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With the exception of paring down callous that often builds over and around verrucae why do we treat them when we know there is no cure?

Martin Langdon

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Verrucae in my clinic are never treated initially to cure but to relieve pain. That's why I treat. If they don't hurt I advise to leave alone and let nature do it's job if it so chooses.

VP's invariably resolve spontaneously ... eventually - could be 1 week, 1 year or 10 years (its unpredictable), so why treat:
1. They can hurt
2. They can spread (self and others)
3. They don't look very good

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Craig Payne
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God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

I can also add a fourth: we are often badgered by the parent to treat their child and often against the childs wishes.

Martin Langdon

Podiatry seems to be shifting its ground when it comes to treating verrucae infections. Is this because they are perceived to be difficult to treat or erradicate or do practitioners truly believe that all VP's resolve spontaneously, as Craig writes, and therefore we should adopt a reassure and refuse approach to management?

Cryosurgery provides an excellent management tool. With experienced application and the correct choice of cryogen, success rates for initial treatment are as high as 96%. Isn't there a case for more effective teaching of VP management at undergraduate level when there is such a high incidence of the virus amongst the younger generations - especially given the added benefit of cryoimmunological response?

Verruca are not perceived to be difficult to treat but to cure. They can be treated with ease and there is good (at least anecdotal) evidence that they resolve far quicker than without treatment. If there were credible cryoimmunological resolution research available we would be morally justified to offer it as a good reason to treat rather than to advise waiting for it to resolve by itself. I would agree there is a case for more effective teaching of VP management including the ethical implications of offering it in the first place.

Martin Langdon

The same can be said about corns but they cannot be transmitted from person to person. Is there an ethical argument to whether podiatrists should be offering treatment with HD's?

There is. Cryosurgery, in comparison to other forms of therapy permits the controlled cryodestruction of tumour, concomitantly possesing the potential to induce host resistance to that tumour, thus potentiating cryoimmunisation and cryoimmunotherapy. As with other forms of immunotherapy, immunological manipulation may enhance rather than inhibit tumour growth. Thus the problem lies not merely in augmenting the host to produce an immune response to the tumour, but in directing the response to being tumouricidal. Therefore, if cryosurgery is to be efficaciously employed not only for the cryogenic destruction of a tumour, but also as a possible means of engendering an immunological response, several factors must be given careful consideration - including the cryosensitivity of the patient, where cryosensitivity is considered to be reflective of the antigenicity of the tissue to be treated and the immunocopetency of the patient; that is the ability to respond immunologically.

References:

Cryosurgery for Skin Cancer and Cutaneous Disorders (Zacarian) 1985

Immunological Aspects of Cryosurgery (Ablin RJ) 1977
Immunologic phenomena induced by cryosurgery (Ablin RJ & Guinan PD) 1979
Cryoimmunotherapy: clinical and experimental considerations of the nature of the immune response. (Goland M) 1975

The passage you quote is used generally (at all types of skin tumours) not specifically at warts. I would be intersted to know if any wart specific data is presented in the references you quote. In the most recent systematic reviews for cutaneous wart treaments there is still insufficent robust research evidence to suggest whether cryosurgery is effective or not. Let's get some more research underway!

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Do you mean as a modality of treatment or as a precursor to an immunological response?

As a treatment modality. What is clear is that the longer the freeze time - the more effective it is in resolving lesions. however, the down side is the that complications are increased (as you would expect).

Not necessarily. It’s not the length of the freeze that’s critical but the rate of freeze - i.e. the freezing velocity. The faster the FV the greater the cell destruction. A rapid freeze will result in intracellular ice formation, which ruptures the cell membrane, whereas a slow FV tends to form extra-cellular ice, which insulates and protects the cells.

There are a number of cryogenic institutions throughout the USA who have any number of extremely rich but dissatisfied individuals who have opted to preserve their bodies for a time in the future when the remnants of the Bush Dynasty are gainfully employed selling veggie-burgers in downtown Austin. They have been cryogenically prepared and stored in Liquid Nitrogen at -196°C. The freezing cycle takes up to 32 hours and the velocity, which is extremely slow, is geared towards preservation. Whether or not these people can be successfully brought back to the land of the living is another discussion, but experimentation with rodents suggest that there may be a possibility.

Cryosurgery as a treatment modality is a well-established and successful procedure in many disciplines – podiatry, dermatology, cardiology, and ophthalmology to name a few. It is not an easy procedure to undertake in the sense that the operator needs to know some basic facts about the physiological aspects of cellular destruction by cold and there are a number of variables, which can influence outcome, such as tissue type, moisture content & etc. But the experienced operator can enjoy a high success rate. During the late 1980’s we undertook a series of clinical trials on a number of pieces of cryosurgical instruments – the most successful of which gave an eradication rate for single plantar warts of around 92% after a single course of Rx (three freeze/thaw cycles). I have also used cryosurgery as an alternative to chemical ablation in matrixectomies and for the Rx of porokeratosis. (see BJPM Oct 1990).


Mark Russell

Do you have any experience of using Cryotherapy on the granulation tissue of a cryptosis?

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Allan Lang, , Fife, Scotland

Hello Alan

I wouldn't freeze granulation tissue unless you want to produce a large haemorrhagic bullae. I usually excise and cauterise or use AGNo3 after the cryptosis has been removed.

Mark

Does anyone ever consider why the verruc. is there in the first place ? look at where it is ,has there been a disruption to the skins integrity ? and treat with something like a silicone pad to reduce friction and pressure , this reduces the discomfort and often works quickly to get rid of the nasty invader !
Tess

New one on me. How does it work?

Hi Robert
My theory is that if we allow the local immunity to work on the verrucae without any irritation such as excess friction or pressure then it has a better chance to fight.I have used the silicone pad method on boarding school girls , the matron treated all verrucae that presented to her clinic over a year with just the silicone and all were successful. Someone could do a study on this maybe one of the pod.students would like to set up a clinical trial ?