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Mosaic verrucae-help with treatment

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

  1. stevewells

    stevewells Active Member

     
  2.  
  3. I use the needling technique for stubborn VPs, mosaic verracae and multiple VPs.
     
  4. stevewells

    stevewells Active Member

     
  5. stevewells

    stevewells Active Member

    Does anyone have a copy of the following paper?

    GW Falknor
    Needling--a new technique in verruca therapy
    J Am Podiatr Med Assoc 1969 59: 51-52.

    It would be greatly appreciated

    Thanks

    Steve
     
  6. bob

    bob Active Member

    Seems like a pretty cool idea. My only concern (already posted on a separate thread) would be if the verruca turns out not to be a benign growth and we end up seeding a malignancy. Unlikely, but not very nice!

    Saw a lecture by a Floridian podiatrist specialising in dermatology that was excellent but seriously scary. Well worth looking at differential diagnoses, especially in any chronic lesions. I guess a case could be made for biopsying them prior to stabbing away just to make sure?

    :santa:
     
  7. Bosch

    Bosch Welcome New Poster

    stay with me on this, it is a bit far fetched.

    I have seen a couple of mosaic warts as you describe, one or two of which were almost disabling. I tried everything, dichloracetic acid, bichloracetic acid, silver nitrate, needling, potassium permanganate, candida injections (for enhanced immune response, etc), SUB Q implantation of wart particle. And nothing worked.

    One day, I was speaking to a drug rep in the office who was leaving samples of VALTREX (for herpes). In the course of the discussion we agreed that the wart virus and the herpes are kind of similar (large DNA) and Valtrex is generally well tolerated....

    I gave it a shot. The first young woman had been dealing with this wart for seven years and it had grown to cover 90% of the plantar surface of her foot. RX Valtrex 500mg BID for two weeks. IT WAS GONE.

    I tried it on another patient being careful to explain the off label usage, the potential problems, etc. Being very careful that the patient was aware of the ridiculous logic that led me to try it in the first place. It worked a second time. In less than a month.

    I have done this 17 times for warts that have been refractory to everything else (even surgery in one instance). It has worked 14 times. Nobody has had any problems with the meds. I work in a large multispecialty clinic and have the support of the internists who were sending the warts to me after dermatology was unable to do anything.
    I called the drug company and they basically said I was stupid and shouldn't be doing this. They did not even want to talk about it.

    I know there is a large psychological effect in the treatment of warts (we have a psychologist who "Buys" warts from young kids--don't laugh--it works sometimes) and
    some of the prima donnas out there are going to call this voodoo medicine and perhaps would report me to the authorities if they could and it may well be justified. But I have 14 grateful patients who were almost ready to have their foot amputated because of painful refractory warts (well, maybe not THAT bad). I get christmas cards every year and one of them even sends me pro football season tickets each year for saving him form the wart.
     
  8. Frisbee

    Frisbee Guest

    Hi Ladies and Gents,

    This is my first post on Pod Arena so greetings to you all!

    I have been reading this thread with interest. With excellent timing I had a patient attend with a mosaic verrucae today. She has had all of the standard treatments (cryo, sal. acid, etc) with no improvent and she is now developing satelite verrucae. The 'mother' is a large VP on the platar aspect of the right hallux. I am grateful to you Kevin for explaining the protocol. I will let you all know how we get on, with photographs of course.

    Adam
     
  9. twirly

    twirly Well-Known Member

    Hi Adam,

    I too will be following with interest.

    Best regards,

    Mandy.

    PS. :welcome: aboard. :D
     
  10. Paul_UK

    Paul_UK Active Member

    Very interesting thread. Possibly a stupid question but do you do a full ankle block to anethetise the foot prior to needling?
     
  11. stevewells

    stevewells Active Member

    You aneasthetise the area you need to so it will depend on the location of the lesion and its relative nerve supply taking into account possible overlap of dermatomes I have one to do on the medial plantar calcaneus so I will try posterior tibial block first - I have another that I am contemplating which is accessible from the toe web so I will be more specific with that one

    Steve
     
  12. Paul_UK

    Paul_UK Active Member

    That makes a lot of sense, lol. This would be a very good study as we seem to be getting more patients coming through with stubborn VP's. Look forward to the pics/more details from everyone.
     
  13. JMD

    JMD Member

    Would local infilrartion around the lesion not be sufficient to anaesthetise the area prior to the procedure?
     
  14. MelbPod

    MelbPod Active Member

    Post tib/ ankle block is a less painful injection than injecting through the plantar skin.
    After anaesthetised, a small deposit at the lesion site can then be administered.
     
  15. stevewells

    stevewells Active Member

    So here we go - as promised some photos of my first"needling"
    My patient is a 50 year old male accountant whose interests are walking and dancing. He has a 2 year hx of verrucae on both feet and within the last 2/12 the left heel has become painful.
    There is no significant medical history. Patient suffers from Hayfever. He presented with multiple small VPs on his right heel two clusters of mosaic Vp on the plantar surface of the left hallux and the left first metatarsolphalangeal joint. There is also a large mosaic VP on the medial plantar surface of the left calcaneus which is prone to fissuring - this is the largest and most painful lesion and was targeted for treatment. There were no contraindications to the use of local anaesthetic and written consent was obtained for the procedure.
    Sufficient aneasthesia was achieved by blocking the posterior tibial nerve with 3% Plain Mepivacaine. The VPs on the left foot were lightly debrided. 100 puncture wounds were applied to the target VP using a 27g needle inserting ~ 5mm. The wound was dressed with sterile gauze and EPB strapping. He was advised to keep it on and dry until the next morning when he could remove it and shower as normal. Light dressings were issued for use if necessary.

    The first two pics are VPs before debridement, the third and fourth after debridement and the last after needling.

    Further photos will be taken every 2/52 to plot the progress
     

    Attached Files:

  16. Wendy

    Wendy Active Member

    Steve
    Having read this thread with great interest I woul just like to say thanks for a great set of photos, am looking forward to seeing the results.
    One question, to those who already use this technique, how long would you use conservative treatment prior to using the needling technique or would you just use the needling technique without trying any other tmt ?
     
  17. blinda

    blinda MVP

    Nice one Steve and thanks again for letting me observe :drinks


    PS But where is the really cool pic?
     
  18. stevewells

    stevewells Active Member

    Oh yeah, I forgot! - Needling isnt the only great thing to come out of the good old US of A!!
     

    Attached Files:

  19. stevewells

    stevewells Active Member

    I've been thinking about this a bit. This is an opinion not backed up by anything other than my thoughts based on experience and anecdotal evidence.

    I think if this works as it should, the principle that you are alerting the immune system to the presence of the virus would surely make this a first choice. I believe strongly that the immune system is largely responsible for eliminating the virus and that other types of treatment reduce the viral load and at the same time provoke inflammatory and subsequent immune responses. (Except maybe surgical excision but you can never be sure you've got it all - unless you take the whole foot off!)
    Mosaic types because they are often large and this would often restrict the extent of the treatment e.g. wound size with electrosurgery/cryosurgery and amount and type of caustics. Recalctrant VPs because nothing else has shifted them.
    I don't buy into the idea of a "mothership verruca" (other than maybe a spreading mosaic)- its a virus that infects the skin - with multiple discreet VPs it's probably just got in in different places one way or another.
    I would select my target vp mainly on ease of anaesthetising and then on relative size, presence of pain etc. Size because I think there may be a possibility of the immune system only seeing the needled VP. After all based on the immune system theory - it hasn't seen them yet so why should it see the others? Of course, the immune system may only need to be alerted of the presence of a virus not its location.
    I have several pts that I am considering this for and none of them are mosaic types but have had extensive treatment to no avail. You would obviously pick your patient carefully! Not sure the kids would be up for a good needlin'!!

    What say the rest?
     
  20. Tree Harris

    Tree Harris Active Member

    What is the likelihood of this procedure having a good outcome with a pt that also suffers from chronic urticaria of (as usual) unknown etiology.
    Their immune response is confused already- could this focus the response to overcome their issues?
    And love the pics in this thread- I am a visual person!!!
     
  21. stevewells

    stevewells Active Member

    Suck it and see!!
    If you have a pt that has a suitable VP why not give it a go and let us know what happens.
     
  22. drsarbes

    drsarbes Well-Known Member

    Saw my patient today (see March 4 post) - approx. 4 weeks post needling.
    This is amazing!
    I'll post one of the pre-op pictures and one from today.
    I apologize for the quality of todays picture, but take my word for this, they look
    great. The larger lesion that was needled is gone, the remaining
    lesions are ALL disappearing.
    I'll see him one more time in 4 weeks.
    I did another one yesterday on a young girl with LOTS of mosaics and solitary lesions. I'll see her next week and take some after photos and post them together.
     

    Attached Files:

  23. stevewells

    stevewells Active Member

    Nice job - hope I get the same result with mine!!
     
  24. Good job Steve. Now you know I'm not totally crazy.;)
     
  25. blinda

    blinda MVP

    Agreed! :cool: Thank you to Steve, Steve and Kevin, I now feel confident to try this on pts myself.

    Cheers,
    Bel
     
  26. Steve Arbes:

    Next time you see this patient, could you get some better lighting on the plantar foot as you did on the first set of photos. I am having a difficult time seeing the lesions with the dimly lit plantar foot.

    Improved photos would make it much more helpful when demonstrating the change in lesion morphology to the many others following along. Maybe some close up photos of specific lesions over time would also be helpful in order to document the skin changes better.

    Thanks for doing this for all of us.
     
  27. Deborah Ferguson

    Deborah Ferguson Active Member

    Hi All
    I was very interested in the `needling` discussion on VP's. I have never heard of this before but I'm keen to try. I am increasingly convinced that much of what we do to VP's has little or no effect and sometimes seems to make matters worse eg. acids etc.
    Pot.permanganate can be used to make explosives but it is still available in the UK if you can proved you are a healthcare professional when purchasing it.
    Regards
    Deborah
     
  28. Ian Drakard

    Ian Drakard Active Member

    Hi all

    I've been following this thread with interest- needling to stimulate the immune response makes so much sense thinking about it. Can think of a few patients who may want to try it so I'll join in the picture show if they agree

    I have occasionally treated patients who have very widespread mosaic vps because they are immunocompromised. The needling obviously cannot be expected to work in this group.

    Does anyone have any suggestions for treatment/management in this case?

    Ian
     
  29. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:

    I never thought you were "totally" crazy, just a little bit!

    I realized too late that the photos were not up to our standards, the patient had already left the office when I downloaded the pictures.
    Sorry.
    I'm not sure what happened, the assistant that took them is normally very good at it.
    I'll make sure the next ones are up to snuff.

    Steve
     
  30. MelbPod

    MelbPod Active Member

    Good point Ian, was pondering this one myself?
     
  31. stevewells

    stevewells Active Member

    Yes - I was thinking about this too - I have a pt on Azothiaprine for chronic colitis. I treat her regularly , often getting rid of the VPs but only to see new ones appear - she has a healthy foot so caustics aren't a problem but i do sometimes wonder if I am chasing rainbows.
     
  32. blinda

    blinda MVP

  33. stevewells

    stevewells Active Member

    Top Girl
    Thanks B
     
  34. hawkesburypod

    hawkesburypod Welcome New Poster

    That's it! Here i am in Australia intrigued by this forum and that's it! Come on guys its 04/04/09 and no results. No pictures.Please give me more. By the way Kevin -have been to a number of your conferences here in Aus. Refer to your publications regularly. Thanks
     
  35. stevewells

    stevewells Active Member

    Patience!! - will be posting some pics at review in the next 2 weeks - look through the thread again and you will see some pics already posted
     
  36. hawkesburypod

    hawkesburypod Welcome New Poster

    The original pics of the treatment were great but i have no other pics available for viewing. May be my browser? I will sit quietly and wait in anticipation. These treatments are unheard of in this country so i am very interested. That's one of the many benefits of podiatry arena. Thanks!
     
  37. stevewells

    stevewells Active Member

    Only saw him on the 27th March so thought I'd give it 2 weeks before getting him back for review - watched pot and all that!! http://www.podiatry-arena.com/podiatry-forum/images/smilies/biggrin.gif
     

  38. Belinda:

    Thanks for providing this article to us. I am not sure if this article is the one I first read about this technique back during my surgical residency in 1983-1984 at the Veteran's Medical Center in Palo Alto.

    My co-resident during my residency, David Arkin, DPM (now practicing in Big Flats, New York) and I, would take turns driving the 45 miles from our homes in San Francisco to Palo Alto every morning during our residency. Whoever was the passenger that day would bring some journal articles along and read the highlights to the driver. Then we would discuss the article and how it might apply to our patients.

    I remember reading the article to Dave on the way to work one morning and we both thought it might be worth trying some day. I thought I remembered something about an electric toothbrush that had been modified with a needle holder to make the multiple punctures in the skin being mentioned within the paper. Therefore, there may be another paper from before 1984 that also mentions this needling technique in one of the podiatry journals. My memory is a little foggy on this since it was 25 years ago.

    Glad to hear that this reintroduction of such a simple technique is proving so interesting to others.
     
  39. carolethecatlover

    carolethecatlover Active Member

    Thanks heaps everybody! I have a lecture on verrucae on Weds pm. This was not mentioned. Now how can I send this thread to my (receptive, open-minded) professor.?
     
  40. twirly

    twirly Well-Known Member

    Hello Kevin et al,



    I too have been following this thread with keen interest. To finally be able to provide a 'proven' treatment with reasonable outcomes would be a real breakthrough.

    I feel sure we all become a little frustrated at bombarding VPs with cryo', caustics, acids & in Robert Issaacs case dead cats! ;)

    This technique appears to have sparked interest for many on Podiatry Arena.

    This also interests me. I remember prior to undergoing an immunisation at secondary school age 11 a 'Schick' test was administered initially to all individuals to ascertain if immunity was already active.
    http://en.wikipedia.org/wiki/Schick_test

    This has me wondering about the device which was used to administer the test. A multiple needle which in one application innoculated an area the size of a new 5 pence piece.

    However, I have searched endlessly online to no avail to find the name of this apparatus. Can anyone remember the having test & perhaps throw a little more light?

    Many thanks,

    Caractacus Potts. :rolleyes:
     
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