that combining the two increases the risk of toxicity? Is that so?

    I have a pt who has a persistent one to the plantar calc area and would like to give both a go and wish to know the safest way?

  21. blinda

    blinda MVP

    Hi Toughspiders,

    Yes, I use either local infiltration or a post tib block, depending on the site of the lesion that I want to needle.

    The pt in question happened to be a GP (great for me as i receive referrals from her now:cool:) so she took self prescribed oral cimetidine later in the same day of the needling.

    I am unsure about increased toxicity, but cimetidine is reported to act as an immunomodulating agent by inhibiting suppressor T-cell function and increase lymphocyte production, so can, in theory, enhance a cell-mediated immune response. Seems to have worked in this case.

    Last edited: Sep 27, 2010
  22. toughspiders

    toughspiders Active Member

    Thanks Blinda, may give it a go.

    How are people anaesthetising the areas...

    This one in particular is dead central plantar calc , im guessing the way to go would be a tibial nerve block & possibly the sural. Or would i need to do a full ankle block?

    Is a long time since i did one of these. :(

    Im thinking of buying the Injection Technique book (metcalf and reilly).. anyone know if its any good.

    How do people brush up on their ankle blocks???

  23. Same as when you learnt at school.

    Theory ie the book you mention by Ian Rielly.

    Demo or 2 from someone who does them alot.

    Then Injection with guidence the 1st time ( mate, loved one or a mate who´s giving the sh!ts)

    practice on mate, loved ones etc.
  24. W J Liggins

    W J Liggins Well-Known Member

    im guessing the way to go would be a tibial nerve block & possibly the sural. Or would i need to do a full ankle block?

    Hello TS

    A single tibial block will be fine for central calc/plantar.

    Don't forget to tell them to bring a mate or loved one to give a lift home. (People such asRobert, Belinda and Mike can probably afford a chauffeur)

    All the best

  25. Haven´t done an injection in 4 years myself - not allowed to by Swedish law as I´m not an MD one of the more crazy things that have reduced my scope of practice , bu there you go.
  26. toughspiders

    toughspiders Active Member

    Thanks Michael, Bill

    Billy no mates me! Plenty id like to stick needles in though and i can think of more interesting places than their feet!!! I may take up Voodooism instead :)

    I need to find someone locally i can cribb off. In the UK this would be so easy!

    I think there are only a few Pod Surgeons here in Brisbane and im guessing that not a lot of Pods here do them regularly. None that i have met so far have.

    Anyone in Brisbane who would allow me to observe/partake would be grateful. Beg
  27. W J Liggins

    W J Liggins Well-Known Member

    If my experience of Oz is anything to go by, just shout 'free beer' and mates'll be pouring out of the woodwork - and that's just the Sheilas!

  28. I give plantar heel cortisone injections nearly daily using ethyl chloride spray. The needle stick on the skin is usually painless using this technique.
  29. blinda

    blinda MVP

    :pigs::rolleyes:...still have 2 years to go on my student loans and waiting for a kindly pod surgeon to `do a deal` to remove my dorsal osteophyte!
  30. W J Liggins

    W J Liggins Well-Known Member

    Be happy to help. I've never carried out a Chopart's amputation and will look forward to it.
  31. blinda

    blinda MVP

    That would certainly put a stop to my impending hallux rigidus...which is Nice. ;)
  32. ajs604

    ajs604 Active Member

    Hey Michele - I have tried duct tape before on a friend and the lsion dispered very quickly. i have not used it in my professional practice though. I normally apply silver nitrate or salycic acid and have had very good results with them.

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