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Silver Nitrate use on VPs and NVCs

Discussion in 'General Issues and Discussion Forum' started by Blue123, Aug 15, 2010.

  1. Blue123

    Blue123 Active Member

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    having recently started mentoring a new graduate podiatrist in a routine private clinic a few days per month i realised a few gaps/memory blanks in my skillset.

    The clinic markets themselves a lot on the treatment of vps and personally i have always opted for advising self tx or cryo, this clinic treats with 75 percent silver nitrate sticks and although i have used this frequently over the years i do not want to mentor a new pod with any of my shortcuts etc so can anyone provide a university standard protocol for the use of silver nitrate??

  2. footsiegirl

    footsiegirl Active Member

    I recently read an article (unfortunately I havent got it to hand right now) which advocated using it for no more than 6 applications due to toxicity. I will have a look and see if I can find it
  3. cornmerchant

    cornmerchant Well-Known Member

    Dont bother , it doesnt work.

  4. Blue123

    Blue123 Active Member

    what works in your opinion cornmerchant?

    Unfortunately not named after that one michael, haha!
  5. cornmerchant

    cornmerchant Well-Known Member

    If I knew the answer to that one I would be a millionaire!

    I get patients to self treat, go to VP cinic for freezing if they are desperate, or I have started needling but dont have much evidence at present as it is wait and see time!

    Just never had any success with Silver nitrate, however keen I was when newly qualified!

  6. blinda

    blinda MVP

    Ah yes, the ol` jelly wrestling scene...

    Back to the OP:
    Whilst I don`t have a university standard protocol for the use of silver nitrate I have done a little research on it`s use in podiatry.

    Whilst it is classified as a caustic (because it is caustic when applied to mucous membrane) it is really a strong astringent and the dark plaque of silver chloride toughens up the epidermal tissue, making sharp reduction easier. It is a protein precipitant, ie it reacts with the protein in cells and is thus self limiting. As CM states; pretty ineffective in VP tx.

    However, the manufactures recommendation for application for each VP is “ 1-2 minutes after reduction of keratinized tissue. Leave 24 hours between each application Four further applications may be applied”. The reason for caution in the amount of applications is that continued use to an open wound can lead to argyria, which is a bluish-black discolouration of the skin due to depositions of granules of silver compounds in the connective tissue, which can take a while to disappear and can cause further complications. But, to be honest, argyria is unlikely and more often associated with colloidal silver solutions than with silver nitrate .

    It has been suggested that it has a mild keratolytic action but this mode is quite insignificant in comparison to the other acidic caustics. I do use it for children as it does not hurt and does not interfere with their daily activities, unlike SalA. The eschar slows down development of the callus and also, IMO, assists in placebo effect. Much like `buying verrucae`!

    For recalcitrant, mosaic or just plain stubborn VP`s I also needle.....fantastic results!

    Hope that helps,

  7. Heather, what has newly qualified got to do with anything, perhaps a little more support and guidence to the newly quailified rather than the "old pull your head till you get some experience ".

    The more support and help from the older heads and gentle push in the correct direction the better for the profession, remember these new grads that come on to places like here are the ones with the open minds that want to learn, get enough put downs or negativity the more likely they are to stop wanting to learn.
  8. blinda

    blinda MVP

    Here`s one I needled 2 months ago...



    Cool, eh?


    PS Sorry about the poor quality of the post op photo, the pt took this and sent it to me a couple of days ago!
  9. cornmerchant

    cornmerchant Well-Known Member


    I am sorry that you misinterpreted my post completely- I was not being negative to new grads- I was merely sayng that when I qualified it was one of the modalities that was sold to us as a treatment and I just didnt get results! I believe Belinda actually confirmed that in her post.

  10. mgates01

    mgates01 Active Member

    The alternative options for treating VPs have been well documented on this site, however, referring back to the original query which included NVCs, I wonder if anyone has any alternative options for treating these. I have a couple of patients (one with a dorsal corn and another with a plantar corn) both of which have been treated over the years rather injudiciously, not by me, with various caustics. This has left the skin appearance and texture rather dystrophic/scarred. Maybe I am looking for a quick fix but I often wonder if one could excise the diffuse scar tissue and re-suture a neater scar-line would this be more beneficial to the patient, bearing in mind any such surgery would be followed by proper off-loading of the area.

    Has anyone any thoughts on/experience of this.
  11. Ballantyne_23

    Ballantyne_23 Member

    Can anyone explain to me the 'needling' procedure that has been discussed here

  12. blinda

    blinda MVP

    It is explained in detail on the first link that Michael provided, in the fourth post on this thread.

    Happy reading, there is a lot to trawl through, but well worth it!

  13. Ballantyne_23

    Ballantyne_23 Member

  14. Mr C.W.Kerans

    Mr C.W.Kerans Active Member

    mgates01 thread on 15.08.10. The condition of the skin damaged by the misuse of caustic agents might be improved by using Bio-Oil - seems to work, but I have only anecdotal evidence and limited personal experience. Worth a try. With regret, no useful insights with regard to managing neurovascular corns (NVC's).
  15. Cameron

    Cameron Well-Known Member


    Silver nitrate is a protein precipitate which in the presence of light turns black. (See any of the pharmacopoeias for more details). It was used to darken the skin striations as a means of aiding diagnosis. i.e. to see clearly if the circumscribed lesion was still present in the case of verruca. When used with neurovascular corns the idea was to dehydrate macerated tissue to aid minute dissectioning with the scalpel at the next visit. Can be used as a styptic too but was thought according to Reid to lead to infection in some cases.

    Somewhere along the line application of AgNo3 was thought to assist in clearing viral infected tissue but there is no independent evidence to support this. Spontaneous clearance of VP after silver nitrate applications would be purely coincidental.

    To the best of my knowledge unlike pyrogallol repeated applications of silver nitrate as a protein precipitant of keratin would neither have an accumulative effect nor prove toxic to the tissues.

  16. Jaimee Brent

    Jaimee Brent Active Member

    What i found interesting is how with patient self treatment (which in my opinion very seldom seems to work with conventional pharmaceutical treatments) effective homeopathic treatments are often looked over.

    i've actually found that the use of the old banana peel therapy is much more effective than the low percentage sal acid tinctures that patients buy from clinics. Furthermore, this wasn't even mentioned at uni.

    Apparently the chemical released from the blackening banana skin is very similar to sal acid, and the application of this to the VP's surface causes the same style of maceration and blistering.

    I've found it very effective. However would not use on Diabetics, as it can cause minor ulcers if it is left on for too long a period.

  17. Cameron

    Cameron Well-Known Member


    You would need to ask the universtiy for their clinical protocols (something I would assume they should issue regularly to clinical supervisors as part of duty of care).

    Most do not even think of the need because we do seem to prefer as a profession occult practice rather than science based practice.

    Best clicinal practice is usually supported by ebp (where avaialable) and in this case reference to the Cochrane Library on the treatment of warts would be helpful to you. Martindale too has useful information to the practitioner. The few podiateic pharmcopaedia still available (in print) do tend to expand on the 'older treatments which can be a intersting read but often lacks any supportive evidence.


  18. jambutty

    jambutty Member

    I have had great success with AgNO3 on NVCs when they can be thoroughly enucleated.
    I have found that even when high-level discomfort is present (which limits scalpel work) persistence has paid off, sometimes with the application of a small amount of sticky Friar's Balsam when the area is macerated.
    Treatments applied every 4 weeks and no more than 6.
    Localised discomfort can occur as the treatment progresses and (of course) underlying causes to be addressed where possible.

    BEWARE the possibility of a reaction to it's toxicity by fair-skinned people (so do not use on this group), I'm not sure of the physiology (?) but the effects are swift.
    Also, a cautionary word I wrongly used it on a client with dyed black hair and a fake tan, she is still alive!

    No success with VPs - only as a styptic after debriding.

  19. Cameron

    Cameron Well-Known Member

    jambutty et al

    As a protein precipitant AgNo3 is ideal on NVC because it presents an eschar (also a barrier to its own penetration) Hence toxicity is an unlikely event . Again according to the older (chiropody) pharmacopae there is an increased risk of (bacterial infection) when using repeated AgNo3 applications but otherwise no cummulative problems. That is what it says in the text, anyway. Common sense might support formation of a (hard) eschar could under certain circumstnaces add to general discomfort on very sensitive areas.

    Using surface analgesics would potentially give a sedative feeling (probably more due to the halo effect) but all is fare.

    In the dim past (and may still be practised) nitric acid solution was regularly used on neurovascular corns but I have no experience of this.

    To be brutally honest I have never seen a neurovascular in 40 years practice. I have treated thousands of corns with dermal protrusions (many butchered by self treatments) but never witnessed neural bundles as described in the text books. One telling diagnostic features apparently is when the steel scalpel is exposed to the surfaced nerve fibres it illicits the same response as chewing silver paper.

  20. Catfoot

    Catfoot Well-Known Member

    You said

    Which actually make me wonder if all those NV corns I've treated were, in fact, imposters ? The response from the patient was just like you described. One lady used to stuff an old towel in her mouth when I did the treatment.

    We were always taught to use AgNO3 in these situations but I now have doubts as to its efficacy.

  21. Cameron

    Cameron Well-Known Member


    I used to see a lady of a particular nervous disposition with painful corns (I have no doubt). Fellow practitioners had previously been challenged with how best to manage these chronic lesions as the record card would attest. The practice then was to pass the client onto another practitioner (usually a novice).

    I was the clinical manager and felt this would be inappropriate. Working with the client was quite a challenge and winning her confidence seemed the way to go. To my shame I told her I had special scalpels with the blades impregnated with local anaesthesia. These had been imported (from France?) and we were trying them out in the department. Adeptly I drew the blade across the callused area and asked if she felt any discomfort. "No" came the reply, so I completed the reduction and sent her on her way. Each time she returned she asked for the special scalpels and was perfectly relaxed. I left that post and went back into teaching and a couple of years past when a visiting podiatrist came to the college and wanted to meet me.

    After the usual introductions she equired, "Glad to meet you at last and always wanted to know where you got your supply of French scalpels with the aneasthetic ?"


  22. Catfoot

    Catfoot Well-Known Member


    Love it!

    When I worked for the NHS I acheived very good results with children who had small VPs by telling them that the Silver Nitrate stick was a "Magic Pencil".......whether the lesions would have resolved anyway we will never know.

  23. Cameron

    Cameron Well-Known Member


    The placebo effect is well known. I worked with a chap who had a bottle of tap water and would regularly tell the school children it was Holy Water. He painted their verrucae with the water and without a word or a lie the cure rate for the Catholic children was significantly high whereas the protestant kids not so, some even broke out into multiple outcrops.

    Had I not seen it with my very eyes I would not have believed it.


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