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Mosaic verrucae-help with treatment

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  #1  
Old 27th February 2009, 03:54 AM
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Default Mosaic verrucae-help with treatment

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hi all,

i wondered if i could get some feedback on treatments for mosaic verrucae. a patient attended my clinic with the plantar aspect of one foot almost coverec with verrucae. this extended to the dorsum of one toe and is also evident on the other foot. this patient has seen a consultant dermatologist who said to put tape on it. she has had the verrucae for approx 7 years and it gets painful as the hyperkeratosis builds up. she is near desperation and is seeking treatment. has anyone successfully treated such large lesions? a colleague suggested the use of potassium pomangernate footbaths (very weak solution). has anyone heard of its use in VP's or tried this treatment option?

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Old 27th February 2009, 11:12 AM
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Default Re: mosaic verrucae-help with treatment

Quote:
Originally Posted by poppet View Post
hi all,

i wondered if i could get some feedback on treatments for mosaic verrucae. a patient attended my clinic with the plantar aspect of one foot almost coverec with verrucae. this extended to the dorsum of one toe and is also evident on the other foot. this patient has seen a consultant dermatologist who said to put tape on it. she has had the verrucae for approx 7 years and it gets painful as the hyperkeratosis builds up. she is near desperation and is seeking treatment. has anyone successfully treated such large lesions? a colleague suggested the use of potassium pomangernate footbaths (very weak solution). has anyone heard of its use in VP's or tried this treatment option?

thanks
poppet
Poppet:

I have successfully used, what I call, the "multiple puncture technique" for treating mosaic verrucae. Under local anesthesis, take a 18 gauge hypodermic needle and punch through the skin to the subcutaneous fat about 100 times to the worst of the "mother lesions" (lesions with worse appearance) of the mosaic verrucae. Bleeding should occur at each puncture hole. Then place a bandage on the foot for 12 hours with the patient bathing normally the next day. The patient has only slight soreness in the area the following day.

In most cases, this will stimulate a immune response within the body that will eradicate all the verrucae plantaris lesions of the foot within about 4-8 weeks. I have found it very successful (over 90% cure rate) in the approximately 10 patients I have performed this technique on. My technique is based on an article published about 25 years ago where a podiatrist used a modified electric tootbrush-hypodermic needle tool where he used the same technique to heal plantar verrucae. I don't have the reference now.

I have also seen a study where verrucae plantaris lesions are excised from one area of the body and then implanted in the subcutaneous fat of the abdomen, to stimulate the immune response to the virus, to accomplish the same effect as the multiple puncture technique. Again, don't have the reference at hand but you may try looking up these articles on the internet.

Certainly worth a try, in my opinion, since there are few side-effects, potential problems with this technique.
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  #3  
Old 27th February 2009, 12:41 PM
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Default Re: Mosaic verrucae-help with treatment

thanks for that kevin,

it sounds a far more drastic (but obviously successful) version of what i often do in smaller VP's. i debride heavily until a few specs of blood ouse through, thus aiming to trigger an immune response. the patient i question knows which part of the foot the VP first appeared and i may treat this on its own and hope that the rest of the foot responds in the usual manner.

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Old 27th February 2009, 01:32 PM
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Default Re: Mosaic verrucae-help with treatment

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Originally Posted by poppet View Post
thanks for that kevin,

it sounds a far more drastic (but obviously successful) version of what i often do in smaller VP's. i debride heavily until a few specs of blood ouse through, thus aiming to trigger an immune response. the patient i question knows which part of the foot the VP first appeared and i may treat this on its own and hope that the rest of the foot responds in the usual manner.

poppet
The idea is to implant the verrucae virus below the dermis to have the best chance of stimulating the immune response. The only thing painful about this procedure is the local anesthetic injection. Otherwise, it's a relatively painless procedure. It's probably about the same pain as having an ingrown toenail removed under local anesthetic.....is this also considered a "drastic" procedure??
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Old 27th February 2009, 06:39 PM
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Default Re: Mosaic verrucae-help with treatment

Here's an article about a podiatrist that surgically implants verrucae tissue subdermally to stimulate the immune response.......also known as autoimmunization.

http://www.pittsburghlive.com/x/pitt.../s_389470.html
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  #6  
Old 27th February 2009, 06:57 PM
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Default Re: Mosaic verrucae-help with treatment

I have a naturopath collegue who recommends taking Thujatablets for one week. Thuja is a derivitive of the cedar plant. Anyone had any experience with this?
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Old 27th February 2009, 07:03 PM
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Default Re: Mosaic verrucae-help with treatment

Kevin, Very interested in this approach as it makes a lot of sense.

Does this approach cause scarring due to puncturing the dermal membrane?

Sally
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Old 27th February 2009, 07:20 PM
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Default Re: Mosaic verrucae-help with treatment

Link provided by naturopath

http://www.naturalhealthanswers.co.u...d%20Verruc as
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Old 27th February 2009, 10:06 PM
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Default Re: Mosaic verrucae-help with treatment

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Kevin, Very interested in this approach as it makes a lot of sense.

Does this approach cause scarring due to puncturing the dermal membrane?

Sally

Sally:

Never seen any evidence of scarring in the patients I have performed this technique on.
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Old 27th February 2009, 11:18 PM
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Default Re: Mosaic verrucae-help with treatment

I think this is the reference for the article I learned how to do the "multiple puncture" technique. Does anyone have access to these early JAPMA volumes that can send me a copy via pdf or snail mail?? I can't find my old article....it's only 40 years old now.....

Falknor GW.Needling--a new technique in verruca therapy.J Am Podiatry Assoc. 1969 Feb;59(2):51-2.
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Old 2nd March 2009, 09:17 AM
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Default Re: Mosaic verrucae-help with treatment

When I described the multiple puncture procedure a few days ago, I said to use an 18 gauge needle for the puncturing of the verrucae. Sorry, this was a mistake. I use either a 22 gauge or 25 gauge needle to do this procedure. An 18 gauge needle is probably too big. Sorry for any confusion this may have caused.
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Old 2nd March 2009, 11:17 AM
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Default Re: Mosaic verrucae-help with treatment

Needling Technique:

I knew Dr. Falknor and when I was a student in Chicago he demonstrated this technique for us. He used the same needle he gave the xylocaine with to perform the needling. It pretty much left a pulpy mess of the wart, but he swore by it.

I must admit I've never used it, but given the testimony by Kevin I may try it next time.

Steve
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Old 2nd March 2009, 02:34 PM
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Default Re: Mosaic verrucae-help with treatment

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Needling Technique:

I knew Dr. Falknor and when I was a student in Chicago he demonstrated this technique for us. He used the same needle he gave the xylocaine with to perform the needling. It pretty much left a pulpy mess of the wart, but he swore by it.

I must admit I've never used it, but given the testimony by Kevin I may try it next time.

Steve

Steve:

I would be interested to see if your results are as good as mine, since not many podiatrists use the needling technique. It has worked very well in my hands so I don't know why it isn't used more. Maybe many don't know about it and the technique hasn't been "advertised" enough to have it become popular?

One of the more interesting cases that I treated using the needling technique involved a 26 year old Hispanic male that had stepped on a nail at work with his right foot and had developed a verrucae plantaris lesion (VP) at the old nail puncture site in the longitudinal arch of the foot. Interestingly enough, he also presented to me with an nearly identically sized VP on his left forefoot that as far as he knew occurred spontaneously. Since he was a worker's compensation injury patient with no private insurance, I could only actively treat his right foot VP, not his left foot VP. Therefore, I needled the right foot VP under local anesthesia and did absolutely nothing to the left foot VP since I thought it would be interesting to see if I could generate an autoimmune response on one foot by the needling technique to affect a cure of the VP on the other foot. Within 2 weeks the right foot VP had turned black and disappeared completely in 6 weeks. The untreated left foot VP turned black within 4 weeks and disappeared in 8 weeks following needling only the right foot verrucae. There appeared to be about a 2 week lag time between the two feet, with the needled verrucae healing about 2 weeks before the non-treated foot. This, to me, suggested very good clinical evidence that I was generating a therapeutic autoimmune response to the human papilloma virus by using the needling technique on one foot to successfully treat the VP on the other foot.
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Old 2nd March 2009, 06:09 PM
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Default Re: Mosaic verrucae-help with treatment

The first and most rewarding case where I used the needling technique for verrucae plantaris treatment occurred about 15 years ago when one of the top ballet dancers here for the Sacramento ballet, a 23 year old female, presented to me in September of that year with a mosaic verruca on the right foot that covered about 60% of the plantar aspect of the foot. She had no insurance had tried topical over-the-counter preparations and had only watched and suffered as more painful verrucae continued to appear on her foot even with treatment. She was considering quitting her dancing profession since she was in so much pain due to the mosaic verrucae.

I had a long discussion with her about the needling technique I had read about during my surgical residency. I told her this technique would make the most sense to me to try due to the extensive nature of the lesions covering her plantar foot. I told her I would try needling just the largest two lesions on her foot (i.e. the "mother lesions") under local anesthesia to see if it helped. After performing the procedure, she didn't return for her two week followup appointment or return back to my office for over two months, so I thought initially that she had not had a good result.

However, in early December of the same year, a full three months after I performed the procedure on her, she came into my office to hand me an envelope for two tickets to the Sacramento Ballet's Nutcracker performance along with a back-stage tour she would personally give my wife and I to see her dance in the lead role of this classic ballet. The tickets and backstage tour was her way of thanking me for completely eradicating the plantar warts on her feet which she said had completly healed within four weeks of my performing the needling technique on her foot. What a rewarding experience to have done something so simple to allow this young lady to continue doing the activity she loved and was so good at!

It is the recollection of patients such as this that I have treated over my 25+ years of being a podiatrist that makes me realize that I was very fortunate to have chosen podiatry as a profession.
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Old 3rd March 2009, 07:42 AM
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Default Re: Mosaic verrucae-help with treatment

Hi Kevin:

Great stories, thanks.

----------------------------------------

I have a patient at present that I've been treating for a least 2 months for VP. He has more a disseminated VP than classic mosaics. He presents with approximately 30 lesions spread throughout his left forefoot (some digital, interdigital, sub ungual) with one in the arch and one in the heel. All the lesions are about the same size, =/< 1.0 cm.

We have both been frustrated by our results thus far.

In this type, where there really is no "mother" wart, would you consider needling "some" of his lesions then wait and see?

Steve
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Old 3rd March 2009, 02:33 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
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Hi Kevin:

Great stories, thanks.

----------------------------------------

I have a patient at present that I've been treating for a least 2 months for VP. He has more a disseminated VP than classic mosaics. He presents with approximately 30 lesions spread throughout his left forefoot (some digital, interdigital, sub ungual) with one in the arch and one in the heel. All the lesions are about the same size, =/< 1.0 cm.

We have both been frustrated by our results thus far.

In this type, where there really is no "mother" wart, would you consider needling "some" of his lesions then wait and see?

Steve
Steve:

I would probably assess which lesions looked the most mature and then needle them. Another consideration would be to do only one local anesthetic nerve block and then needle multiple lesions that were in the field of anesthesia. In theory, however, you should only need to needle one lesion to trigger the autoimmune reponse. What would be interesting is to do digital photographs of the treated and untreated lesions at weekly intervals to see the changes that occur in their appearance over time. This could be presented as a nice little case study for JAPMA that could be combined with a short discussion of the literature on autoimmunization techniques for human papilloma virus.
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Old 4th March 2009, 02:50 AM
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Default Re: Mosaic verrucae-help with treatment

This is all very interesting and has spurred me to undertake a small literature search on needling.

In one study E Van der Velden (1997) modified a tattooing machine to inject the cytostatic drug bleomycin directly into the VP. Of the 11 patients, that remained in the study, seven went into full "remission" that was maintained for at least 2 years. It does question whether success was due to the mode of action of the medication or the technique (puncturing ) employed.

Does anyone know where I can find needling being demonstrated?

Cheers,
Bel
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Old 4th March 2009, 04:47 AM
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Default Re: Mosaic verrucae-help with treatment

Like Belinda I am interested a demonstration of needling. Where in the UK will I find this?
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Old 4th March 2009, 07:30 AM
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Default Re: Mosaic verrucae-help with treatment

This could be presented as a nice little case study for JAPMA that could be combined with a short discussion of the literature on autoimmunization techniques for human papilloma virus.
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Hi Kevin:
Sounds doable.

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Old 4th March 2009, 09:19 AM
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Default Re: Mosaic verrucae-help with treatment

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Like Belinda I am interested a demonstration of needling. Where in the UK will I find this?
The technique is very easy. Once the patient's foot is anesthetized, using a 25 gauge hypodermic needle, the wart is punctured to the subcutaneous fat (about 6 - 7 mm depth on the plantar skin) about 100 times, or until the whole wart looks like "raw hamburger" (if it isn't bleeding actively, then you haven't gone deep enough). Then dress the foot with a single 2 x 2" or 4 x 4" sterile gauze pad with coban to hold it in place and have the patient take the bandage off the next morning before showering and that's it! The patient generally reports little to no pain in the foot the next day from the procedure.
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  #21  
Old 4th March 2009, 09:49 AM
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Default Re: Mosaic verrucae-help with treatment

Thanks Kevin, It does sound a simple procedure. I will be trying it shortly. Ill let you know the outcome.
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  #22  
Old 4th March 2009, 11:28 AM
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Default Re: Mosaic verrucae-help with treatment

Thank you Kevin, I appreciate the simplistic advice. l would LOVE to do a project on this. However, I am busy with another trial and other dermatology research at this moment in time. Give me 6 months and I`ll be there...

Ok, another silly question here; is it appropriate to use the same needle for the ankle block and also for the needling of the VP?


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  #23  
Old 4th March 2009, 02:46 PM
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Default Re: Mosaic verrucae-help with treatment

Kevin do you use this method for regular verrucae or mosaic type only?
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  #24  
Old 4th March 2009, 03:20 PM
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Default Re: Mosaic verrucae-help with treatment

Sally and Belinda:

I typically use the needling approach for plantar warts when I have multiple verrucae to deal with. The most difficult part of the procedure is convincing the patient that implanting the human papilloma virus into their body will be beneficial to them.

Also, you can use the same hypodermic needle for the aneshetic block and for the needling. I typically use a new hypodermic needle for the needling of the verrucae. Either way will work.
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Old 4th March 2009, 03:30 PM
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Default Re: Mosaic verrucae-help with treatment

OK Kevin:
Watch what you ask for! haha

This patient I was asking about happened to be on my schedule for today.

He is a 28 y/o M with a 10 year history of verrucae left foot. All previous treatments have failed.
He felt, as I did, that the lesion at the base of the 5th digit was the "mother" wart.
I used a 25G needle, injected a couple ccs of Xylocaine plain and then used the same needle to "needle" the wart.
Here are the photos.
Hopefully in a few weeks I can show you a "normal" photo.
He's returning in a week so I can check it and take another photo.
I'll up load it then.
Steve
Attached Images
File Type: jpg 28 y:o VP 1.jpg (36.3 KB, 4685 views)
File Type: jpg needled 2.jpg (61.8 KB, 4697 views)
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  #26  
Old 4th March 2009, 06:07 PM
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Default Re: Mosaic verrucae-help with treatment

Steve

Great photos, looking forward to seeing more in the next few weeks. I am very interested in this technique Kevin, thanks for sharing. I am currently trialling different methods to treat VP due to limited long term success with standard cryo/sal acid treatment.

Cheers

Nick
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  #27  
Old 4th March 2009, 06:13 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by drsarbes View Post
OK Kevin:
Watch what you ask for! haha

This patient I was asking about happened to be on my schedule for today.

He is a 28 y/o M with a 10 year history of verrucae left foot. All previous treatments have failed.
He felt, as I did, that the lesion at the base of the 5th digit was the "mother" wart.
I used a 25G needle, injected a couple ccs of Xylocaine plain and then used the same needle to "needle" the wart.
Here are the photos.
Hopefully in a few weeks I can show you a "normal" photo.
He's returning in a week so I can check it and take another photo.
I'll up load it then.
Steve

Steve:

Looks good. You work fast, my man! If the needling technique works, you should start seeing changes in the other plantar warts within 3 weeks. Hope the needling technique helps this poor fellow.
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California School of Podiatric Medicine at Samuel Merritt College

E-mail: kevinakirby@comcast.net
Website: www.KirbyPodiatry.com

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107 Scripps Drive, Suite 200
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My location

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  #28  
Old 6th March 2009, 02:28 AM
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Default Re: Mosaic verrucae-help with treatment

Hi Kervin,

Have you tried needling on other plantar warts other than mosiac verrucae?
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  #29  
Old 9th March 2009, 12:30 AM
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Default Re: Mosaic verrucae-help with treatment

hi all,

wow, i have been away and just logged on to see i have started a thriving thread! great stuff.

Kevin, in one of my replies my 'drastic' bit came from me making a mistake. i re-read your reply and realised that my brain had not registared the use of LA i feel very silly and would like to appologise.

having read all the emails on this, i will have a chat to this lady about the proceedure and will also post some pre/post op pics. it would be good to see others that try this technique out posting some images as i find them so useful.

thanks for the links for the papers which i will read before undertaking any treatment.

a colleague advised the use of potassium pomanganate footbaths as a treatment option for mosaic VP's. has anyone else seen, heard or tried this??

thanks again to all the contributors of this thread, very interesting stuff, keep it coming

poppet
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  #30  
Old 9th March 2009, 01:50 AM
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Default Re: Mosaic verrucae-help with treatment

Potassium permanganate is a very old treatment which has its use in the treatment of VP. However, I have heard it has been removed from circulation due to the fact it can be used to make explosive devices.
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