Mosaic verrucae-help with treatment

Hi there. I have also been reading with great interest and had my first pt. this morning. 2 varrucae (one on each foot) present about 5 years and unable to clear with standard treatments.
After performing a TP block and another LA at the varruca site, about 130 puntures into the wart site (i have trouble counting). Photos were taken pre-debridement, post debridement and post treatment. She will return in 2 weeks.
I will post photos although i will be fumbling through that. havent posted photos here before.
I have another patient booked in monday for the same treatment.
Cheers
Simone

 

hi all,

i have been following all your replies, pictures, comments and questions with great interest. a big thank you to all of you, especially to kevin and all those who have tried and tested this method of treatment and posted pics on this site for all of us to build the confiedence to go ahead with our own patients.

ok, i have another LA question...i have a patient i am going to do this tt on. the location of her 10yr+ VP is on the plantar aspect just under her 2nd toe but not quite on the MPJ and is slightly to the tibial side. i was going to do a PT block but wondered if i should also do a local inflitration or a deep peroneal block too? i would be interseted to know peoples thoughts. i will try to sort pics to add to the cache on this thread.

poppet

 

got any pictures of this one poppet? - I often just go for local infiltration if I can reach it with the needle from the id space - if not you can approach from dorsally between the metatarsal bones (never been a big fan of this)
if you can't reach it from the id space then I would do a post tib block - that should be enough but you could infiltrate locally provided you have an anaesthetised an area of plantar skin - don't try to locally infiltrate without because it is very painful to inject through the plantar skin!!
The last set of pictures I posted was via the id space and i made it comfortably with a long needle - is it a similar distance? - if you think you are going to get close to the end of the needle this way don't try it because you don't want to break the needle off at the base!

hope this helps

 

Steve - how is that young lady doing now?

 

hi steve,

thanks for your reply and thoughts. i have no pics at the moment, sorry. the VP is almost in the ID space between the hallux and 2nd toe but actually on the plantar aspect.

thanks
poppet

 

Is anyone aware if any follow up research has been published after this paper?

I have searched for Gordon W. Falknor DPM (Author of paper) to no avail. Is this gentleman still in practice?

Many thanks,

Mandy.

 

THEN APPROACH IT FROM THE ID SPACE - QUICK AND EFFECTIVE

 

I propose we call this Percutaneous Immune Stimulation

What say y'all


Steve

 

I`d say you could have chosen a better acronym!

cheers,
Bel

 

Doh!! -

 

Hi Mand`

I did a small literature search and could not find anything other studies that injected cytostatic drugs, such as bleomycin, directly into the VP. Some of these reported a high incidence of remission, which does make one wonder whether it was the meds or the technique of puncturing which can be attributed to the success rate.

Cheers,
Bel



-

 

Just been reading through this thread for the past hour or so. Great info and photos. Nice to see a foot ridded of those bloody things..

About 6 months ago a 20 year old female patient presented to me with chronic mosaic verrucae. They had been present for 1.5 years, and she had seen 5 different podiatrists and a handful of different doctors for all the normal treatments of verrucae ( no needling done though)..

On the initial consult i performed the standard debridement, salicylic acid and monochlor acid application, and advised her to take a zinc supplement daily. I also spent a decent amount of time telling the patient with alot of confidence that there was no reason why her warts wouldn't go away.

On the review in 2 weeks, the verrucae were 75% better. The patient stated that in the space of about 4 days they began to go black and shrink. In another 2 weeks there was literally no sign of a verrucae at all. It is quite amazing seeing such a transformation in the space of 4 weeks.

Over the last few years of practice I have about 5 other people with chronic verrucae that had seen numerous different podiatrists, doctors for no success.. After seeing these patients, every single one of these patients had no sign of a verrucae 4 weeks later. Solely with standard treatment and zinc supplments..

Why is this?

1. Placebo?
2. zinc supplements are very important for the immune system in fighting verrucae?
3. Treating a patient with bedside manner, and instilling alot of confidence in their mind?

I personally think placebo plays a massive part in the treatment of verrucae. Showing patients before and after photos of other patients' results also works wonders for instilling confidence in their mind.

It is also disturbing to know how many health practitioners have a poor attitude when treating patients. A practitioner's attitude when delivering and explaining a treatment is very important.

I think Anthony Robbins would be quite successful at treating patients with warts..

Sorry to get off topic,

thanks for all the info about needling, looking forward to learning and experimenting with it.

Cheers

 

Hi Josh:

"I personally think placebo plays a massive part in the treatment of verrucae. Showing patients before and after photos of other patients' results also works wonders for instilling confidence in their mind."

Why do you think that is?

Steve

 

Hi Steve,

There is always someone from a placebo group in a clinical study that will show improvement or complete loss of their initital complaint. I don't know why or how placebo works, the human mind is a mystery isn't it..I think placebo and positive thoughts are an important ingredient for overcoming any problem, health related or not.

Regarding my personal experience with patients with chronic mosaic verrucae, maybe the verrucae were eradicated due to 1) zinc supplement, 2) a positive idea I planted in their mind, 3) was a complete coincidence and had nothing to do with 1) or 2). who knows...

Over my years I have seen various health practitioners for varying health complaints. Sometimes I have seen practitioners that have been very lacklustre with their attitude when diagnosing and treating my problem.. They mumble a few words such as , "not 100% sure why, could be this, could be that, try this, if this doesn't help not too sure what we can do." You leave the rooms feeling pretty lacklustre yourself and not overly hopeful of your complaint resolving in a hurry.

On the other hand I have seen practitioners who are extremely positive, confident and jovial. " Yes, I'm confident this is what it is. I've seen this many times before and fixed the problem.. I believe you'll be back to your best in no time." You leave the rooms feeling bloody fantastic, and you are 100% realistically confident that your complaint will improve.

A patient is more likely to experience a placebo reduction or eradication of symptoms from a practitioner that is confident, positive and appears to the patient as genuinely wanting to help.. common sense would suggest this wouldn't it? Teamed with evidence-based treatment a positive and genuine attitude is not that difficult for a practitioner to display..

Showing before and after photos of other patients who have overcome chronic verrucae..Automatically gives the patient confidence in you, because you have obviously fixed this problem before..You always take someone more seriously that has actually done or achieved something themself rather than someone who talks about something they dont have any personal experience with. And as Kevin said, showing the pics saves yourself alot of words.

I have never been to an Anthony Robbins seminar and probably never will. But i'm sure if big Robbins slunk around the stage and mumbled, noone would leave with a positive experience.

Cheers

Josh

 

Hi Josh:

I understand what placebo is......what I was wondering is how it relates to wart eradication.

If you feel that somehow your consultation with a patient stimulates their immune system, then that is not a placebo effect, it is a real, although difficult to measure, physiological effect.

I have seen this is my own practice, particularly in children. When a verruca (ae) has been unresponsive to conservative treatment and we decide to schedule an excision, several times I have had the warts resolve spontaneously prior to the scheduled surgery.

I always assume that somehow the patients immune system was activated.

Steve

 

Hey Steve,

I never doubted for a minute that you didn't know what placebo was Wasn't sure exactly what you were asking in your previous question.

I have no idea how placebo relates to eradication of warts and other medical complaints. Who knows what exactly triggers the immune system and body to decide to overcome a problem.

The point I was trying to make was that I think a patient is much more likely to experience the effects of placebo if they truly believe in their head that something is going to work. And I think the attitude of the practitioner plays a big part in whether a patient truly believes something is going to work.

Josh

 

Food for thought

http://en.wikipedia.org/wiki/Neural_top_down_control_of_physiology

 

And

Goebel, M. U., Trebst, A. E., Steiner, J., Xie, Y. F., Exton, M. S., Frede, S., Canbay, A. E., Michel, M. C., Heemann, U. Schedlowski, M. (2002) "Behavioral conditioning of immunosuppression is possible in humans". Faseb J. 16: 1869-1873 PubMed



if it works one way surely it can work in the other?

 

Can I do an Honours project on this? Verrucae Immune Reaction=VIR..... or Verrucae Immune Needling auto reaction =vinar....???

 

Morning, afternoon, evening all,

I thought the following information may prove useful to those who may not have administered a tibial block in a while.

http://emedicine.medscape.com/article/83135-treatment

Although I'm sure we're all up to speed.

Regards,

Mandy.

 

Hi Mandy:

I checked out the link and I'd like to comment;
I do not think that inducing paraesthesia is good technique. In fact, transitory neuritis following Post Tib block is the #1 complication, and the #1 cause is needle trauma to the nerve.

The Post Tib N is pretty much always in the same place ( I can attest to this because of the many tarsal tunnel releases I have performed) No need to go around poking needles until you irritate it in order to find it.

Steve

 

Hi Steve,

I agree that to intentially traumatise the nerve is indeed a bad idea.
Good technique, in my opinion prevents the requirement to attempt this. Sound knowledge of the structures/anatomy in the area should prevent this, although I always advise patients of the possibility of nerve irritation as part of my pre-injection discussion along with any potential post-op complications prior to the consent being signed.

At college we were never taught to potentially increase the risk of post op complications but to locate the desired area to be anaesthetised by following landmarks & locating the P/T pulse & marking prior to injecting.

I considered the web page to be potentially valuable as a refresher. However I would again concur with your thoughts on avoiding intentionally traumatising the nerve.

Thank you Steve,

Many regards,

Mandy.

 

I've also read this with interest as it would be something I would like to offer the quite numerous pt's we have to refer back to the GP with VP's. They invairbaly get a blast of cryo with the practice nurse, that doesn't work. We don't offer any Tx whatsoever (NHS Podiatry dept).

That link to the tibial block method is very informative. I would add that location of the post tib artery could also be made easier using a doppler, in the cases where you can't feel it. Saying that, if you can't feel it then you need to question suitability for this at all....another issue though.

I've never done a post tib block other than on a prosthetic foot/ankle at uni but would be comfortable having a go.

Just need to convince "the management" to let us trial this on a few people with a view to introducing it as another treatment we can offer.

Anyone on here doing this within the NHS or is it all just PP??

 

Hi DGRoberts,

It is indeed frustrating if your department currently do not offer any treatment for VPs (the trust I used to work for was the same). I left the NHS some time ago to persue a career in P/P.

I would suggest you print the original PDF which Blinda previously posted on this thread. Also print off the pre & post-op pictures which the Steves' have kindly posted & present your manager with the suggestion. Be prepared for your manager to expect a protocol & hopefully if they're progressive they may allow you to trial it.

Good luck.

Mandy.

 

Hi all

I have read all your posts with fascination as I too struggle with the little blighters far too often!

I tried needling technique a week ago on a young lady (mid 20s) on the mother lesion, and have reviewed her today (one week post op). The mother lesion is on the right plantar surface (met head) and there is a small one on the medial MPJ.

I anaesthetised via the toe webbing to directly beneath the lesion. Not much pain (do it very slowly) and then stabbed it over 100 times with the same syringe needle.

The patient has had no post-op pain at all, took a single paracetamol "just in case", has had no bleeding and didn't need the felt padding I applied (PMP with a u). The lesion has a haematoma underneath (seems to be at the dermo-epidermal junction) and appears slightly raised due to this. She is returning in 3 weeks to see if any cell mediated immune response has been stimulated. I will keep you informed......

I forgot to take a pre-op photo but have the post-op and 1 week pics which I'll post here.

I have booked another 4 patients in for this procedure over the next few weeks. If this really works I am thinking of putting a trial together for my MSc Pod. Surg dissertation next year - anyone know of any papers other than those previously mentioned please?

All the best

Julian

immediately post-op photos:

 

and one week post-op:

 

"I've never done a post tib block other than on a prosthetic foot/ankle at uni but would be comfortable having a go.

Just need to convince "the management" to let us trial this on a few people with a view to introducing it as another treatment we can offer.

Anyone on here doing this within the NHS or is it all just PP??"


Hi DG
I lead a team of podiatrists within the NHS and actively encourage them to try out new techniques, (as long as they fall within our scope of practice of course). We tend to do new things (like this) as a group so that everyone can learn from the inital consult. We've carried out about 4 needlings so far and I'll get one of my colleagues to post the photos once we begin to see some significant changes.
Those members of my staff who had not previously carried out a Post Tibial block usually practiced on one another rather than attempting it on a patient in the first instance. Staff are always reassured at how relatively easy and painless an injection it is to receive - this is always good experience when your trying to convince a patient.
Maybe you could try and convince a colleague to do it with you and practice your tibial blocks on each other - that's assuming you can convince "management" to allow you to practice the skills you trained in!!
Good luck

Michael

 

Hello all,

Patient:
Age. 39
Good general health
No medication/no known allergies
Occupation. tiler
Activity. competative cyclist


Pt. complains of: VP over 12 years duration. previous treatments include. Cryotherapy by GP. Various acid self administered treatments with no resolution.

18th May 2009.

Tibial nerve block. 2ml Mepivacaine
Debrided area.
Needled with 25g needle > 100 times.

photos attached. 1) pre-op
2) post needling.

Dry, sterile dressing applied + spares provided if required.
Review in 2/52

Permission granted by pt. to use photographs.

 

Spoke to one of my tutors from my university days yesterday about this technique - she has been using it for a long time - described a slightly different approach using similar technique but in addition fans out from edge of VP at 45 degrees - anyway she reports high initial success but estimated a 50% recurrence of the same verrucae - Has Kevin (or anyone else that has been doing this for a long time) got any follow-up data?

 

Mandy and Colleagues:

Thanks for the photos Mandy and everyone. This is becoming one of the better clinical threads ever on Podiatry Arena.

However, since so many photos are being posted, I would like I offer some advice on taking clinical photographs since I previously taught photography during my undergraduate years.

When taking close-up photos of feet, such as Mandy's last photos, one must be careful that the photos are in focus, so that maximum clinical information may be derived from them. With any lens, there will be a minimum distance away from the lens where the camera and lens can bring an image into sharp focus so you must know what this distance is when performing close-up photos for your camera before you take such photos.

For example, in Mandy's photos, and assuming this is a digital camera and the reason the photos are not in sharp focus is because the camera was too close to the foot, it would have been better to move farther away from the foot until the lens of the camera could focus properly on the subject and then, if one wanted to show only the foot when posting the photo, one could simply crop the photo with a photo editing program such as Adobe PhotoShop or Corel PhotoPaint. Alternatively, many digital cameras have a "macro mode" where this minimum distance changes to where the camera can be within only a few centimeters of the subject and still get a good image. However, when using "macro mode"in many cameras, the standard camera flash system doesn't work well so that auxiliary lighting from another source must be used to ensure good photo quality.

That being said, thanks to all of you who are contributing photos to this thread for making this such a clinically educational thread for all of us.

 

Regarding photography.

If you have a digital camera look for the macro mode icon



Depending on your camera it should take an sharply focused image up as close as 1cm away, depends on your camera.

Use this for the super close up shots then switch back to normal mode.

Also make sure you well lit, try shining your exam lamp on the area, if you have one.



The fuzzy pics above are unfortunately of little use, good effort though!!

 

Thank you Kevin et al,

In shame I admit that the photographs following the initial treatment were taken from a camera phone. The subsequent pictures I anticipate will be of better quality.

Lord Lichfield & David Bailey may sleep well in their beds.

I strive to improve.

This (along with many others) is joining my 'most favoured' threads. I will never regret joining the ranks of Podiatry Arena. I stand in awe of such a valuable resource.

Many, many thanks,

Mandy.

 

In regards to photo quality, if you look at Julian's photos from May 16, 2009, you will notice that the background is in focus but the area of interest, in the foreground, is out of focus.

This problem probably occurred since the focus of the camera was not set for the foreground, but focused rather on other objects further away from the camera. Many digital cameras will highlight the subject it is focusing on with a box of some sort so that you can make sure that your photo is focused on the subject of most interest. Also, using a flash helps greatly in these instances since with increased light on the subject, the smaller will be the lens aperture (i.e. higher f-stop setting), which will increase the depth of field of the photo (i.e. increase the range of distances from the camera lens that are in focus). These principles can all be neatly explained using physics concepts, which I won't bore you with, but which I read about extensively during my teenage years.

Hopefully these little tips will help those of you who want to document these types of procedures with photos will allow you to do so in a more professional-appearing manner.

 

Hi Kevin

Thanks for the tips! Photos were taken on my nokia phone , hence the focus problems, great idea regarding cropping the pics. Will do better next time!

All the best

Julian

 

Wish I had some pics to crop....my digital camera was stolen by the toerags who broke into my surgery last week

Still lesson learnt; must download pics on to PC same day.

 

toerags - good way to put it!

 

it's when they steal the pc as well

 

Apologies for going off the thread but my tip. Email yourself all important files/photos. Regardless where you are, providing you have internet access you can access them anywhere.

Only a suggestion.

Mandy.

 

This reading was given to us as a tutorial. There is an interesting section on the use of Bleomycin pricking the wart repeatedly with a monolet needle, which appears to be a 'modified tattooing apparatus.
. Sterling, J.C., Handfield-Jones, S. and Hudson, P.M. (2001)
GUIDELINES FOR THE MANAGEMENT OF CUTANEOUS WARTS.
British Journal of Dermatology (Volume 144 Issue 1) 4-11
The question NOT asked in the article is: Was it the pricking or the Bleomycin that caused the 92% cure rate.
JULIAN: I want to do a (Hons??) study on it too.

 

Hello all,

Most recent enquiry RE: verruca treatments available is from the mother of a young girl aged 9. Type 1 diabetic. Excellent diabetic control. (according to pt's mum). History of longstanding vp's >2 years duration. The GP has previously cryo'd & a variety of over the counter remedies have also been utilised, unfortunately without improvement to the lesion which has now spread & causes discomfort.

Pt's mother is keen for me to provide the 'needling' technique.

In any other similar circumstance ie. Young diabetic pt. with optimum glucose control I would be happy to provide eg. nail surgery for an O/C.

My question: What is the youngest individual you would provide this treatment for? (I appreciate much depends also upon the maturity of the child). Also do you consider this appropriate in this instance?

I am yet to actually assess the young lady in question so of course I would also engage in a full history etc.

Many thanks. As always I value any feedback.

Regards,

Mandy.