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hi guys,
ive been following a thread in the general discussion forum regarding this particular type of treatment for verrucae. it involves LA and needling of plantar warts to promote an immune response. wondering if anyone in or around Sydney has used it? keen to learn more.

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I've used it in Melbourne

I used it recently in Melb, applying LA to heel caused moderate but short lived discomfort for patient. Procedure went to plan, however I was only able to review with the patient at 1 and 6 weeks post op, so am unclear as to the long term results.
Simple procedure to perform. Followed step by step guide as per Kirby.

It was done in US.
Anesthetize the area and needle the largest wart completely turn it to swiss cheese.
A scab will form in a few days and all the other warts will start to disappear.
I have suceeded with this and believe the sal acid method actually does the same thing.

There is no literature and therefore i CANNOT SIGN MY NAME BUT SOMEONE NEEDS TO DO A STUDY!!!!!

You are stimulating an immune response - there are plenty of studies on treatments of VP's. Gary Dockery writes a bit about the above technique, and Kevin Kirby discusses it regularly. Personally if you are going to do this, I don't see why you wouldn't sharps excise it and phenolise the base - much easier and efficient. Basically by dong the above technique you are curretting the lesion anyhow.

Curretting and phenolizing this is a very good and proven technique with supportive studies for singular VP lesions. This wasn't the topic why did you bring it up? But when you have multiple recurrent VPs (e.g. mosaic ) you can't do each one and besides the recurrence factor.
needling is an interesting way to deal with many recurrent warts but again I have never seen or heard of a double blind study or any research done to cause an immune response. I am sure weekly treatment with strong acids may cause a immune response as recurrence is rare with this method as well. Kirby and Dockery have never done a double blind study on needling. Why did you mention them?

Needling:

I started using this due to the difficulty in treating patients with recalcitrant multiple lesions; those that were not conducive to excision and quick recovery.

Although quite skeptical at first, with the "prodding" of Dr. Kirby I have now done quite a few of these ( I haven't counted but at lease twenty) and have only had one that needed a repeat treatment. Most have been a needling of ONE lesion in patients with multiple lesions.

To say the recurrence in excision/phenolization is rare is an overstatement. Whatever your definition of RARE is I doubt we can categorize the rate as RARE.

In addition, I have never felt that I was initiating an immune response when I excised a verrucae. I do, however, think that it's quite obvious that the needling technique does.

It's a very simple treatment that is MUCH less tender than excision (especially considering that not all the lesions are treated) and very successful.

Visit the HELP WITH MOSAIC VERRUCAE thread.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

I raised it because needling mosaic (or other) verrucae is nothing more than blunt curettage really. You turn the lesion to mush, then curettage it and then potentially phenolise it.

This causes (hopefully) an immune response - and boom lesions resolved.

The advice I have always issued this advice to patients (even with those pain in the rear end stubborn returning lesions): to stimulate an immune response any which way possible.

Paul:

Don't know if I can agree with you that the needling technique is "nothing more than blunt curettage". The needling technique probably works since the virus particle is being driven deep to the dermis, into the subcutaneous fat, stimulating an immune response. Rather, blunt curettage is performed (at least with the podiatrists that I know) by scraping the verrucae out of the foot at the epidermal-dermal junction, and then possibly phenolizing the base. Blunt curettage, if done properly, does not penetrate deep to the dermal-subcutaneous fat boundary. My clinical experience is that blunt curettage of one verrucae plantaris (vp) lesion does not cure vp lesions distant to the treated vp lesion. On the other hand, the needling technique can treat multiple verrucae on the same foot by only treating one vp lesion and can even be used to treat vp lesions on the contralateral foot.

I would be interested if other clinicians have had the same anecdotal findings as I have had regarding the curettage versus needling techniques.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

No worries Kevin - but an immune response is an immune response, any way you wish to look at it.

Paul:

How do you know that a verrucae plantaris currettement procedure produces an immune response to the virus?

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

The same way you know pushing into the subcutaneous fat does....

:)

Paul:

So you are saying that when you currette one lesion of a mosaic verrucae, that this will then eliminate all the other warts of the mosaic verrucae within 4-8 weeks? I have never seen this happen, have you??

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Thanks Kevin and Steve for looking in the Aussie forums and sharing your expertise.

Cheers
heather

__________________
Heather J Bassett
137 Wheatsheaf Road
GLENROY VICTORIA 3046
AUSTRALIA
03 9306 8557

No worries!

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Hi Paul:

When the needling is performed there is no curettage. The lesion is needled (turned to mush as you so aptly put it) and nothing more.

If you'd like to curette after needling then go ahead, but it's not necessary, adds to the post op discomfort and does not increase the success rate.

AND let's give Dr. Fraukner his due......it's NEEDLING not multiple puncture.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Kevin:

When you "needle" a mosaic verrucae are you not trying to stimulate an immune response?

So if we follow that basic concept, you stimulate a localized immune response with acid, liquid nitrogen, needling, curretting bluntly or with a blade or however you want (banana skin anyone?) you should also resolve the lesions in the immediate vicinity. I am sure many of my colleagues will attest that treating large lesions in isolation often resolved satellite lesions as well who have had no treatment! Why? Immune response...

Take it a step further and look at some of the research behind oral tagamet (cimetidine) . Sure no one is saying its ground breaking stuff, but it is suggestive of a cell mediated immune response upon taking it.

Holy hell - so it stops acid reflux and fixes warts - this is the good gear!

I have had multiple complicated mosaic verrucae patients (who could not have localized treatment such as those mentioned above for various reasons) respond well and completely resolve after 8-12 weeks of tagamet 300mg per day. Now those patients may have spontaneously resolved anyhow, but hey we could say that about all VP's we see and treat.

Why do cheap chemist alternatives such as weak acids, corn pads etc...work? Immune response.

Why does the cochrane database of reviews suggest one of the best treatments for verrucae pedis according to the literature is zinc oxide sports tape! Agast! Well not really, keep the tissue moist, add friction, it gets red and irritated and whoopee an immune response!

No arguments from me here Kevin on needling, I had this advice from you almost 10 years ago and have used it since then - works a charm, but in concept every treatment for verrucae is essentially trying to achieve the same overall outcome - immune response.

An immune response is exactly that - even by any other name!

Interestingly there is a growing movement in Australian clinical practice to NOT treat verrucae in a healthy patient (especially teenagers) - why? Eventually there
will be a cell mediated immune response and they will spontaneously resolve anyhow. Same principal as mentioned above!


Regards,

Paul

Paul:

I didn't know that the public health services for both England and Australia have now decided to move toward not providing proper treatment for painful verrucae. Is this the case?? In my eyes, to force a teenager, or anyone, to live with such a painful lesion while waiting for the eventual "cell mediated immune response" to occur, is nothing more than a governmental agency trying to save money, all at the expense of the health and well being of their citizens.

Let's hope that we all can do better than that for our patients.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Agreed to a large extent, however there are cases of isolated VP's in certain patients if they are non painful and do not appear to be spreading I do not bother treating.

Thanks for the discussion Kevin - it's been interesting and hopefully it will stimulate some more talk in this thread.

I would like to see some more recent research on this method (other than the 1969 Falknor article), any ideas?

I think it all appears to be talk and "ideas" if there is no conclusive researched based evidence for either then nothing can be right or wrong.

Sandra:

Who is going to take the time to do it? Who is going to fund it? Will you??

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Edgl and Kevin:
Thanks for your posts. I've enjoyed reading your input so far Kevin, and had hoped you or others could direct me to publications so that I could read a little more on the subject. As Edgl says, perhaps there's no right or wrong at this stage, but I would enjoy reading further studies if there is any other info out there.
Regards
Sandra

1: J Am Podiatry Assoc. 1969 Feb;59(2):51-2.Links
Needling--a new technique in verruca therapy.

Falknor GW.

Theres the PUBMED search...and original reference for this discussion.

Click here for the clinicians version!

Interesting how Bleomycin gets a fair amount of hits in a search - Kevin have you used this much? In Australia it has not been easy to gets your hands on...although I haven't tried recently.

Thanks Paul, will read through the Google hits!

Don't know if any will help - I was more making a point about how much useless info there is out there, rather than the useful stuff. Makes for a funny read anyhow.

:)

I see what you mean........... LOL!

When I did my top up degree a few years ago (I originally qualified in '83) I did a retrospective study on the blunt dissection of verrucae done the the School of Podiatry in Plymouth, of the lesions which were successfully erradicated all the untreated lesions resolved within 3 months of the original lesion being excised.
I have never surgically excised vp's but have been successfully treating them for many years. It seemed to me from the cases I studied for my dissertation that the patients had considerable post operative pain and had a wound which took about 3 weeks to heal.
I have used the needling technique on only a couple of patients so far but have found post operative pain to be minimal, only the simplest dry dressing is required and only for 24 hrs.
I am now a huge fan of needling, it's simple, and highly effective.

Nina

I can't agree - I sharps resect and phenolize plantar lesions daily and I see patients reporting 1/10 on a VAS. Does it surprise me - a little, however using sharps we do not really traumatize tissue (such as a blunt curette) and I think this makes a massive difference.

Its all about technique! There are numerous examples in bone surgery as well where good intra-op technique and dissection lead to less post op pain.

Perhaps the cohort I studied had more post operaive pain because the majority were done by students. How long do you phenolise for?