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Mosaic verrucae-help with treatment

Discussion in 'General Issues and Discussion Forum' started by poppet, Feb 27, 2009.

  1. Derek:

    You can believe what you like. In my hands, ethyl chloride spray with proper local anesthetic technique is the way to go, and has no risk of injury to the posterior tibial nerve.
  2. Tim VS

    Tim VS Active Member

    Hi Kevin ,

    Always keen to learn. Would you mind setting out in greater detail your protocol for local infiltration. In particular, equipment used and how long you spray the area for prior to injection.

    Much obliged to you.


  3. DTT

    DTT Well-Known Member

    Yep me too Kevin, I'm up for ANY pain free Tx :drinks

  4. Suzannethefoot

    Suzannethefoot Active Member

    Thanks for that.

    Do you mean Martin Harvey though?

    I added cool smileys to this message... if you don't see them go to: http://s.exps.me
  5. DTT

    DTT Well-Known Member

    OPPS Sorry Yes Martin Harvey, sorry about the typo.
  6. I've done a goodly number of these now, certainly into the low hundreds. I've tried both ankle blocks and local infiltrations quite a bit.

    I make it a habit to ask how painful a patient finds a proceedure after I've done it, on a scale of one to ten. With tibial blocks they generally report something in the 2 or 3 range. With infiltration its much, much higher, especially if one is injecting into the plantar skin. That tibial blocks hurt less than infiltrations is not in any doubt for me. Provided of course the practitioner has good technique. If its somebodies first time and they spear the PT nerve then wiggle the needle about some, take it out, stab it again etc it's bowel looseningly painful. Believe. *

    The lesser pain of the tibial block must, of course, be balanced against the risk of injury to the tibial nerve. As with any risk assessment, one must judge both sides. You've been at this a long time Kevin, how many injuries to the PT nerve have you caused?

    Besides that the only benefit of Infiltration over Tib block which I can see is convenience. Personally, I'll swallow a bit of inconvenience if it means saving the patient a bit of pain.


    *Of course careful supervision by an experienced clinician should prevent this ;)
  7. pd6crai

    pd6crai Active Member

    This sounds like a random question, but when doing the multiple puncture technique, what should the patient experience? Someone says the lesion turns black? How long before they see any improvement?

    I have only just learnt how to do the technique and am yet to see the end result!
  8. blinda

    blinda MVP

    Oh,I`m a Believer. I tend to use tibial blocks more as, like you, I always ask the pt to describe any injection discomfort. I did 3 needlings today and, as usual, local infiltration scored higher. However, I do use ethyl chloride, which eases much of the initial `prick` when I use local infiltration, for example, in the Sural nerve dermatome area.

    Indeed. Maybe it`s a bit over the top but I also like to demonstrate to the pt that I have identified where their artery is by using the doppler and inject posterior to that. Part of the theatre I suppose (pinging machines and all that jazz), but appropriate technique and identifying where the nerve is rather important, eh Robert?

    Hi pd6crai,

    Be nice to have a name..The pt shouldn`t experience pain, obviously. Pinpoint bleeding must occur at every puncture so a scab should form, which I suppose could be described as black. They should notice deep rubour during the inflammatory process, then the lesion should shrink and completely resolve. This can take anything between 4 and 8 weeks in my experience.

  9. Tim and Colleagues:

    I am certain that a posterior tibial (PT) nerve block can be less uncomfortable for the patient when doing the verrucae needling technique. However, PT nerve blocks also take much longer until he patient's plantar foot is anesthetized, are much less reliable in achieving complete anesthesia (in my hands) and puts the patient at substantial risk for posterior tibial nerve symptoms, for weeks to months, if this large nerve is penetrated by the needle.

    I have accidentally speared a few PT nerves in my 26+ years of practice and it is not a pretty site for the patient. Most of them describe it as having their foot hooked up to a 220 volt circuit and will complain of parasthesias, or worse, for up to 6 months following sticking a needle into the nerve. Not my idea of good medicine.

    When I perform the local anesthetic injection for the verrucae needling technique, I will use a 1.5 inch, 25 gauge needle on a 5 cc hypodermic syringe loaded with 5.0 cc of 0.5 % Marcaine (bupivicaine) plain (without epinephrine). If at all possible, I will do the injection either from dorsal or from the medial or lateral side of the foot where there is less cutaneous nerve density to make things more comfortable for the patient. However, I often do the injecton from plantar if necessary and have no problems with injecting any plantar location of the foot, as long as I have ethyl chloride spray at my disposal.

    I start the injection procedure with the patient lying flat, in a supine or prone position (i.e. whichever position is easier for me to do the procedure in). I then use ethyl chloride spray for about 10-15 seconds in a circular motion of about 10 mm diameter or until the skin starts to "frost". [The ethyl chloride spray works better if the bottle is held at least 12-18 inches from the foot which ensures that the liquid spray will be colder once it hits the foot.]

    As soon as the skin is frozen with the ethyl chloride spray, the hypodermic needle is immediately punctured through to the subcutaneous tissues. The patient normally does not feel this needle puncture. Then, very slowly, I start to infiltrate the subcutaneous fat directly dorsal to the plantar verrucae (about 3 mm from the dermis) with the local anesthetic injecting a little anesthetic then advancing the needle forward a little more, then injecting a little more anesthetic. The needle is then repositioned a few more times slowly so that the whole plantar verrucae lesion starts to blanche to a whiter color. The patient will always be completely numb at the plantar lesion within 15 seconds of finishing the local anesthetic injection.

    The injection rate is about 1 cc for every 15 seconds so that the normal injection of 4ccs will take about 60 seconds. This is uncomfortable for the patient but not unduly so. Most patients describe the pain about the same as getting a local anesthetic injection from the dentist. The patient is then prepped with a betadine solution and a fenestrated drape is used to isolate the area of the plantar lesion and the needling is immediately started. Time from ethyl chloride spray to start of the needling procedure is about 3-4 minutes.

    You must remember, though, that I have been giving local anesthetic injections for over 28 years, taught students and surgery residents at CCPM on ankle block technique 27 years ago, and give about 3-6 cortisone and local anesthetic injections per day in my office so I am very comfortable with my injection techniques. In addition, in further support of the use of plantar injections without PT nerve blocks, all of my cortisone injections for plantar heel pain (i.e. proximal plantar fasciitis) are done with the patient prone, their affected knee flexed to 90 degrees and using ethyl chloride spray for a direct plantar heel injection at the point of maximum tenderness. I learned this technique from Jack Morris, DPM, one of my Biomechanics Professors, when I was a Biomechanics Fellow at CCPM in 1984 and it is the best technique, in my opinion, for giving cortisone injections for plantar fasciitis. I do about 10 of these plantar heel injections, directly plantarly on the heel, every week.

    Maybe someday I will try to do a video of these techniques and post them up on youtube if I ever get the time. Right now, however, things are very busy as I am starting to get ready for a series of three seminars I will be lecturing at in June.

    Hope this helps.
  10. stevewells

    stevewells Active Member

    Hi Kevin - thank you very much for this - just one question - do you use the stream type ethyl chloride or the aerosol type?

  11. Steve:

    I use the stream type. It works great.
  12. blinda

    blinda MVP

    Aha. That would make a difference.

    Good question. Where did you buy yours, Steve? It`s a POM isn`t it?
  13. Tim VS

    Tim VS Active Member

  14. Hi
    6 weeks ago I treated a 15 year old female using the needling technique, she had several plantar VP and had had a previously unsuccessful needling. She presented last week with multiple warts around the proximal nail folds of almost every finger. Has anyone encountered this before? Is is the virus going into panic mode before it dies?
    Help gratefully accepted.
  15. Janet:

    In the 10+ years I have been using this technique, I have never seen new warts pop up elsewhere after doing the needling procedure. Oral cimetidine also is known to work well in children and adolescents for verrucae. You may want to consider referral to a dermatologist for a case such as this.

    Here is a good article on various treatments available for warts.

    Good luck.:drinks
  16. stevewells

    stevewells Active Member

    Apologies to Bel and Tim for not replying - I think something went wrong with my thread subscription - anyhoo
    Yes this is where I get it from !!! - I have both and the jury's out as to which one is better - I think the aerosol direct stream version is easier to use but that's a personal preference.
    Bel maybe we should have a session to experiment!!!!!

  17. blinda

    blinda MVP

    You know i cant resist an invitation to experiment ;) just say when.

    Nice article, BTW Kevin :drinks

  18. Bel:

    That was a "sick" article....;)
  19. Leah Claydon

    Leah Claydon Active Member

    I've been this technique for the past 6 months. I usually talk through all the verruca treatment options and the brave opt for needling, others prefer to save it for a last resort. I would say the results I am getting a not as good as publicised above - I'm getting around 60% clear up on 1st treatment. This is definitely not due technique problems I think that it is due to the fact the ones that are coming to my clinic are on mature patients with long standing lesions that have not responded to any other form of treatment and are therefore by nature more resistant to treatment. I can confirm though that apart from the initial local angalgaesic post operative pain is very low and well tolerated by patients. They definitely seem to prefer to cryo and it's a more convenient patient for the working person who does not want to be coming in every week.
  20. stevewells

    stevewells Active Member

    Thanks for posting Leah - I seem to be getting similar results to yours - somewhere between 60 and 70% and I was thinking along those lines too.

  21. I hope that no one was under the impression that verrucae needling is 100% successful. Like any other verrucae treatment procedure, it is not perfect. For solitary lesions, I would guess that my treatment results are approximately 80%. However, for mosaic verrucae, where I first described my experiences with the needling procedure in this thread nearly 3.5 years ago, I don't think there is any better procedure.
  22. blinda

    blinda MVP

    Agreed. :drinks

    It is important to remember that; ultimately, any VP treatment is only as good as the patients` immune system, as with any viral infection.
  23. poppet

    poppet Active Member


    well i am so pleased my original post has generated so much interest. sorry i havent been posting much as i have been setting up my own clinic! all going well and looking forward to trying this treatment again.

    i do have a lady who i have been seeing for sometime who i feel may benefit but money is prohibiting her from taking up my offer so wondered if there are any NHS pods that are doing this in the South East...we are in Shoreham-by-Sea but she is willing to travel to get this sorted...she has tried bazuka extra, cryo, sal acid, thuja, duct tape with no effect....gets emotional about it still being there and this week it was seemingly larger...eeek!

  24. navski

    navski Welcome New Poster

    i cant seemed to work out how to write a new thread on here so i thought i'd just jump in here as its the most relevant to my questions.

    I wanted to know how you do a local infiltration with LA for a plantar VP. Is Scandonest plain ok to use or should i have adrenaline in it.

    I couldnt seem to get the injection in right to begin with. Even had some LA squirting straight back out!!!! aargh..
    can someone help guide me how to get this part of the procedure right please.

  25. dgroberts

    dgroberts Active Member

    Would it be correct to assume that patients are being charged a similar fee for nail avulsion for this procedure?

    I would be very interested to know what people charge for this. If you're brave then please post it up, otherwise a private message would be appreciated.

  26. Leah Claydon

    Leah Claydon Active Member

    I don't mind putting it out there how much I charge for this.
    I don't think it is right to charge the same as a PNA.
    I charge £75 - probably going to get my had blown off for sticking my head above the parapet here. It only takes 20 mins from start to finish including gaining consent. It's a low cost procedure the most expensive part being the using of a sterile pack procedure pack.

    I've contributed to this thread before stating I think the success rates are exaggerated. Since posting last I personally have found this treatment is no better than any of the other treatments available. I think patients are impressed by the "theatre" of this procedure and because rather than the traditional treatments of acids and cryo it is perceived as 'proper treatment' that cannot be duplicated at home.

    It's such a pity that my results have been so disappointing. Verrucas are a nightmare to deal with and to have been able to offer a truly effective treatment would have been fantastic addition to our weaponry against this infection.

    I would have felt professionally embarrassed if I had charged £300 for this procedure if it had not worked.

  27. DTT

    DTT Well-Known Member

    Hi Leah

    20 mins from start to finish including consent ???????:confused:

    Might I suggest respectfully you re-assess your technique and thereby improve your outcomes ?

    We get around 85% success with this modality but the actual Tx is around 45 mins with a further 15 mins to ensure all bleeding is controlled befor the Pt leaves my surgery.

    We charge more than you but a fair charge for the time and Tx involved .
  28. macci13

    macci13 Member

    Hi All..

    Really good tread and sace studies, thanks!

    I have been trying the needling procedure under ankle block for some time now and have good results so far.

    Few questions:

    What is the likelyhood of leaving callus/corns on needled sites in the plantar foot?

    Has anyone experienced the VP not anesthetising even when all around the VP is anesthetised and is well within the specific dermatome which is also numb!??

  29. zsuzsanna

    zsuzsanna Active Member

    I think you would need a lot more than the amount needed to put in a foot bath. Is that how it was used? I remember gargling with it when I had a sore throat so it must have some antibacterial properties, but how does attack a VP which is under the skin?
    It is an oxidising agent.
  30. cecilia1923

    cecilia1923 Member

    Regarding the treatment of vp's. Using history-taking, I normally find that the vp has been brought on by stress or that it could be a pre-emp to something like glandular fever . I always make a point of making the patient aware of this. I then debride the vp, get it to bleed slightly and then apply the silver gaffa tape. I tell the client to re-apply the tape as soon as it comes off. I make an appoint for 2 weeks time and repeat. I do this up to about 4 more times.
    This has been in the main very successful.
  31. zsuzsanna

    zsuzsanna Active Member

    Thank you for your suggestion. I will try it. I have used a similar method before with Sleek tape but I did not recall so soon after the first treatment.
  32. podhugh

    podhugh Member

    I've read all the posts here about mosaic verruca treatments. I have a patient whom I would like to try the needling technique, unfortunately my degree course did not cover the administration of anaesthetic for an ankle block - so that means I can't try it, or is there another way???:confused:

  33. j1nxst3r

    j1nxst3r Member

    Hi All,

    I'm a 1st year Podiatry student at Durham, UK and have been reading this thread with interest!!!! I'm writing an assignment on Verrucae and have found an article in Podiatry Now (May 2011) written by an NHS podiatrist in Hounslow on needling. In the article 70% results were on single lesions (although the technique was only used on 14 patients).

    I hope this helps!

    Mike Taylor
  34. stevewells

    stevewells Active Member

    You could do it the way Kevin suggested - i.e. local infiltration after 20 secs or so of ethyl chloride spray over the area to be injected.

  35. podhugh

    podhugh Member

    Thanks I read through again - have bought the cryoanalgesic and will try next week.
    Thanks to Durham student too. I did my course there and qualified 2008. Good Luck it's a great school.
  36. Generally, the ethyl chloride spray freezes the skin within 5-10 seconds, at which time I pierce through the skin with the hypodermic needle. I don't think I have ever used the ethyl chloride spray for 20 seconds in the same location for needle anesthesia. Too long of a spray time may cause thermal injury (i.e. frostbite).
  37. stevewells

    stevewells Active Member

    kevin - in a previous post you quoted 10-15 secs.
  38. Did I ever say 20 seconds? I don't think so.
  39. MENCI

    MENCI Member

    Hello, Dr Kirby mi nombre es Mario Mencía, soy podólogo y enfermero en España más concretamente en la provincia de Toledo en la ciudad de Talavera de la Reina, en mi práctica diaria me he encontrado algún papiloma en mosaico aunque aún soy demasiado novato como para hablar con la maestría con la que lo hace usted, pero quería comentarle un caso de un paciente que tengo de 12 años que vino a mi consulta hace 3 meses y estoy tratando con ácido nítrico al 60% en cura oclusiva con vaselina salicílica al 30% y en tto coadyuvante con THUJA OCCIDENTALIS 30 CH EN GRÁNULOS, al principio fue bien y parecía que iba a resolverse al primer mes, en la siguiente sesión a los diez días volvió y el paciente presentaba las lesiones igual que el primer día así que volví a empezar de nuevo y así llevo dos meses. le incluyo en 2 archivos adjuntos imagenes del primer día cuando llegó y otra imagen a los quince días previa deslaminación como verá hay 2 VP madre y lo demás son lesiones ides a distancia.

    Por lo que he leído en su post , a lo que usted se refiere es a producir una inoculación del virus en el organismo para producir digamos una vacunación del paciente a través del propio virus, como ocurre con el virus de la gripe cuando no lo inoculan a través de una vacuna, no?

    agradecerle de antemano su respuesta, muchas gracias.

    Attached Files:

    Last edited: Nov 29, 2012
  40. podhugh

    podhugh Member

    Can we get a translation guys?

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