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Risks to consider in VP treatment; including needling.

Discussion in 'General Issues and Discussion Forum' started by blinda, May 24, 2014.

  1. blinda

    blinda MVP

    Members do not see these Ads. Sign Up.
    Dr Farina Hashmi presented this paper at the Primary Care conference this week, which stimulated a great deal of interest and discussion;

    The safety of utilising the needling method was vehemently questioned by a member of the audience, which certainly deserves answering. Another delegate maintained that we should not be treating verrucae at all, instead we should be creating an environment in which the virus is unable to inhabit/thrive. Interesting.

    These comments highlight the importance of both patient and practitioner understanding the aetiology of HPV infection, their sub-types, as well as the risks and benefits of ANY verruca treatment.

    Whilst it is true that there is currently sparse evidence on the safety and efficacy of needling verrucae, it should be noted that this is NOT a new treatment modality and has been successfully utilised internationally for over 45 years. Farina rightly acknowledged this and I support her `call for randomised controlled trials into this promising treatment`. Until that happens, we should consider the risks and benefits that are already available to us.

    Is it a VP....or something else?
    It goes without saying that, as with any treatment plan, correct clinical diagnosis of any lesion is of paramount importance. If you`re at all unsure of diagnosis, or any lesion is worsening/ not responding to tx ALWAYS refer for biopsy. A large portion of claims against practitioners for `verrucae` treatment with adverse events reported, is for the misdiagnosis of what was actually a malignancy, ie; amelanotic melanoma, squamous cell/nodular basal carcinoma, etc can look remarkably similar to HPV. To compound matters, there is also the very misleading term `Verrucous Carcinoma` used for a squamous cell carcinoma, which is not associated with the Human Papilloma Virus. `Verrucous` is merely a pictorial expression for describing the appearance of the malignancy; ie, `verruca looking`. See here; http://www.ncbi.nlm.nih.gov/pubmed/15108936

    Does needling present any danger of `spreading cancer`?
    As practitioners we are obliged to understand and explain to our patients the relevance of HPV sub-types. This is imperative as many people wrongly associate `HPV` with `Cancer`. All warts on the body are of the human papilloma family. There are over 100 HPV types and amongst these there are about 40 genital HPV types. Amongst these are the HPV sub-types that are associated with malignant change. The `High risk` HPV types are the ones that have the DNA potential to progress to cancer, thus they are considered carcinogenic. These are; HPV-16, HPV-18, HPV-6, and HPV-11. The HPV-16 and HPV-18 are the most prevalent types involved in the pathogenesis of anogenital (e.g., cervical) cancer, and HPV types 6 and 11 cause genital warts and laryngeal papillomas. That said, most men and women with high risk HPV do not actually progress to cancer, as the body builds the needed immunity to the acquired HPV type.

    So, to reiterate; high-risk HPV types have been identified in cancers of the cervix, vagina, vulva, anus, and penis. Therefore, they are also called carcinogenic HPV.
    Low-risk HPV types are virtually never found in cancers. Therefore, they are also called non-carcinogenic.

    The sub-types HPV-1, HPV-2 & HPV-4 are associated with the hands and feet and seldom undergo malignant change. It`s not impossible, but very rare indeed as these sub-types can only replicate in the epidermis and utilise methods to positively avoid infection of deeper tissue (unlike the high risk alpha-PV types mentioned earlier, which infect genital mucosa) as this would induce an immune response to eradicate the virus.

    Basically, 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

    DNA structure determines the HPV sub-type and it is with this information that the recently available preventive vaccines for high risk types were formed; to target the specific sub-types HPV-16, HPV-18, HPV-6, and HPV-11. I`m sure that in the not-too-distant future, a vaccine will be developed using the same technology to target the benign sub-types associated with hand and foot warts. Until then, we can only utilise treatments that have been shown to both destroy HPV infected keratinocytes and induce an enhanced immune response to eradicate the virus.

    Is HPV infection indicative of an `Impaired` Immune System?
    Caution should always be exercised whilst discussing “impaired immune systems” with patients who have HPV infection. Whilst it is acknowledged that immune-compromised patients are obviously more at risk of contracting and manifesting any viral infection including HPV, we cannot and should not assume the vice is versa. Moreover, we should be reassuring our patients that HPV infection is not indicative of an “impaired immune system”, as this clever virus has adapted ways to positively avoid a localised immune response in healthy, immune-competent patients.

    There are a number of factors involved that contribute to the absence, or reduction, of a cellular immune response in immune-competent patients. Briefly they are;
    • The epidermis is avascular.
    • Latent virus particles in adjacent cells are not destroyed in keratolytic treatments (Bristow & Stiles, 2011)
    • HPV can alter Langerhan cell function and activate T suppressor cells (Frazer, 2009)
    • Virally infected cells have no surface markers (Bergot et al, 2011)

    In addition to the references cited above, see the interesting site here;
    http://www.bio.davidson.edu/people/sosarafova/Assets/Bio307/emmccracken/page 05.html

    So, Is needling verrucae “dangerous”?
    As with every verrucae treatment modality, needling is not suitable for all patients. A full medical history should reveal any contraindications such as; true needle phobia or allergy to LA. Of course, the decision of whether to treat is incumbent on the practitioner according to ascertained risk. Thus, a patient with peripheral vascular disease, DM or any other underlying systemic condition which renders them `high risk` for delayed healing should be carefully considered for any VP treatment that creates a wound by tissue destruction; i.e. acids, cryotherapy, laser treatment or needling. In high risk patients, the option of `no treatment` is often most suitable, or utilising conservative care in purely offloading any painful lesion and frequent sharp reduction of overlying callus as the most appropriate treatment plan.

    There is a plethora of literature detailing adverse events associated with caustic and freezing verrucae treatment which has resulted in tissue breakdown, abscess and deep seated infection, even amputation, yet practitioners continue to utilise the same treatment modalities. Why? Because current scientific evidence suggests that caustics are still deemed to be significantly efficacious and relatively safe IF USED APPROPRIATELY AND WITH CAUTION....much like needling. As stated earlier in this post; needling is not a new treatment modality and has been successfully utilised internationally for over 45 years, but is yet to be subjected to randomised controlled trials. Trials are in the pipeline and meanwhile, retrospective studies are continuing to suggest this is a safe and efficacious treatment.

    If we have considered all of the above, ie; correct diagnosis, aetiology of HPV and suitability of the individual patient requesting VP treatment then, in my professional opinion, needling is no more "dangerous" than any other VP therapy. In fact, it could be argued that there is less tissue destruction as a more controlled wound is created than with caustics and freezing.

    It has been stated that treatment should result in resolution of all or a great percentage of warts, be painless, need only one or a part of a lesion treated, create no scarring and offer HPV immunity for a lifetime. Needling a single lesion as first described by Falknor in 1969, appears to tick these boxes. This is, of course, part of ongoing research.....watch this space.

  2. Ian Linane

    Ian Linane Well-Known Member

    Thanks Bel. I wonder if the content of this should be further expanded to go into Pod Now where it may reach a broader podiatric audience than here?
  3. blinda

    blinda MVP

    Great minds, Ian.......
  4. wdd

    wdd Well-Known Member

    It has been stated that treatment should result in resolution of all or a great percentage of warts, be painless, need only one or a part of a lesion treated, create no scarring and offer HPV immunity for a lifetime. Needling a single lesion as first described by Falknor in 1969, appears to tick these boxes. This is, of course, part of ongoing research.....watch this space.

    While realising that Dr Hashmi's paper was focusing on bigger things like cancer and suppression of the immune system I still Wonder about the statement that this treatment 'creates no scarring'.

    The verruca is stabbed with a needle a large number of times. I think I have read that the intention is to make the area 'mushy'. The area bleeds, indicating that the damage is not confined to the epidermis.

    Where does the statement that the technique creates no scarring come from? What is the level of evidence for this statement?

    Was the researcher focusing on identifiying scarring or was it done by eyeballing the area when the the main focus was looking for resolution of the verruca? Was any magnification used to determine scarring? Was it followed up six months later or a year later or even five years later?

    My concern with scarring is related to the plantar aspect, ie an area of highly specialised tissue whose structural and functional integrity allows it to absorb and transmit forces with minimal injury to the skin and subcutaneous tissues.

    OK. Microscopic scarring may be invisible to the naked eye and may not cause a problem for décades after the needling but reduced tissue vitality, directly or indirectly associated with ageing could mean that the area of microscopic scarring becomes the site of a pressure lesion.

    How is the statement 'creates no scarring' arrived at?

  5. blinda

    blinda MVP

    Hi Bill, Hope you`re enjoying your Sunday afternoon :drinks

    No, Farina and Ivan`s paper was on needling with some new data on auto-inoculation, not malignancies or compromised immunity. Sorry if I gave that impression.

    That`s right. We puncture through the dermis into the subcutaneous tissue, so yes there is damage to the dermis, but this is limited as there is only pin-point bleeding unlike cutting through the dermis. We discussed it here, http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=300845&postcount=44 a while ago where I found a very interesting paper which confirms that that pin-point bleeding usually heals with complete tissue regeneration, whereas an incision, no matter how small, usually results in scar formation.

    That was, and still is, my clinical observation post operatively at 8 weeks and a year later. My paper was only published a year ago, so give me time! Like I said, it`s a work in progress.

  6. wdd

    wdd Well-Known Member

    As a child I remember playing with my mother's sewing machine. I would run pièces of paper through it (without thread on the machine) and look at the patterns created by the pin poin holes. As that became a bit boring I adjusted the stitch length and very quickly discovered that by shortening the stitch length sufficiently I could cut the paper in two. To put it another way I could join up the dots and create a linear cut.

    I would think that the same type of thing is possible when needling a verruca? I would also think that the risk of joining up the dots is related to the size of the point of the needle, the needle diameter and the proximity of the puncture wounds amongst other things. I notice that there is no fomula suggesting an appropriate density of needle insertions. Could it be important, ie too close might join up the dots and ultimately result in scarring?

    Approximately what density of puncture wounds would seem about right?

    Do you have a pattern that you follow when needling, eg left to right top to bottom, to minimise the risk of placing needle holes too close to one another?

    Keep up the good work.

  7. blinda

    blinda MVP

    I like your thinking, Bill.

    The sewing machine analogy is one that I have often contemplated. Ok, maybe I wasn`t thinking of Singers, more of a tattoo gal myself, but I get the picture. All i can say, from a clinician point of view, is that I have not seen any scarring resulting from this procedure. Quite the opposite in fact. On occasion I have had patients present with plantar VP`s enmeshed with scar tissue from previous treatments, in particular from electro-surgery and laser treatment. Astonishingly, needling the area has not only resolved HPV infected keratinocytes, it also appears to have reduced/improved existing scar tissue, albeit from my very subjective clinical observations...fascinating stuff, eh?

    Density of needle insertions, or depth of penetration, will vary according to site of the lesion and upon which aspect of the foot you are needling. As you (of all people) know, the thickness of the epidermis, dermis and subcutaneous layers vary throughout the body and from person to person and even on different aspects of the plantar surfaces. For example, the epidermis of the heel can be approx 4mm thick and the base of the mets just 1.5mm. So, you would penetrate to a depth of approx 5-6mm on the heel and approx 2-3mm on the base of the mets.

    I personally don`t have a specific pattern that I follow other than to produce pin-point bleeding until there is no more resistance felt over an entire designated lesion. Obviously, you wouldn`t go any deeper than just below the dermis as you could cause damage to other structures.

  8. blinda

    blinda MVP

    For the record; the original post in this thread are my thoughts and observations based on current available evidence, not the comments made by either Dr Hashmi or Dr Bristow.
  9. wdd

    wdd Well-Known Member

    Hi Bel,

    Thanks for pointing me in the direction of the followind reference.

    published 29 May 2004, doi: 10.1098/rstb.2004.1475359 2004 Phil. Trans. R. Soc. Lond. B
    Mark W. J. Ferguson and Sharon O'Kane therapeutic intervention free healing: from embryonic mechanisms to adult−

    In the article they mention that at that time there were drugs, intended to reduce or eliminate scar formation, undergoing clinical trials. Are they on the market now?

    Astonishingly, needling the area has not only resolved HPV infected keratinocytes, it also appears to have reduced/improved existing scar tissue, albeit from my very subjective clinical observations...fascinating stuff, eh?

    It certainly is fascinating. If needling reduces scarring it might have applications way beyond verruca treatment and way beyond the foot?

    When I was thinking about density I wasn't thinking about it in 3D only in terms of the 2D density.

  10. dyfoot

    dyfoot Active Member

    Thanks blinda, fantastic work. When are you coming to Australia to present this at a conference?
  11. wdd

    wdd Well-Known Member

    So, you would penetrate to a depth of approx 5-6mm on the heel and approx 2-3mm on the base of the mets.

    I would imagine that the 'thickness' of the tumour would add an x-factor to the above?

    I tried online to find photos of scarring following treatment of plantar verrucae but without success. All I found was a before treatment and after resolution photo of plantar skin. The only apparent difference was that the striations in the area of the lesion seemed wider and deeper than those round about. It's looked similar to what you see when you reduce callus. Any ideas what the signifcance of the hypertrophied striae might be?

    I'm sorry that I'm full of questions but this will be the last one in this post at least. What does scarring following treatment of verrucae look like?

    Best wishes,


  12. zsuzsanna

    zsuzsanna Active Member

    Very interesting and thought provoking article. I have never done needling (being a coward!) but wondered if paring the VP until there is slight bleeding of capillaries helps to 'inoculate' the body with the virus and produce an immune response.
  13. blinda

    blinda MVP

    Yes, but you still only need to achieve pin-point bleeding. I wouldn`t advocate penetrating any deeper.

    I don`t have any photos of scarring post vp treatment, but to the casual observer it looks no different to a common or garden variety of scar tissue; fibrotic. If you`re after info on the formation of hypertrophied striae, you may find this article of some interest; http://www.derm.theclinics.com/article/S0733-8635(05)70451-4/abstract

    Don`t apologise for asking questions, Bill. How else do we all learn :drinks

  14. blinda

    blinda MVP

    Thanks, zsuzsanna.

    The work of Parton and Sommerville asserted that resolution of a single plantar verruca could be successfully achieved by lightly debriding the lesion to produce capillary bleeding and then abraded with fine glass paper....but that was in children aged 4–14 years, so spontaneous resression could not be ruled out.

    I wouldn`t describe capillary bleeding as auto-inoculation as the viral particles are not being planted into deeper tissue. That said, any trauma which induces inflammation does have potential to initiate an adaptive immune response. Whether the appropriate amount of cytokines would be produced in this localised inflammatory process is impossible to predict.

    Ref; Parton, A.M.; Sommerville, R.G. The treatment of plantar verrucae by triggering cell-mediated immunity. J. Br. Pod. Med. 1994, 49, 205.
  15. podiatry.on.line

    podiatry.on.line Welcome New Poster

    Maybe I have missed reading about this but I assume that 'needling' is performed under local anaesthesia ?
  16. blinda

    blinda MVP

    You wouldn`t wanna create a beefy red wound without it ;)

    Prof Kirby describes the technique perfectly and includes a beautiful illustration in this thread;


    With 68 pages there`s a lot to trawl through, but well worth it.
  17. Ian Reilly

    Ian Reilly Active Member

    Interesting thread, Bel

    Can i just jump in on plantar scarring? I do all of my neurectomies though a plantar incision with very few problematic scars, inspired by some of the technique tips of Dock Dockery (we audit all our results on PASCOM). Not what we were taught at Pod School!

    I've done many corn and VP excisions over the years. I will do flaps and certainly lots of cure for plantar corns and often the scarring is minimal, or at least better than the original lesion.

    Ive switched from curettage to 2 rounds of needling for VPs as i see about a 10% recurrence and 10% problematic scarring in the VPs. No scarring to date with needling...


    Last edited: Jun 2, 2014
  18. blinda

    blinda MVP

    Hi Ian,

    That`s interesting. I`m a fan of The Dock too; Cutaneous Disorders of the Lower Extremity is my bible.

    I agree, a small painless scar is often a better option than any painful lesion.

  19. blinda

    blinda MVP

    Too much :morning:. Obviously.
    Last edited: Jun 3, 2014
  20. TransDerm Solutions

    TransDerm Solutions Welcome New Poster

    The lack of a definitive treatment that everyone can agree on, that is effective and patient-friendly is troubling. In the case of large mosaic warts, de-bulking of the lesion for pain relief and access through the typically hyperkeratinized tissue is critical. Needling doesn't seem to address those treatment needs.
  21. Of course, Mr. TransDerm Solutions, you wouldn't think that any other treatment other than using TransDerm Solutions is very good, would you?

    Why don't you go advertise somewhere else and go away!
  22. TransDerm Solutions

    TransDerm Solutions Welcome New Poster

    Quite the contrary - many treatment techniques are being combined in order to try and secure a successful outcome for the patient. As Michelle Lipke illustrated in her exhaustive article "An Armamentarium of Wart Treatments", (12/2006 Ed. of Clinical Medicine & Research) there are still hundreds of wart treatments being used by clinicians and non-clinicians today with varying degrees of success reported anecdotally. Needling happens to be one that is seeing quite a bit of interest lately. It has been very interesting to follow this narrative. No personal affront was intended - but the patient's discomfort is an important consideration. Thanks for your reply...
  23. admin

    admin Administrator Staff Member

    There is NO fine line between being a useful member of the community and advertising. No advertising.
  24. blinda

    blinda MVP

    Your assumption is incorrect.

    Yes, we are all aware of Lipke`s 2006 review. In fact, Lipke`s observation that “lack robust evidence of a therapy, does not mean that it`s not worth knowing about nor worthy of use in practice, particularly when specific tx been reported with a reasonably high clinical success rate” was cited in my published clinical review of needling VP in practice. Moreover, I reported "All treated patients reported their pain level after needling as either “none” (n = 29 [64%]) or “mild” (n = 16 [36%]) describing mild symptoms such as “bruising” or “slight discomfort”. So, yes. I am affronted when you accuse practitioners who utilise this treatment method of not "considering patient`s discomfort", when the research clearly states otherwise.
  25. Why do these people who want to advertise their product not want to tell us who they are? Are they afraid of being associated by name with the product they are trying to shamelessly advertise on Podiatry Arena?

    Craig, it's about time we made rules that product/company names may not be allowed as member names on Podiatry Arena. They are abusing the privilege of posting on Podiatry Arena by putting up their product/company name/slogan/advertising graphic every time they post here on Podiatry Arena.

    I think it looks bad for an academic healthcare professional site to allow this type of advertising. No advertising graphics should be allowed on their signatures and no product/company names should be able to be used as their member name.
  26. blinda

    blinda MVP

    I completely agree, Kevin. This particular company has had previous posts removed for attempting blatant advertising.

    Just planting seeds.....(Hicks, `93)
  27. Dr. Bates

    Dr. Bates Member

  28. Kaleidoscope

    Kaleidoscope Active Member

    On the subject of scarring, I have pictorial evidence (before, during and after) of a needled site that previously had a long term scar incorporated into the VP which, post-needling has completely disappeared - along with the VP.

    The pt is extremely pleased as the scar was as a result of a most unpleasant incident in her childhood and seeing it was a constant reminder.


    (Please forgive my lack of detail)....but wasn't there too a recent TV programme
    /internet video (sorry cannot remember any detail only that it was say within 6 months) where a young girl was scarred as a result of an accident with a kettle (?) of hot water to the left side of her face and despite alot of surgery, during which her face had been rebuilt, it sadly left scarred white skin which she was told could not be improved further.

    She wouldnt accept this, and took up tattooing, and worked on her own face with pigments the colour of her facial skin. Such 'needling' not only got rid of the whiteness but wonderfully broke down the scar tissue, and she was congratulated on her perseverance and told that her persistance gave hope to others with similar facial scarring?

    Linda Russell

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