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The Treatment of Verrucae Pedis Using Falknor's Needling Method: A Review of 46 Cases

Discussion in 'General Issues and Discussion Forum' started by Kevin Kirby, Apr 2, 2013.


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    Congratulations to Belinda Longhurst (Blinda) for a very nice paper just published on Falknor's needling technique for verrucae plantaris.:drinks

    The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

     
  2. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Thankyou, Kevin. This would not have been published without your original posts explicitly describing this treatment, right here on Podiatry Arena.

    Ivan and I owe you a beer or two.

    Cheers,
    Bel
     
  3. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Bel:

    And you know I consider you the Goddess of Podiatric Dermatology.....don't you? ;) Keep up the great work!:drinks
     
  4. Admin2

    Admin2 Administrator Staff Member

  5. thekwie

    thekwie Active Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Thank you for this.
    Only discovered needling 12 months ago, but so far VERY happy with results. Great to have some recent, "official" literature to refer to.
     
  6. Ian Drakard

    Ian Drakard Active Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Thanks Bel :drinks

    What took you so long ;)
     
  7. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Great work Bel

    though I would `thank you` as you wrote the paper as all, Hope you don´t mind Kevin
     
  8. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Don`t get me started.....But, hopefully this will stimulate enough interest for others who are in a better position (i.e. uni/NHS staff) to further this research in the form of controlled trials.

    Cheers,
    Bel
     
  9. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    A brilliant paper. For me the highlight was the background information. Well done you.
     
  10. Ian Linane

    Ian Linane Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Started reading this lunchtime and got a bit more to go. Excellent reading in that it is firstly readable!! Not always easy to do with a paper. Like Rob I have enjoyed and found the back ground stuff really helpful. Look forward to the rest. Biggest praise Bel? Persisting against and overcoming the stumbling blocks along the way. Well done.
     
  11. Anne Stephens

    Anne Stephens Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Thank you Bel - an excellent piece of work!
     
  12. drsarbes

    drsarbes Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Well done.
    I'd be interested to know if those who perform this procedure frequently have a similar success rate, and what possible reasons you can give for the failures.

    For instance; the failures I have had, or the times I have had to repeat the procedure seem to be more for digital verrucae.

    Also large mosaic verrucae with a large number of satellite lesions (even on the other foot) seem to have the highest success rate.

    Steve
     
  13. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    I would say my success rate hovers around 75%, but I've never done a study of this. In fact, as far as I'm concerned, Bel is now the expert on this procedure....I was just the one that remembered reading Falknor's paper in 1984 and trying it on a few of my patients.
     
  14. DaveJames

    DaveJames Active Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Thanks Bel - just printed a copy and will have a read this evening. :drinks

    Kind regards,

    Dave
     
  15. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Hi Steve,

    Since writing the review, I have been discussing this with a few who are interested. Well, mainly Robert Isaacs as he is coming round to the idea that dermatology is cool...

    I`ve always suspected that HPV sub-type has a bearing on tx success;

    HPV1 (single) is notoriously stubborn as it creates a huge amount of vacuolization - hence the rubbery, macerated texture and far more disturbance of cell differentiation through the entire thickness of the epidermis than HPV2 & 4.

    HPV2 (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 why you are observing a higher success rate.

    HPV4 (multiple) causes a thicker granular layer only, but a more compact horny layer.

    Fascinating, eh? Or is it just me?

    Cheers,
    Bel
     
  16. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    So, picking the horse for the course, how might one improve the chances of a positive treatment outcome in say the HPV1 sub-type? Deeper penetration? Or, a different approach altogether?
     
  17. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Not deeper. HPV lays dormant in the basal layer and can only replicate in the spiny/grany layers so does not penetrate any deeper than the epidermis. But, unlike HPV2 & 4, HPV1 appears to form an capsule around the papillloma (although that could just be the extensive vacuolization) which renders it more difficult to treat. Of late, I have been `scooping` out the mass post needling, which appears to work better. I know Dave Smith and Robert have also been doing this.

    Basically, you gotta stimulate those cytokines any which way you can.
     
  18. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    So, why not just perform a blunt dissection for this variant/ all variants? It has, after all, been suggested that blunt dissection provides a higher cure rate than the needling technique reported in your study. http://www.ncbi.nlm.nih.gov/pubmed/2209078
     
  19. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    `Cos you need to address the latent viral particles in the basal layer. Blunt dissection does not (or at least, it shouldn`t because it would produce scarring) do this. By pin-point pushing the virus into the subcutaneous layer (ie no scarring), it would appear that a greater level of cytokine production is induced, to seek out these particles in the basal layer. At least that`s the hypothesis.
     
  20. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Yeah, in 1990. I`ll take a closer look at that paper later. Supper time now.
     
  21. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Couldn`t access the full article you referenced, so I cannot comment on the claimed cure rate. However, note what the latest Cochrane review states re dissection;
    and this from here;
    From my own clinical observation, HPV1 lesions tend to protrude further out of the epidermis post needling and you can quite easily use a melon-baller to scoop out the pulverised mass, without damaging the dermis, thus reducing the risk of scarring. We discussed it here;

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?p=287008&highlight=HPV1#post287008
     
  22. Paul Bowles

    Paul Bowles Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Nice work Belinda well done - have you looked at the research on tagamet as well? We find sharp resection the preferable method clinically but have used oral tagamet on several occasions for multiple lesions on the plantar foot.
     
  23. drsarbes

    drsarbes Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Might find this interesting:

    Don't recall if I told the arena on the original thread for Faukner's procedure...but I met him while in school in the late 70s in Chicago. He was a guest lecturer and, obviously, lectured on his needling technique.
    What I remember most is that he made a rather grand entrance into our lecture room from the rear of the classroom once we were all seated. He wore a black cape!
    Not easy to wear a cape...you need a particular personality to get away with it...he had it. Quite flamboyant.

    Steve
     
  24. David Smith

    David Smith Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Hey well done Belinda, Just printed it off for some quiet reading tonight by the telly.
    :drinks

    Regards Dave Smith
     
  25. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    What gauge needle is everyone using? I know the ubiquitous 27 g is standard but I've seen a few done with a much larger needle (18g I think). It worked where the 27g had not but I worry about scarring with a needle that big. What's your weapon of choice over the water?
     
  26. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    I use the 18g needle as standard, Rob, and isuall flatten the barrel about 3mm from the tip. Use a fine set artery forceps. Not had any scarring post op. Superb work, Bel...:drinks
     
  27. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    I use a 25 gauge needle. It's important to push through the dermis into the subcutaneous fat, from my clinical experience. If there is minimal bleeding, then you probably haven't gone deep enough. The surgical site should look like bloody ground meat after you are done.
     
  28. alaranjo

    alaranjo Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Does anyone uses Dermapen? I found a video on youtube about it and wondering if it's possible to use in this technique.

    Thanks
     
  29. alaranjo

    alaranjo Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Hey forgot to ask something, does anyone uses this technique in "normal" warts or just mosaic ones? Is the post-operative to painful or not?
     
  30. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    I have not performed this technique, but to the neutral reader here is where I'm getting confused:

    Blinda wrote:
    While Kevin wrote:

    My understanding was that the idea of this technique was to push the viral tissue into the dermis, "where the body's immune system can see it". If each of the penetrations with needle should be "pushed through the dermis to the subcutaneous fat" and the lesion needs to be "pulverised", then surely there is going to be damage to the dermis which could lead to scarring. Why would the scarring using this technique be any less than with a blunt dissection of the lesion?
     
  31. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Good point. However, I also puncture through the dermis into the subcutaneous tissue. Taken from the review;

    Of course there is damage to the dermis, but this is limited as there is only pin-point bleeding, unlike the cutting away, if you like, of the lesion associated with electrosurgery, curettage and cautery.

    When I first started utilising the needling method, I noticed that HPV1 sub-types appeared to form a thicker capsule which increased resistance to tissue destruction. On more than a few occasions, once the lesion was punctured to the point of no reactive pressure, the mass would visibly `bulge`. A few patients reported this protrusion as uncomfortable post operatively, so I decided to use blunt dissection in careful removal of the needled mass and was surprised at how easily the lesion came away as the epidermal tissue had already separated from the dermis. So there is no cutting of the dermis, just a pulling away of the pulverised lesion and little chance of scarring.
    That said, with the right technique, blunt dissection alone should not produce scarring either.

    Incidentally, I did not the use patients whom I used secondary blunt dissection on in the review.
     
  32. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Just out of curiosity, how are you classifying your lesions? What other strains of HPV form plantar warts?
     
  33. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Talking about blunt dissection.
     
  34. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    You talking to me?;) HPV1, HPV2 & HPV4 are usually found on the hands `n feet.
     
  35. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    I know. As i said, needling appears to seperate the epidermis from the dermis so the lesion virtually `pops` out with just a little careful encouragement with a curette.

    In primary blunt dissection, you need to cut the epidermis away from the dermis, so there is an increased risk of scarring. You also don`t expose latent viral particles to the subcutaneous layer so, theoretically, there is a reduced presentation of these to the immune system.
     
  36. Paul Bowles

    Paul Bowles Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    On sharps dissection of these lesions there is a clear delineation of base of lesion and tissue beneath. In form they are predominantly encapsulated to some degree. Disruption of tissue above the layer basale will not cause scarring - if the basale is disrupted this is when potential scarring can become an issue. In 15+ years of sharps dissecting these lesions I have never had a scar result.
     
  37. blinda

    blinda MVP

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    Agreed. Many skilled practitioners, such as yourself, successfully dissect this way and without scarring. But, I have seen a few pts with scarring and it is a risk highlighted in the Cochrane review.

    Interesting point re cemetidine, Paul. What dosage do you recommend?
     
  38. Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    I have never seen any scarring with the needling technique. In blunt dissection, if the dermal layer is penetrated to the subcutaneous fat, then scarring will likely develop due presumably to the fact that the dermal layer has been grossly disrupted over many dermal cells that are contiguous to each other. In needling, the dermis is only punctured, not cut or torn, so this presumably is not sufficient trauma to cause the dermal scarring seen in with poor blunt dissection technique.

    By the way, I use a Miltex curette for blunt dissection and the verrucae will practically "pop out" using proper technique with this instrument. I've never had any scarring to my patients with 30 years of using blunt dissection. However, without proper technique and instrumentation, scarring is not only possible, but is quite likely to occur with the blunt dissection technique.
     
  39. Paul Bowles

    Paul Bowles Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

    300mg a day is the dose we normally use but you can go higher in adults.

    The most scarring I have ever seen is from a colleague who was using cryotherapy weekly on a lesion sub 1st for almost 12 months! By the time she got to me there was no wart simply prolific scar tissue.....I think they were applying "cryo" to scar tissue.....for most of the treatment!
     
  40. DTT

    DTT Well-Known Member

    Re: The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases


    Kevin
    I took this from another thread


    The needle gauge seems to have varied somewhat :confused: as I have quoted you on this to others.

    Now I'm not sure, can you clarify please ?

    Cheers
    D;)
     
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