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Trichloroacetic acid vs needling for stubborn vp treatment

Discussion in 'General Issues and Discussion Forum' started by MD311, Aug 16, 2015.

  1. MD311

    MD311 Welcome New Poster

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    Hi all,
    First time poster here- please go easy. :eek:
    I have a patient who has a very stubborn vp cluster on the plantar/lateral aspect of his heel. The cluster is around 40mm in diameter. The patient is in his early 40s, nil medial history to report and is on no meds. His neurovascular findings are all excellent.
    The cluster has been gradually increasing in size for around 3 years but due to work commitments (he is a farmer) and being disheartened by previous treatments not working he has let it get rather large. Over the 3 or so years he has tried most treatment options including off the shelf topical creams, duct tape/elastiplast, cryo, offloading etc.
    I was thinking he may be a candidate for a more radical treatment option of either trichchloracetic acid crystal in sal acid, OR needling until LA. I understand both have their risks and I have had some experience with both modalities BUT have not had any previous experience with such a large lesion.
    Any advice would be greatly appreciated. I'm worried that 'opening up' an area of that size would be far too painful on a weight baring area even with offloading which I have discussed with patient but he is keen to get rid of it regardless.
    Thank you so much for your time and input!
  2. blinda

    blinda MVP

    Hi MD311,

    If you are certain that the large lesion is a verruca, then needling would be my preference over trichchlor. Unlike acids (which can breakdown adipose tissue, track along tendons and cause deep seated abscesses), needling is self limiting and you only need to needle one portion of a large lesion to obtain an appropriate immune response, as the presentation of virus-infected keratinocytes to the subcutaneous tissue has the potential to create a controlled innate response, followed by an adaptive response.

    I offload lesions that are on W/B parts to minimise `bruising`.

  3. Simon Ross

    Simon Ross Active Member

    Dear MD311,

    WRT acid that you mentioned.

    1. Unless you really know what you're doing with it, leave well alone, it can be unpredictable!

    2. WRT litigation, VPs are very near the top of the tables.

    3. Acids/freezing, the success rates aren't that good, and as wise man Ivan Bristow once said, in a survey done, a significant proportion of people who had had VP treatments said that if the knew what the side effects would be, they would never have had it done in the first place.

    With any VP treatment such as freezing/acid, you should give the patient an info leaflet, and get the patient to sign a piece of paper.

    If a correctly worded piece of paper has been signed, it is infinitely easier for an expert witness/barrister/professional body to defend you, providing you have done things correctly, if things do go wrong.
  4. MD311

    MD311 Welcome New Poster

    Thank you both very much. I appreciate it. Bel- how big of a portion would you needle?
  5. Rob Kidd

    Rob Kidd Well-Known Member

    I bow down to the wisdom of Bel et al above, but if I had a 40 something person in front of me with this sort of wart cluster, I would be thinking - immuno compromised. Just thinking aloud............
  6. blinda

    blinda MVP

    I usually needle an area of around 10-15 mm in HPV-2 (mosaic), which acheives positive results, but without seeing the lesion, it is difficult to advise. Can you load a pic?

    Rob, I would only refer for further investigation of wbc if the pt had a hx of other and recurring infections. It is relatively common for healthy immuno-competent adults to have these lesions for between 15-20 years, as the virus has adapted ways to avoid/dampen down the required innate immune response to eradicate it.
  7. LeonW

    LeonW Active Member

    As you are trying to notify the body of the presence of a pathogen (unwelcome guest) the greater the trauma the greater the immune response. ( not too much trauma as u dont want scarring)

    You need to give the body time to respond to the trauma and become aware of the virus and for the immune and healing response to kick in.

    I sometimes try using cryotherapy (liquid nitrogen) i find that the trauma is minimal and the tissue is largely unnafected in many cases.
    Afterwards to tissue often seems to be unchanged.

    Thus the immune response will also be minimal.

    I find a combination of thermal cautery and needling/sharp debridement has the most potent affect. Thermal cautery is essentially causing a burn to the wart. So u could use a surgical model of a soldering iron or just flame a blacks file and touch the wart. After traumatizing it with a needle or a scalpal. It is best to do this a bit every week giving it a chance to heal and reduce in size to lessen chances of scarring. Emphasis on limited trauma often allowing time to heal in between each Tx. Increasing intervention every week until sufficient impact is obvious.
    It can take 2 months to show significant signs of improvement. However in the case of a longstanding wart you have been waiting a while in any case. The wart should be in a constant state of healing, this will maintain the immune response and process of resolution.

    Please comment readers on what you think!
  8. blinda

    blinda MVP

    Personally, I don`t subscribe to either Liquid Nitrogen or electrodesiccation/cautery as both are well documented as causing pain and scarring. Could you please explain your rationale behind combination therapy of `thermal cautery and needling`?

  9. LeonW

    LeonW Active Member

    Dear Belinda I understand the trauma caused by a burn is different than that caused by a cut, it follows that the bodys response to a burn is different from its response to a cut/puncture.
    The idea it to have the body activating as many different responses as possible to the area involving the wart.
    Then the of activation the immune system will be greater and more thorough.

    What are your thoughts Belinda on this?
  10. Rob Kidd

    Rob Kidd Well-Known Member

    Forgive this Bel - but I am delighted that you can spell desiccation! You would be staggered who cannot! Rob
  11. blinda

    blinda MVP

    Indeed. Both heal with scarring, which is why I don`t utilise either them.

    That is true.

    Not really. Resolution of HPV can only be achieved by either surgical removal (which results in scarring and does not allow for immunity for further lesions to develop as it does not address latent viral particles in adjacent tissue) or by initiating first an appropriate innate and then, via cell-mediation, an adaptive immune response. The trick is achieving the cell-mediate response between the two phases as HPV emits anti-inflammatory proteins to prevent T-Cells from getting the memo from the messenger cytokines. Clever fellas, eh?
  12. blinda

    blinda MVP

    I`m frequently staggered, Rob.
  13. Rob Kidd

    Rob Kidd Well-Known Member

    When I was a student of evolutionary biology - about a million years ago, I had to write an essay about the strategies organisms has to face on leaving the water and avoiding desiccation. Of course I spelled it dessication and a got a wigging for it! Biologists are ****ty about English,and about grammar - their own worst enemies quite frankly.

  14. MD311

    MD311 Welcome New Poster

    Thanks you all very much. Bel- I won't see him for another week but would love to hear your input when I do load a photo. Thank you!

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