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Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

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  #1  
Old 10th June 2011, 12:57 PM
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Default Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

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Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): a randomised controlled trial.
Cockayne S, Hewitt C, Hicks K, Jayakody S, Kang'ombe AR, Stamuli E, Turner G, Thomas K, Curran M, Denby G, Hashmi F, McIntosh C, McLarnon N, Torgerson D, Watt I; on behalf of the EVerT Team.
BMJ. 2011 Jun 7;342:d3271. doi: 10.1136/bmj.d3271.
Quote:
OBJECTIVE:
To compare the clinical effectiveness of cryotherapy versus salicylic acid for the treatment of plantar warts.

DESIGN:
A multicentre, open, two arm randomised controlled trial.

SETTING:
University podiatry school clinics, NHS podiatry clinics, and primary care in England, Scotland, and Ireland.

PARTICIPANTS:
240 patients aged 12 years and over, with a plantar wart that in the opinion of the healthcare professional was suitable for treatment with both cryotherapy and salicylic acid.

INTERVENTIONS:
Cryotherapy with liquid nitrogen delivered by a healthcare professional, up to four treatments two to three weeks apart. Patient self treatment with 50% salicylic acid (Verrugon) daily up to a maximum of eight weeks.

MAIN OUTCOME MEASURES:
Complete clearance of all plantar warts at 12 weeks. Secondary outcomes were (a) complete clearance of all plantar warts at 12 weeks controlling for age, whether the wart had been treated previously, and type of wart, (b) patient self reported clearance of plantar warts at six months, (c) time to clearance of plantar wart, (d) number of plantar warts at 12 weeks, and (e) patient satisfaction with the treatment.

RESULTS:
There was no evidence of a difference between the salicylic acid and cryotherapy groups in the proportions of participants with complete clearance of all plantar warts at 12 weeks (17/119 (14%) v 15/110 (14%), difference 0.65% (95% CI -8.33 to 9.63), P=0.89). The results did not change when the analysis was repeated but with adjustment for age, whether the wart had been treated previously, and type of plantar wart or for patients' preferences at baseline. There was no evidence of a difference between the salicylic acid and cryotherapy groups in self reported clearance of plantar warts at six months (29/95 (31%) v 33/98 (34%), difference -3.15% (-16.31 to 10.02), P=0.64) or in time to clearance (hazard ratio 0.80 (95% CI 0.51 to 1.25), P=0.33). There was also no evidence of a difference in the number of plantar warts at 12 weeks (incident rate ratio 1.08 (0.81 to 1.43), P=0.62).

CONCLUSIONS:
Salicylic acid and the cryotherapy were equally effective for clearance of plantar warts
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Old 10th June 2011, 02:18 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Related threads:
Other threads tagged with verruca
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  #3  
Old 11th June 2011, 05:00 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

is there another study that investigates if there is any difference in recurrence rate from using the s.acid and cryo?
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Old 13th June 2011, 10:33 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

What about the needling?
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Old 13th June 2011, 10:36 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Quote:
Originally Posted by carolethecatlover View Post
What about the needling?
Now that would be the study

Bel et al paper number 2

Cryo v´s Salicylic acid v´s needling v´s control group.

6 days
6 weeks
6 months

reveiws
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  #6  
Old 13th June 2011, 10:42 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Well Mark, I'lll do it with you, but when I graduate, I want to do a paper on Dyshidrosis. But I do love verrucae too.
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Old 13th June 2011, 10:48 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Quote:
Originally Posted by carolethecatlover View Post
Well Mark, I'lll do it with you, but when I graduate, I want to do a paper on Dyshidrosis. But I do love verrucae too.
Carole its Mike

and Im not your guy on this one for so many reasons which is why I suggested to someone else.

Goodluck with the exams etc etc
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Old 14th June 2011, 12:44 AM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

This is what you realy need, TERASIL - see how the blue granules attack the virus



Apparently this product contains no harsh chemicals - No, the activated minerals Gently Kill the virus so that's good eh? Just smother them while they sleep with a nice soft downy pillow aaahh sweet and gently DIE!

Dave
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Old 14th June 2011, 01:04 AM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Quote:
Originally Posted by mike weber View Post
Now that would be the study

Bel et al paper number 2

Cryo v´s Salicylic acid v´s needling v´s control group.

6 days
6 weeks
6 months

reveiws
It`s in the pipeline. Ethical approval has been problematic as I no longer work for the NHS....but we`re getting there
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Old 14th June 2011, 03:52 AM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

I was suprised that they used the best type of freezing i.e. liquid nitrogen applied by the best method i.e. a podiatrist and then strangely say they only used a gentle freeze! what does that mean? does it mean that the tissues are not effectively frozen so as to avoid secondary trauma??? Then yet the acid was not the highest concentrate and applied by the patient i.e. highly unreliable. If the objective of this research was an exercise in statistics then they did a good job but for me its a surprisingly pointless exercise if they really wished to discover the best treatment method between acid and cryo.

Here's an analogy. Who can run 200m the fastest men or women?
Use elite male athletes but put a sharp stone in one of each of their shoes and female accountants who occasionally run for fitness but allow them to enter their own times to complete the distance, with no one watching to check (and then put in the shortcomings that you expect they under estimated their times since 21.2 seconds seems a little fast for non elite athletes??) . Then do an in depth five page statistical study of the results to discover the difference between the two cohorts. Does it answer the original question no not really no matter how clever the statistics were.

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Old 15th June 2011, 05:40 AM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

WOW terrasil sounds like a wonder drug?!? :-)

On that note I will hit the soft downy pillow! But not to Die?!?!

Sorry folks past my bedtime!!

Cheers
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  #12  
Old 20th June 2011, 12:26 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Has anyone ever tried a combitation therapy of salicylic acid (50%) & phenol(80%) for the treatment of warts.

I once tried this method and it worked like a bomb, fast & effective.Done on 2 pts
method: 1st week 50% s-acid for 7days,
day 7, expose the verruca by removing masceration tissue
draw 0.2ml of phenol, slightly prick & inject phenol with every location pricked,
cover with strapping & tcb 5-7days,
after week 2 or 3 the verucca may be clear.
3-4 weeks of patient's time was saved

Researchers, you may try this to establish an extra clinical wart removing technique.
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  #13  
Old 22nd September 2011, 03:27 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

EVerT: cryotherapy versus salicylic acid for the treatment of verrucae - a randomised controlled trial.
Cockayne E, Curran M, Denby G, Hashmi F, Hewitt C, Hicks K, et al.
Health Technol Assess 2011;15(32).
Quote:
Objective
To compare the clinical effectiveness and cost-effectiveness of cryotherapy using liquid nitrogen versus 50% salicylic acid for the treatment of verrucae (plantar warts).

Methods
Design
A multicentre, pragmatic, open, two-armed randomised controlled trial was undertaken with an economic evaluation. Participants were randomised using simple randomisation, with the allocation sequence generated by a computer in a 1 : 1 ratio. The sample size calculation was based on the difference in cure rates at 12 weeks between the two groups. In order to give 80% power to show a difference in cure rates of 70% versus 85% required 120 patients in each group or 133 patients after allowing for 10% attrition, i.e. a total of 266.

Setting
Participants were recruited from 14 sites in England, Scotland and Ireland: two podiatry clinics, one of which was in Scotland, four university podiatry schools, one of which was in Ireland and eight general practitioner (GP) practices in five different regions of England.

Participants
Potential participants were identified by a health-care professional from the study site from GP referrals or self-referrals received by the podiatry or GP practice for the treatment of verrucae. Patients were eligible to participate in the trial if they presented with a verruca that, in the opinion of the health-care professional, was suitable for treatment with both salicylic acid and cryotherapy, and were aged 12 years and over.

Interventions
Participants randomised to cryotherapy using liquid nitrogen received a maximum of four treatments, 14–21 days apart, delivered by a health-care professional. The first treatment was a gentle freeze lasting approximately 10 seconds, with subsequent treatments undertaken according to the site’s usual practice. Debridement, masking and padding of the site were also undertaken according to the site’s usual practice. Participants randomised to patient self-treatment with 50% salicylic acid (Verrugon, William Ransom & Son Plc, Hitchin, UK) were instructed on how to use the acid by a health-care professional and instructed to apply it once daily for a maximum of 8 weeks.

Main outcome measures
The primary outcome was complete clearance of all verrucae at 12 weeks. Secondary outcomes were complete clearance of all verrucae at 12 weeks, controlling for age, whether or not the verrucae had been previously treated and type of verrucae, with a second model to explore the effect of patient preferences, time to clearance of verrucae, clearance of verrucae at 6 months, number of verrucae at 12 weeks and patient satisfaction with the treatment.

Results
A total of 240 participants (90% of the sample size) were recruited to the trial, with 117 patients allocated to the cryotherapy group and 123 to the salicylic acid group. There was no evidence of a difference between the proportions of participants with complete clearance of all verrucae at 12 weeks between the salicylic acid and cryotherapy groups {14.3% vs 13.6%, chi-squared test statistic 0.02 [1 degrees of freedom (df)]; p = 0.89}. Cryotherapy was also associated with higher mean costs per additional healed patient [£101.17, 95% bias-corrected and accelerated confidence interval (CI) £85.09 to £117.26]. The probability of cryotherapy being cost-effective is 40% for a range of willingness-to-pay thresholds of £15,000–30,000 per patient healed. The results of the study did not change when the analysis was repeated but controlled for age, whether or not the verrucae had been previously treated and type of verrucae or patients’ preferences at baseline.

There was no evidence of a difference in the clearance of verrucae at 6 months between the salicylic acid and the cryotherapy groups [30.5% vs 33.7%, chi-squared test statistic 0.22 (1 df); p = 0.64] nor in time to clearance between the two groups [hazard ratio (HR) 0.80, 95% CI 0.51 to 1.25; p = 0.33]. There was no evidence of a difference in the number of verrucae at 12 weeks between the two groups (incidence rate ratio 1.10, 95% CI 0.84 to 1.45; p = 0.47).

Conclusions
There was no evidence of a difference in clearance rates of verrucae between the 50% salicylic acid and the cryotherapy using liquid nitrogen groups. However, the results of this study are applicable only to verrucae or plantar warts and not to warts at other sites, such as the hands, which may respond differently to cryotherapy.

The findings of this study would not be generalisable to other freezing agents, such as nitrous oxide or over-the-counter (OTC) freezing treatments, as they freeze at a higher temperature than liquid nitrogen. Nor could the results be extrapolated to other concentrations of salicylic acid available as OTC preparations, which are usually of a lower concentration, or to the treatment being applied by a health-care professional.

Cryotherapy is associated with higher mean costs per patient healed compared to salicylic acid. Both higher mean costs and lack of evidence of a difference in effectiveness result in cryotherapy having a low probability of being cost-effective, even at high (> £15,000 per patient healed) cost-effectiveness threshold values.

Implications for future research
There are other treatments available for cutaneous warts, but with very little good-quality evidence assessing their effectiveness. The effectiveness of these treatments is worthy of further study.
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Old 3rd March 2012, 11:51 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Cost-effectiveness of cryotherapy versus salicylic acid for the treatment of plantar warts: economic evaluation alongside a randomised controlled trial (EVerT trial)
Eugena Stamuli, Sarah Cockayne, Catherine Hewitt, Kate Hicks, Shalmini Jayakody, Arthur Ricky Kang'ombe, Gwen Turner, Kim Thomas, Mike Curran, Farina Hashmi, Caroline McIntosh, Nichola McLarnon, David J Torgerson and Ian Watt
Journal of Foot and Ankle Research 2012,
Quote:
Background
Plantar warts (verrucae) are extremely common. Although many will spontaneously disappear without treatment, treatment may be sought for a variety of reasons such as discomfort. There are a number of different treatments for cutaneous warts, with salicylic acid and cryotherapy using liquid nitrogen being two of the most common forms of treatment. To date, no full economic evaluation of either salicylic acid or cryotherapy has been conducted based on the use of primary data in a pragmatic setting. This paper describes the cost-effectiveness analysis which was conducted alongside a pragmatic multicentre, randomised trial evaluating the clinical effectiveness of cryotherapy versus 50% salicylic acid of the treatment of plantar warts.

Methods
A cost-effectiveness analysis was undertaken alongside a pragmatic multicentre, randomised controlled trial assessing the clinical effectiveness of 50% salicylic acid and cryotherapy using liquid nitrogen at 12 weeks after randomisation of patients. Cost-effectiveness outcomes were expressed as the additional cost required to completely cure the plantar warts of one additional patient. A NHS perspective was taken for the analysis.

Results
Cryotherapy costs on average GBP101.17 (bias corrected and accelerated (BCA) 95% CI: 85.09-117.26) more per participant over the 12 week time-frame, while there is no additional benefit, in terms of proportion of patients healed compared with salicylic acid.

Conclusions
Cryotherapy is more costly and no more effective than salicylic acid.
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Old 8th March 2012, 06:29 AM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Hi everyone Re: cryo vs salacylic acid for verrucas - no one has discussed the issue of scarring after cryotherapy.
I have several patients whose verrucas were treated successfully (& unsuccessfully) with cryo only to have residual scarring for ever, causing more painful lesions than the original warts! My treatment philosophy is not to treat unless causing pain or disability, & then advise pts in first instance to self treat with sal acid, cover, & return for debridement if necessary. If still resistant then progressing to further treatment if necessary. I think it is also important that patients are fully informed of likely outcomes etc with all treatment options, otherwise are they able to give informed consent?
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Old 12th November 2012, 06:35 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

The effect of patients' preference on outcome in the EVerT cryotherapy versus salicylic acid for the treatment of plantar warts (verruca) trial
Sarah Cockayne, Kate Hicks, Arthur R Kangombe, Catherine Hewitt, Michael Concannon, Kim Thomas, Farina Hashmi, Caroline McIntosh, Gwen Brierley, David Torgerson and Ian Watt
Journal of Foot and Ankle Research 2012, 5:28 doi:10.1186/1757-1146-5-28 Published: 12 November 2012
Quote:
Background
Randomised controlled trials are widely accepted as the gold standard method to evaluate medical interventions, but they are still open to bias. One such bias is the effect of patient's preference on outcome measures. The aims of this study were to examine whether patients' treatment preference affected clearance of plantar warts and explore whether there were any associations between patients' treatment preference and baseline variables in the EverT trial.

Methods
Two hundred and forty patients were recruited from University podiatry schools, NHS podiatry clinics and primary care. Patients were aged 12 years and over and had at least one plantar wart which was suitable for treatment with salicylic acid and cryotherapy. Patients were asked their treatment preference prior to randomisation. The Kruskal-Wallis test was performed to test the association between preference group and continuous baseline variables. The Fisher's exact test was performed to test the association between preference group and categorical baseline variables. A logistic regression analysis was undertaken with verruca clearance (yes or no) as the dependent variable and treatment, age, type of verruca, previous treatment, treatment preference as independent variables. Two analyses were undertaken, one using the health professional reported outcome and one using the patient's self reported outcomes. Data on whether the patient found it necessary to stop the treatment to which they had been allocated and whether they started another treatment were summarised by treatment group.

Results
Pre-randomisation preferences were: 10% for salicylic acid; 42% for cryotherapy and 48% no treatment preference. There was no evidence of an association between treatment preference group and either patient (p=0.95) or healthcare professional (p=0.46) reported verruca clearance rates. There was no evidence of an association between preference group and any of the baseline variables except gender, with more females expressing a preference for salicylic acid (p=0.004). There was no evidence that the number of times salicylic acid was applied was different between the preference groups at one week (p=0.89) or at three weeks (p=0.24). Similarly, for the number of clinic visits for cryotherapy (p=0.71)

Conclusions
This secondary analysis showed no evidence to suggest that patients' baseline preferences affected verruca clearance rates or adherence with the treatment.
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Old 6th December 2014, 03:25 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

A Double-Blind, Randomised, Placebo-Controlled Trial of EMLA® Cream (Eutectic Lidocaine/Prilocaine Cream) for Analgesia Prior to Cryotherapy of Plantar Warts in Adults.
Lee SH, Pakdeethai J, Toh MP, Aw DC.
Ann Acad Med Singapore. 2014 Oct;43(10):511-4.
Quote:
INTRODUCTION:
Cryotherapy with liquid nitrogen is an effective, safe and convenient form of treatment for plantar warts. EMLA® cream (eutectic mixture of lidocaine 2.5% and prilocaine 2.5%) is a topical local anaesthetic agent that has proven to be effective and well tolerated in the relief of pain associated with various minor interventions in numerous clinical settings.
MATERIALS AND METHODS:
In a single-centre, double-blind, randomised placebo-controlled study, 64 subjects were randomised into 2 groups. The subjects had a thick layer of EMLA® cream or placebo cream applied to pared plantar wart(s) and onto the surrounding margin of 1 mm to 2 mm under occlusion for 60 minutes prior to receiving cryotherapy. The pain of cryotherapy was evaluated by the subjects using a self-administered Visual Analogue Scale (VAS) immediately after the cryotherapy.
RESULTS:
There was no statistical difference between the mean VAS score for EMLA® cream (47.0 ± 21.4 mm) and placebo (48.9 ± 22.0 mm). Those with more than 1 wart had a significantly higher VAS score than those with only 1 wart (59.1 ± 21.8 vs. 44.3 ± 20.4, P <0.05) but this did not affect the therapeutic effect of EMLA® cream prior to cryotherapy.
CONCLUSION:
We conclude that the application of EMLA® cream prior to cryotherapy does not reduce the pain associated with cryotherapy.
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Old 12th July 2016, 11:38 PM
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Default Re: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae)

Implementation of blinded outcome assessment in the Effective Verruca Treatments trial (EverT) – lessons learned
Sarah Cockayne, Catherine Hewitt, Farina Hashmi, Kate Hicks, Michael Concannon, Caroline McIntosh, Kim Thomas, Jill Hall, Judith Watson, David Torgerson and Ian Watt
Journal of Foot and Ankle Research20169:21
Quote:
Background
Trials using inadequate levels of blinding may report larger effect sizes than blinded studies. It has been suggested that blinded outcome assessment in open trials may in some cases be undertaken by assessments of photographs. The aim of this paper is to explore the effect of using different methods to assess the primary outcome in the EVerT (Effective Verruca Treatments) trial. It also aims to give an overview of the experiences of using digital photographs within the trial.

Methods
We undertook a secondary analysis to explore the effect of using three different methods to assess the primary outcome in the EVerT trial: assessment of digital photographs by blinded healthcare professionals; blinded healthcare professional assessment at the recruiting site and patient self-report. The verruca clearance rates were calculated using the three different methods of assessment. A Cohen’s kappa measure of inter-rater agreement was used to assess the agreement between the methods. We also investigated the experiences of healthcare professionals using digital photographs within the trial.

Results
Digital photographs for 189 out of 240 (79 %) patients in the trial were received for outcome assessment. Of the 189 photographs, 30 (16 %) were uninterpretable. The overall verruca clearance rates were 21 % (43/202,) using the unblinded patient self-reported outcome, 6 % (9/159,) using blinded assessment of digital photographs and 14 % (30/210,) using blinded outcome assessment at the site.

Conclusions
Despite differences in the clearance rates found using different methods of outcome assessment, this did not change the original conclusion of the trial, that there is no evidence of a difference in effectiveness between cryotherapy and salicylic acid. Future trials using digital photographs should consider individual training needs at sites and have a backup method of assessment agreed a priori.
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