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Hi all
I've been treating a 30 something fit healthy male, for three 1cm dia verrucas for about 3 episodes now, along with this the pt had what looked like a corn to the R5th mpj I enucleated it and it seemed fine. He came back about 3wks later saying that the 'corn' had been hurting. Checked the area again and it was very painful to palpate on direct pressure, I debrided some callous away and the lesion had the appearance of a verruca, although when I wiped vertically over the lesion with cotton wool the pt said it really hurt almost like there was a foreign body present. I was convinced that there was a foreign body and advised trying magnesium sulphate to try and draw whatever it was out. The pt attended last week still in pain - I should add that throughout this treatment the area has never been red, hot, swollen. Again there was callous formation which I debrided and on closer inspection there were 5-6 almost like little spines or whiskers protruding out of the lesion ( I'll try and upload a photo ) this appears to be the cause of the foreign body feeling! I have never seen anything like this, one other thing that may be of significance is that the pt was on hols in Thailand about 2-3 months ago - he doesn't remember treading on anything but couldn't rule it out!

Help would be appreciated and where to go next????

Thanks

Marc London ( bartypb )

 

That'll be an HPV-1. Vacuolisation throughout the entire thickness of the epidermis renders this painful on WB. The 'whiskers' are thrombosed capillary loops, which are dragged to the stratum corneum during proliferation of virally infected keratnocytes.

cheers
Bel

 

One of my personal favourites the type 1 ;):dizzy::eek:

Can we have a photographic guide to verrugon types here please for numpties like me?

 

You're not taking this very seriously, are you Dr Spooner? Anyway, I thought you were more partial to an HPV-7?

I'll see what I can do...

 

Thanks for that blinda, what would be your treatment regimen if it's full thickness would cryo be worth a go or would you needle the lesion?

Thanks in advance

Marc

 

Hi Marc,

The latest Cochrane Systematic review revealed little high quality evidence of effectiveness of MOST wart tx: http://summaries.cochrane.org/CD001781/SKIN_topical-treatments-for-skin-warts

Figures bandied around for non-genital warts are;

– 52% Effectiveness Salicylic Acid
– 54% Effectiveness Cryotherapy

But, remember those figures include hand warts (and other body parts) where the epidermis is not as thick as the plantar surface.

Personally, I rarely utilise cryo for a couple of reasons. To be effective is has to be rather aggressive (read liquid nitrogen) which can smart somewhat. There is also some evidence of increased risk of adverse effects such as blistering, and scarring, dependant on practitioner application/training,etc.

That said, I stumbled on this old, but interesting ;) post written by Mark some years ago, where he highlighted that cryo produces a tissue specific response and "Evidence shows that cell destruction by freezing is accompanied by antigen formation through the liberation of lipoproteins from the cell membrane", which (in theory) can produce the required cell-mediated global immune response to eradicate the virus, as with needling. http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=6873&postcount=2

I have had some success with needling this sub-type of HPV, but will also curette the pulpy lesion (post needling) due to the extensive vacuolization which renders it more difficult to treat.

Cheers,
Bel

 

Not sure if this is gonna work, but I`ll try to upload some slides from one of my presentations. Bear with....

Taken from a post I wrote a few months ago, which goes into a little more detail on HPV and risks to consider; http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=97416

...the HPV sub-types associated with hand warts and verrucae are described as;
HPV-1 (single) is notoriously difficult to treat as it creates a huge amount of vacuolization – resulting in the rubbery, macerated texture and far more disturbance of cell differentiation through the entire thickness of the epidermis than HPV-2 & 4.
HPV-2 (mosaic) produces some vacuolization in the spiny and granular layers, leading to a honeycomb-like picture on histology as it proliferates. This is probably the most superficial sub-type, so could explain a higher success rate with most treatment modalities.
HPV-4 (multiple) causes a thicker granular layer only, but results in a more compact horny layer....

Ok. Couldn`t upload individual slides, so I`ve attached a taster of the presentation. You`ll have to book me if you want the whole shebang;)

Cheers,
Bel