Mosaic verrucae-help with treatment

i treated one similar patient (over 200 vps) with sal acid, monochlor and pyrogallol - but it took 15 months, another tried tape but failed.....still out there somewhere....

Julian

 

Thank you for responding Julian,

I think this young lady is perhaps ready to encounter the 'next level' of treatment options. Caustics & indeed cryo' have been less than complete in their action so I am wondering if others would consider 'needling' as a viable alternative in this case?

Again I ask for the considered opinions of those more experienced than I in administering this technique. I trust the opinions of those with greater experience & value greatly their previous experiences & wish to know would they consider (in this case) this to be a viable option.

Again, many thanks for all replies.

Yours,

Mandy.

 

Interesting-
I have used this needling technique for mosaic warts. We were taught this in our little Pod-Med teaching blocks in Podiatry School. It works.
I'd recommend consultation for these patients to a good Internist- the reason I see these so often in our clinics is because the immunocompromised population is high in New Orleans--

some dermatology residents have done the needling, followed by surface application of phenol; the thought being that it provides some bleeding control and may help ellicit immune response- I don't agree with this on plantar lesions, and I honestly can't say how the outcomes were; second-hand accounts claim that it works well
-John

 

any chance of a photo so we can see what you're dealing with please?

thanks

Julian

 

found a clear 1 week post op pic for the previous pt!!

 

I had heard the same thing, about the explosive devices............ but easily obtained some from my local pharmacy.
I have never used Potassium permanganate for VP's, but love it as a treatment option for advanced and severe tinea pedis.
I have a question about the needling........... I have heard about all the great successes, but what about the unsuccessful cases. Kevin, I understand you have had one unsuccessful case, did you repeat the treatment? Is it appropriate to repeat the treatment if it is unsuccessful?
Have any other practitioners found this treatment to be as successful as Kevin?

 

Like any verrucae treatment technique, needling is not perfect. If needling fails, then I will generally proceed with currettement/excision of the verrucae. Even though I don't treat a great number of verrucae (only about 2-4 month), of those patients I have performed the needling technique on, probably less than 10% failed. The needling technique can be used as soon as you think the child can stand the pain of a local anesthetic injection.

One note on the technique, I will always make sure the verrucae looks basically like raw ground beef when I am done with it....lots of needle punctures, making sure I go well into the subcutaneous fat with the needle to get plenty of bleeding. Some of the photos I have seen on this thread makes me think that many of you are being way too timid with the needle and not going deep enough or enough times (I am still talking about the needling technique, by the way). Remember, the idea is to push the virus into the body, not tickle it on the skin!

 

DEFINITELY WENT DEEP AND GOT LOTS OF BLEEDING WITH MINE - TOOK THE PICS AFTER STEMMING HAEMS WITH DIRECT PRESSURE ALTHOUGH HAVE BEEN MORE AGGRESSIVE WITH LATER CASES

 

For months now I have been trying to get a patient to agree to needling but as soon as I mention LA they opt for the more conventional treatments. Does anyone else have this problem?

 

As a matter of interest is seems that a plastic surgeon uses a similar technique to treat his patients wrinkled lips and scars.

http://www.environ.co.za/contents/articles/skin_needling.htm

 

yes, several patients have decided against as they are scared of injections....not much you can do about that. Promote the features and benefits....major one being that if it works it's a "one-hit wonder", and they will not need ongoing and awkward treatment. It is also much cheaper if its works than months of other therapies.

I explain that the worst bit is the injection, ask if they have had injections before and how they found them, and that after the LA there is no pain during the procedure. If your injection technique is good then the patient will only feel the first "stab" as you can then anaesthetise in advance of your needle progression.

If they are not convinced I usually suggest chemical therapy or taping, after weeks or months of treatment they may change their mind.......

Hope this helps

 

Hi JMD,

If the pt. is a touch 'needle shy' Entonox may be of use pre-op.

Previously discussed in the following thread: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=12653&highlight=entonox

You do not indicate your location. Our local branch of the Society of Chiropodists & Podiatrists are holding our annual basic life support & anaphalyaxis session in Doncaster in August this year. Entonox administration training may be offered as part of the session for those interested. Our local ambulance service is providing the course.

Please let me know if this is of any interest to you.

Regards,

Mandy.

 

Hi Mandy,

I am from bonnie Scotland, the place where the sun never shines.

In August I am attending a medical gas training course on the use of entonox and will probably offer this prior to LA procedures for nervous patients. I believe it is the description of the needling procedure that puts patients off. I have never liked the word 'needling' and I am looking for an alternative phrase such as, subcutaneous VP infiltration. What do you think?

By the way, just saw a patient with multiple VPs and I did not use the word 'needling' and he has booked in for the procedure.

 

How did you describe it and do you describe the procedure on your written consent to the local anaesthetic?

cheers

 

JMD

how about hpv immunisation....same as is being done in teenage girls to prevent cervical cancer? or subcutaneous hpv immunisation? If you explain it in similar ways to vaccination the patient may be more willing.....

Julian

 

Hi all,

Have been following this thread from the beginning with much interest. As a result we have now performed several needling procedures within our department (NHS South East Highland). Saw our first patient back today for her 4 week post op review. Photos speak for themselves- delighted!









Pic 1: Before t/t
Pic 2: After t/t
Pic 3: 2 days post t/t
Pic 4: 4 weeks post t/t

As you can see they are all but gone. This patient also has mosaic VPs on her left heel which unfortunately do not seem to have responded, had hoped by treating one foot other may also clear. Early days yet though and given the results of her R/ Hallux, the patient is more than willing to come back and have her R/ heel done if required. Heres hoping our other patients have such impressive results!

Thanks
Naomi

 

Apologies for the oversized pics- new to this! Oh well at least you can see them in detail!
N

 

When a patient first presents with a VP I like to give a full explanation as to its cause and how it can be easily transferred between individuals. I also like to give advice on all treatment options prior to mentioning the needling technique. When I do mention this technique I make a point not to use the word needling. I explain that although there has been no real scientific study the procedure is gaining popularity within the podiatry profession with reports of 80-90% success rate. The patient is also given a form which gives a general description of the procedure with FAQs and answers, If the patient agrees I or my nurse carry out vascular and neurological tests. At this time the patient signs a consent form giving authorisation for the procedure. This form is separate to the one signed for the LA.

 

Naomi:

Very nicely done clinical photos! Please, for all those who want to see an example of what nice clinical photography is all about for presentation or publication, Naomi's photos are fine examples of good lighting, good focus and good detail. Thanks for that, Naomi.

 

Mandy:

Instead of using something like Entonox, why not use ethyl chloride spray to temporarily freeze the skin during the injection? I have been using ethyl chloride spray for nearly all my local anesthetic and cortisone injections for the past two decades and this greatly diminishes the initial pain of injections. This is a very simple technique that works very well for nearly all patients to reduce the discomfort of local anesthetic and cortisone injections.

 

Nice one Naomi - hope you do eight week review pics too - at this time I wouldn't count your chickens though - I have had great responses with caustics that look like this only for them to spring up again - if they do completely go - which looks likely - PLEASE PLEASE do follow up in 6 and 12 months to see if they return - NOBODY made any comments about my post last week regarding the 50% recurrence quoted by a colleague of mine who has used this approach on and off for many years

 

Thank you Kevin,

Certainly worth consideration. I will offer this option as a possible alternative in future. If it is just the initial scratch which causes the patient discomfort then I think your option is a very useful one. However if the pt. is truly needle phobic Entonox would (only in my limited experience) be my first choice as often even the thought of the needle sends the individual into an anxious state.

I would also like to add my thanks to Naomi for her impressive photographs. Naomi may I ask providing you are credited with the treatment photographs would you have any objection to my downloading & printing them for patient information purposes?

Many thanks,

Mandy

 

Steve:

I haven't had verrucae plantar lesions recur in my patients, to my knowledge, after using the "needling technique". However, this is theoretically possible, especially if the body's immunity status changes or if there are different "strains" of virus that the body will need to become immune to in order to prevent future infections.

By the way, Steve, you had very nice photos also.:drinks

 

Thanks Kevin but I wasnt fishing for compliments - Honest!!!!!!

 

Here's another question for you Kevin - I want to check my technique attached is a picture of one I did today after needling - 27g needle at least 150 punctures to approx 5mm depth with profuse bleeding - the photo was taken after the haem was stemmed with direct pressure and just prior to dressing after wiping clean - does this look right? - need to know if my technique is lacking!!

 

Thanks to Steve Wells for letting me be present at this session.

Ian

 

Steve:

This technique sounds and looks good to me. However, I have been using a 25 gauge needle for my puncturing since I think the bigger needle is a little stiffer, a little easier to handle and it makes sense that it may carry more virus particles into the foot than does a 27 gauge needle. Don't know for sure, just a guess.

 

great thanks kevin - will try that

 

Hi Steve,
Thanks for that, I have booked patient in for 8 week post op review and will post pics then. Will certainly review her longer term also. We are expecting several other patients in over the next week or so for their 4 week check and so will follow them all through in the same way.

Even with a 50% recurrence rate I feel it is definately still worth doing, I tend to find recurrence for blunt dissections probably higher than that and not suitable for these mosaic lesions any way. I would be interested to know what kind of recurrence to other people experience after blunt dissections of more isolated lesions?
Naomi

 

Hi Mandy,
I have no objection to this, patient consented to use for health promotion purposes so all good,
N

 

I would just like to say thank you to all those who have put pictures up, they are a great help.

I would like to try this myself but my manager would like to see any evidence of it working before he will give the go ahead, would anyone mind if I used the pictures and findings posted here to put to my manager?

 

What are the indications for an ankle block versus local infiltration (& vice versa) in cases that are being discussed here? Patient tolerance is perhaps greater with an ankle block than local infiltration?

 

Hi all, I've just jumped onto this thread, and wanted to add my couple of cents worth.... We use this needling technique at our clinic and with a 100% success rate we strongly advocate it. We perform it as per kevin's directions and have done so for several yrs on approx 30 odd patients. We do also use this technique on singular longstanding warts for appropriate patients. I strongly advocate this technique. It's quick, easy, produces great results and doesn't require back and forth visits for the patient.

 

Hi Burris - thanks for the info - but it would be helpful to put those statistics in context impressive as they are - you say 30 patients over several years - you must have a specific selection criteria for this technique - I am often seeing around 30 VP pts a month - can you elaborate at all? - 30 pts over several years doesn't sound like you advocate it that strongly with all due respect.

steve

 

Position of lesion and relevant nerve supply, what the patient is doing immediately after procedure (not easy driving or getting around on a numb foot!!, comfort (prefer ankle block over local infiltration again depending on location) local pathology in area of injection site - will add any more i can think of

 

Hey Mate,

Any results from the Photo Foot? Its been 2 months now.

 

As a former dental nurse, I have seen dentists who give injections so carefully, and stealthily(sp)?, that the patients have to ask for an injection before he starts! some were bad, but dentists give a lot more injections, practice makes perfect.

 

And th emouth is very different to the foot!!!!!!

 

hi all,

a big thank you to those who have posted on this tread; some great stuff still coming through...

Mandy, would you mind if i also pinched your pics as they were particualry impressive!

About the 'name' of this therapy...in an info letter i called this tt 'verrucae immune stimulation therapy' (shortened to VIS therapy)...how does that sound to you all?

regards

poppet

 

Cool, although I rather liked Steve`s Percutaneous Immune System Stimulation ...