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Mosaic verrucae-help with treatment

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

  1. blinda

    blinda MVP

    Hi All,

    With regard to immunocompromised pts, I would consider some of these as ideal candidates for the needling technique (obviously after considering any other pathology/systemic conditions and ascertaining vascular, neurological status). These pts are more susceptible to infection as a result of suppressed immunity. So to perform, what I would consider, a less invasive procedure that does not create blistering, ulceration or necrosis (as is the case with Sal Acid, cryotherapy, cantharidin, etc) would surely be reducing the risk of infection?

    The idea that the virus is implanted into subcutaneous tissue should also increase the likelihood of stimulating the desired immune response as HPV is considered to be in the basal layer of the epidermis; therefore cell mediated immune response is not facilitated. Whilst Parton & Somerville (1994) suggested abrading the surface of the VP to cause capillary bleeding to promote cell mediated immunity, I think implanting the virus below the dermis takes this premise further and agree with Ian in that this technique makes so much sense.

    I have a healthy 48 year old pt taking low dose methotrexate, for psoriasis, with a hx of recurring VPs. He has had cryotherapy repeatedly to remove the VPs only to have new VPs appearing elsewhere on both feet.

    Having explained to him that his immune system is suppressed by his medication he is now considering the idea of `needling`. My concern is that the painful VP, which he wants me to needle, is quite close to the Achilles tendon insertion into the calc. The last thing I want to do is damage the tendon so would I be correct in rather wanting to needle another VP site inferior to this, fibular aspect of the calc?


    Cheers,
    Bel

    Ref; Parton AM, Sommerville RG. The treatment of plantar verrucae by triggering cell-mediated immunity Brit J Pod Med 1994; 49:205.

    BTW Mand`, I don`t remember the 'Schick' test, being that much younger than you ;), but oddly enough my ageing hubby also remarked on the similarity of this method!
     
  2. twirly

    twirly Well-Known Member

    Hi Bel,

    Ah those halcyon days of childhood. Fair takes me back to wiping my chalk answers off my slate board & waiting patiently for the gruel to be served.

    ...................... you can go off a person y'know. :boxing:

    Kind regards,

    Mid life crisis. Doncaster.

    :boohoo:
     
  3. carolethecatlover

    carolethecatlover Active Member

    Dear all, Yes, I had the 'Shick' test....circa 1980... to see if I had ever been exposed to TB. Or is this the Manussus test...multiple needles on a little disc pressed on my wrist.

    I was thinking about this Mosaic Verucca needling technique, correct me please in my thinking, I am just a 2nd year student....the reason the body does not produce antibodies to the MV is because it does not know it is there. The MV is hiding in the dead layer of the glabraous skin, making no connection to blood or living tissue....so we punch a little thru to the blood, saying 'here it is' and the body recognizes the 'enemy' and sends out antibodies...
    the man with psoriasis is interesting....psoriasis is dead cells turning over too fast...I would love to do a punch test on psoriasis....see where I'm going?

    Please put up a flag so we know where you are from!
     
  4. blinda

    blinda MVP

    Hi Carolethecatlover

    This is one theory of how the HPV evades the immune system; ie it sits below the radar in the basal layer of the avascular epidermis. Another theory is the postulated ability of HPV to locally activate T suppressor cells....plus many others.

    Just a 2nd year student? JUST A 2nd YEAR STUDENT?!!Well you are braver than I was. I was just a tad scared of being `mashed into a pulp`by posting on PodA as a student....

    http://http://www.youtube.com/watch?v=ud7YNNA0Mwo

    I`m afraid I don`t subscribe to flags, (But `Winchester (UK) Podiatry` could give you a clue as to my whereabouts ;)) as i am not of the nationalistic sort. However, IF I was pushed to decide it would be this one. Did you spot it in the video?

    Sir Robin not-Quite-So-Brave-as-Sir Launcelt flag.jpg

    :drinks

    Cheers,
    Bel
     
  5. drsarbes

    drsarbes Well-Known Member

    Hi Carol:
    Perhaps you can describe how the majority of verrucae are successfully eradicated by our immune system while others are not and how this fits into your theory of warts "hiding" from the host.

    Also, when large mosaics, particularly on the plantar aspect, develop fissures through the now hyperkeratotic skin, why are these not eventually eradicated as well via the immune system. Some of these fissures are to the depth that they cause bleeding; certainly there must be viral introduction in these wounds.

    Or why can patients give a history of repeated verrucae that have spontaneous "cures" only to have subsequent warts that are persistent? Or a patient with several warts at the same time and some went away and some did not?

    I do like the "hiding" idea............

    Steve
     
  6. Steve and Steve:

    Any more post-needling clinical photos of your patients? We can't wait to see the results.
     
  7. drsarbes

    drsarbes Well-Known Member

    Just for you Kevin (I'm sure I'll run late all morning now!!!!!!!!! lol)
    Here's a 16 year old I did about 3 weeks ago, I have pre and one week post.
    She had these for over a year with poor results from repeated chemodestruction/debridement/OTC/etc......

    I needled a section of the Mother Mosaic. I did absolutely nothing to the remaining lesions so any changes you see between the initial series and the one week post op is all attributed to possible immune system resolution.

    Steve
     

    Attached Files:

  8. drsarbes

    drsarbes Well-Known Member

    Here are the one week post
    Steve
     

    Attached Files:

  9. stevewells

    stevewells Active Member

    My patient is in this week on Friday for his first review - watch this space!
     
  10. twirly

    twirly Well-Known Member

    Thank you everyone for this thread,

    I have a further question for Steve & Steve ;) Well 2 questions actually. :eek:

    1). Are either of you intending to publish a paper on this method?

    2). How would you advise costing/charging this treatment?

    Many thanks,

    Yet another inspirational thread from Pod' Arena. :drinks

    PS. I would not wish anyone to think I see this TX as a money spinner. More a proven alternative to previous treatments.

    Many thanks,

    Mandy.
     
  11. stevewells

    stevewells Active Member

    Hi Twirls

    I have several cases that I am about to "needle" so will be thinking about doing maybe a case study/or a number of case studies - I am trying not to get too excited at the moment - obviously I hope that these are all successful but I am cautious about seeing this as a sudden "Holy Grail" of treatment. I would like to know why it hasn't been in wider use as its been around since the '60s. Anyway lets see what happens. Doing my first review Friday this week. Have got a beautiful case that I was hoping to do today but she cancelled as she has just had some minor foot surgery and was at the hospital today for her redress. She has had every treatment under the sun and they have been around for 10 years plus. I tried Electrosurgery to remove them - unsuccessfully (Blinda saw this one a while back - remember B?) Last time I saw her I suggested a dermatology referral and perhaps a biopsy but we were going to put it off until after the surgery.

    As for charging - I charge for my time - plus a charge for the local. I book the patient for a half hour just in case i have problems with the local. If I am doing an ankle block I get them in at the end of a session as they can sometimes take a while to get the foot numb. Reviews are 15 minutes and charged accordingly.

    If this turned out to be a very successful treatment it could reduce my income as the patient would have fewer visits but hopefully that would be offset by an increase in patients once word gets around - if I increase my success rate I will make sure local GPs know about it and word of mouth always produces more referrals. Also I would feel much better about predicting outcomes when advising patients on treatment approaches. I am sure that we often get a bad rep when patients spend a lot of time and money on treatments that eventually are unsuccessful even though they are made fully aware of that possibility when they embark on the course of treatment.

    The treatment is easy to perform and has little risk that I can think of other than those normally associated with local anaesthesia. The treatment gives me extra options - I did one today that I probably wouldn't have immediately chosen except that the young lady in question goes back to University in 2 weeks and is doing the London Marathon next week - that rules out caustics. She will keep me updated my email. She has 3 very small VPs - one she has had for several years the others more recent. I have not posted pics as they are very small and I am not in complete control of the follow up - will only post this one when I have all the info to hand - I will post all the others as I go along so expect a couple more this week

    Hope this helps


    Steve W
     
  12. drsarbes

    drsarbes Well-Known Member

    Hi Twirly:
    Publish.......probably not. I barely have time to upload these photos.
    I'll leave that for someone else.

    Charges........I charge per size as usual. If the lesion is 2cm that I'm needling I charge for an excision lesion 2cm.

    Steve
     
  13. martinharvey

    martinharvey Active Member

  14. drsarbes

    drsarbes Well-Known Member

    i All:
    Quick note on needling for those who are going to try this.....
    I just did another one and realized something about the technique.

    When I needle I keep needling until there is no more resistance; i.e.,
    when you have "perforated" the area so much that you do not feel any more reactive
    pressure when inserting the needle then you are done (or move on to another area)

    Hope that helps

    Steve
     
  15. drsarbes

    drsarbes Well-Known Member

    OK:

    THIS is really unbelievable!

    I just saw my patient S.M., my initial attempt at needling a verrucae.

    He is now 8 weeks post needling. If you check back in this thread you will see more of his photos, but I have uploaded one of the photos from TODAY along with one of his pre-needling photos.

    I cannot really believe the response we obtained. His warts are just about erradicated - ALL of them! I needled one relatively small area at the base of the 5th digit.
    As you can see there are just 2 very tiny areas that represent old verrucae. ALL of his interdigital, heel verrucae as well as the rather nasty one in the central area of his forefoot are all gone!

    The post picture is just the way he came in, no debridement was done.

    What can I say? This works - and after MANY MANY failed attempts at chemo destruction/debridement.

    NEEDLE ON.

    Steve
     

    Attached Files:

  16. blinda

    blinda MVP

    Hi Steve,

    Thank you for posting this fabulous series of photos:drinks. You mentioned previously that you may be using them for JAPMA, are you still considering this?

    I only ask as I am contemplating putting together a patient information leaflet on needling. The biggest hurdle is convincing the patient that introducing the virus into the subcutaneous tissue will increase the likelihood of stimulting the desired immune response, when they have come to me to take out the VP!

    Obviously these photos could not be used in my information, but it would help if I could state that a case series is going to be published.

    Cheers,
    Bel
     
  17. drsarbes

    drsarbes Well-Known Member

    Hi Belinda:
    I'm happy you enjoyed the photos.
    It was Steve WELLS that stated he might publish.

    Feel free to use these photos (giving me credit would be appreciated)

    Information packet...... I don't think you need to get TOO descriptive.
    Telling patient's that you will introduce live viruses into their blood stream would not be a huge practice builder!

    Steve
     
  18. blinda

    blinda MVP

    Hi Steve,

    Thanks for giving permission to use these photos. I will, of course, reference and provide credit to your goodself. I`ll give Steve Wells a shout.

    :D Yup, I`m sure I can think of a better way to word it. Think I`ll stick to "stimulating the desired immune response"!

    Cheers,
    Bel
     
  19. drsarbes

    drsarbes Well-Known Member

    "stimulating the desired immune response"!

    Nice.

    Or

    "Immune enhancement therapy........ like Viagra for your antibodies"

    HAHA

    Steve
     
  20. Steve:

    Glad to see the suggested needling technique has worked so effectively for your patient. This is exactly the type of response I have seen in my practice now using the technique for over ten years.

    Thanks for such beautiful clinical photographs that you have provided for the international podiatry profession. You are to be commended for all your time and effort at clearly demonstrating the efficacy of this relatively simple treatment of isolated or multiple verrucae plantaris lesions.

    By the way, Steve, instead of going into great detail about trying to describe the complex immunologic mechanisms involved in the needling procedure with your patients, I would put these photos into a small photo album in your office and simply show your patients the before and after photos. I'm sure that in this case a few photos will save you at least a few thousand words..... and a lot of time.;)
     
  21. moe

    moe Active Member

    Hi All,
    We have been considering this treatment for a patient.
    My concerns are post needling pain as this particular patient has been very sensitive even with a slight amount of debridement and use of acids.
    He has already tried acids and the dermatologist tried him on DCP (a solution that the patient paints on daily for immune stimulation, he gave up on this as the foot got extremely itchy ) The verrucae is sub met 3rd and we have also dispensed soft innersoles for pressure relief, but I'm not convinced he will be able to cope with pain post treatment.
     
  22. stevewells

    stevewells Active Member

    Of the 3 patients I have treated with this none have experienced any post op pain
     
  23. moe

    moe Active Member

    Thanks
    I'm gaining more confidence to give it a go
     
  24. Steve:

    We are still waiting for the post-needling photos you promised all of us from over a month ago.:drinks

     
  25. drsarbes

    drsarbes Well-Known Member

    Kevin:
    Glad you enjoyed the pictures and thank you for the kind words.

    Moe:
    You can expect less pain post needling than with post curettage. If your patient has a low pain threshold you might consider a PT block for anesthesia instead of intra or peri lesional.

    Steve
     
  26. moe

    moe Active Member

    Yes I was thinking that might be the best way to go
    Cheers
     
  27. Deborah Ferguson

    Deborah Ferguson Active Member

    Hi All
    I have never used this technique for treating VP but one concern I do have is the risk of introducing a bacterial infection into the already damaged area of skin. Has anyone found this has occurred.
    Thanks
    Deborah
     
  28. stevewells

    stevewells Active Member

    Sorry folks - had a bit of trouble uploading - have got to resize photos - will try to post this evening
     
  29. stevewells

    stevewells Active Member

    Ok this the the first chap I did needling was done to the heel only

    forefoot
    first pic is day one pre debridement
    second pic at 4/52 pre debridement
    third pic at 6/52 pre debridement

    see next post
     

    Attached Files:

  30. stevewells

    stevewells Active Member

    Same series post debridement
     

    Attached Files:

  31. stevewells

    stevewells Active Member

    Now the heel pre debridement
     

    Attached Files:

  32. stevewells

    stevewells Active Member

    and the heels post debridement
     

    Attached Files:

  33. stevewells

    stevewells Active Member

    You can see in each case there is no significant change yet
    I did notice predebridement that the forefoot seemed to be producing less skin and the heels more but on questioning the patient admitted to sometimes using a pumice on the forefoot because the area under the 1st ipj gets sore

    haven't posted the pics of the right calc as there are no changes there
     
  34. stevewells

    stevewells Active Member

    Next lot is a 39 YO lady, pregnant (due in 4/52)
    10Y + hX VPs to heel recently had one appear R5 DPIPJ
    Has Aplastic anaemia and sometimes has immune system issues
    Obstetrics and Haematology both confirmed ok to try treatment

    several of the VPs on the heel were selected as they had been there the longest again post tibial block performed

    First series is pre and post debridement at first visit
     

    Attached Files:

  35. stevewells

    stevewells Active Member

    The next series is 2-3/52 later again pre and post debridement
    notice the blackened VP on the heel? - these are the ones that were needled

    look forward to any comments and observations
    I am wondering if I did enough?

    Will post further series at next reviews

    Had trouble a when I tried these last time getting them to upload but I think i have it sussed now!!


    WHEEEEWWW!!!!!!!
     

    Attached Files:

  36. carolethecatlover

    carolethecatlover Active Member

    Thanks! I am wondering if I could study this as an Honours project?
    Is Moe one of our tutors?
    Carole, halfway thru course!
     
  37. Paul_UK

    Paul_UK Active Member

    What are people using in the way of local anaesthetic? Are you all using full ankle blocks?
     
  38. stevewells

    stevewells Active Member

    I am using 3% plain Mepivacaine - so far have only used posterior tibial block at the ankle because of the location of the target area - however, if I needed to I would do a full ankle block. As there is little post op pain I haven't felt the need to prolong the anaesthesia.
     
  39. moe

    moe Active Member

    No Carole, I'm not one of your tutors. I am a pod in private practice in Adelaide
    Best of luck with your studies
     
  40. stevewells

    stevewells Active Member

    Hi all

    Did another one today - checked out Steve Arbes other posts had a mental note about what he said about needling until no resistance felt so thought I'd put that in my protocol this time

    This chap has 3 x vps under met heads RF - very long Hx - "tried everything" - last treatment was nitric acid based in new zealand before xmas

    Anaesthesia - 3% plain Mepivacaine - local infiltration via web space 3/4 -

    Only needled one VP - want to see if the others go without needling

    Photos in order are pre and post debridement then post needling before swabbing and after swabbing - after needling this looked much more like Steve's one at fifth toe web in his pictures -

    Patient returning for review in 4/52
     

    Attached Files:

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