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Our PCT has just made the policy decision to stop treating VP's. Altogether.
This is the culmination of a move over 8 years going from treat all of them to treat the ones who get refferred, to treat the painful ones, to treat the painful ones on high risk patients, to don't treat at all.
The rational is that
A: the treatments are almost universally painful and most VPs are more painful after treatment than before.
B: Low and unrepeatable success rates with everything bar Aggressive cryo and electrodessication.
C: They'll go by themselves anyway so whats the point?
I know several private pods who have patients back every 4 weeks for debridement and a dab of Silver nitrate, sometimes for years! These patients have been led to beleive that if their lesions are not resolving it's because its a Really tough lesion. I struggle to see this as ethical.
Obviously this is an NHS department but i'd be interested to know how people feel about this from both the public and private sector. Is treating VPs an expensive waste of time or are we missing out on a valuable area of practice?
Our PCT has just made the policy decision to stop treating VP's. Altogether.
This is the culmination of a move over 8 years going from treat all of them to treat the ones who get refferred, to treat the painful ones, to treat the painful ones on high risk patients, to don't treat at all.
The rational is that
A: the treatments are almost universally painful and most VPs are more painful after treatment than before.
B: Low and unrepeatable success rates with everything bar Aggressive cryo and electrodessication.
C: They'll go by themselves anyway so whats the point?
I know several private pods who have patients back every 4 weeks for debridement and a dab of Silver nitrate, sometimes for years! These patients have been led to beleive that if their lesions are not resolving it's because its a Really tough lesion. I struggle to see this as ethical.
Obviously this is an NHS department but i'd be interested to know how people feel about this from both the public and private sector. Is treating VPs an expensive waste of time or are we missing out on a valuable area of practice?
Thankyou for your views
Robert
How about treating the ones that are spreading? You see people coming in with several warts that have been present for years and during this time have multiplied. There is no indication that these would resolve on there own. We use nitric acid or curettage and have high success rates with these.
>I know several private pods who have patients back every 4 weeks for debridement and a dab of Silver nitrate, sometimes for years! These patients have been led to beleive that if their lesions are not resolving it's because its a Really tough lesion. I struggle to see this as ethical.
Not sure whether it involves ethics but it may breach morality and would certainly indicate incompetence as the action of silver nitrate solution on the skin is to create precipitation of protein which in the presence of light, turns black. This gives the operator the opportunity to trace the skin striations and identify a circumscribed lesion. It provides an aid to diagnosis but has no medicinal (anti-viral) purpose whatsoever. Neither for that matter would regular reduction of the overlying keratin.
>Obviously this is an NHS department but i'd be interested to know how people feel about this from both the public and private sector. Is treating VPs an expensive waste of time or are we missing out on a valuable area of practice?
How about treating the ones that are spreading? You see people coming in with several warts that have been present for years and during this time have multiplied. There is no indication that these would resolve on there own. We use nitric acid or curettage and have high success rates with these.
Nope, we're not doing those either. As you say there is no evidence that these go by themselves, (although i suspect there could be) however there is also no evidence that they don't!
Quote:
Not sure whether it involves ethics but it may breach morality and would certainly indicate incompetence as the action of silver nitrate solution on the skin is to create precipitation of protein which in the presence of light, turns black. This gives the operator the opportunity to trace the skin striations and identify a circumscribed lesion. It provides an aid to diagnosis but has no medicinal (anti-viral) purpose whatsoever. Neither for that matter would regular reduction of the overlying keratin.
Agreed. It's a regular source of argument at meetings. I've been arguing the fact that a protein precipitant is different in effect to a caustic for years. The case is not helped by the fact that silver nitrate comes in packets with CAUSTIC written all over it.
Not sure i agree with you on the regular debridement thing. I've always worked on the basis that aggressive debridement (to the very bloody stage) caused inflammation -> increase in white blood cells -> increased chance of effective immune response. But as you say there is no evidence to support this.
Regular reduction of the keratin layer would have no effect on the stratum spinosum (presumably where the virus is). Reducing bulk may however make the client feel comfortable which is another story, of course. Haemorhaging may then be deatl with by using silver nitrate soln as a stypic.
I am interested to see what effect (if any) the introduction of innoculation against cervical cancer will have on the clinical incidence of plantar warts.
Our PCT has just made the policy decision to stop treating VP's. Altogether.
This is the culmination of a move over 8 years going from treat all of them to treat the ones who get refferred, to treat the painful ones, to treat the painful ones on high risk patients, to don't treat at all.
The rational is that
A: the treatments are almost universally painful and most VPs are more painful after treatment than before.
B: Low and unrepeatable success rates with everything bar Aggressive cryo and electrodessication.
C: They'll go by themselves anyway so whats the point?
I know several private pods who have patients back every 4 weeks for debridement and a dab of Silver nitrate, sometimes for years! These patients have been led to beleive that if their lesions are not resolving it's because its a Really tough lesion. I struggle to see this as ethical.
Obviously this is an NHS department but i'd be interested to know how people feel about this from both the public and private sector. Is treating VPs an expensive waste of time or are we missing out on a valuable area of practice?
Thankyou for your views
Robert
Robert
You talk about treatment as being the actual application of a caustic, cryogen or electrodessication. In my opinion this is only one part of the treatment and actually the least important.
To me the most crucial and fundamental part of any treatment is the explanation by a Healthcare Professional of what the problem is. The Human Papilloma Virus, that causes warts and verrucae, is no exception. I hope that whilst your PCT Podiatrist is no longer going to "treat" the VP they are still going to "treat" the patient and spend time fully explaining HPV. If not however else are we as a profession going to break down the stigma associated with this virus?
I spend a minimum of 30 minutes with each patient that comes along with a verruca to my practice. During this time the patient learns about the human papilloma virus, its effects on the skin, where it comes from, how it has infected them - each person understands the Etiology, Histology, Pathology, differential diagnosis oh you name it, they understand it whether they have been educated to degree level or left school at 14! If it takes me an hour to explain to a patient, I achieve understanding.
Once a patient has this understanding, then they can keep a perspective on this innocuous skin lesion and at this point we (not I, but guided by me) discuss reasons for treatment and a suitable method. Usually this is skin debridment to make the patient more comfortable followed by self management. If resolution of the verruca occurs then the patient understands this is an added bonus and is an effect of the immune system not our intervention.
Robert, if you view application of caustic etc as treating a verruca then you are definitely missing out on an area of valuable practice. You are shifting the problem straight into the hands of other healthcare professionals in the treatment of verruca. Predominately within my locality the treaters of VP's are now the Practice Nurses - who not only treat VP's with cryo but anything that resembles a VP!
I was a child of the 60's when you had to sit out swimming and PE if you had a verruca. Oh how I looked forward to the examination of my feet by the school PE teacher! You talk to your over 40years of age patients and you will find this stigma is firmly entrenched in their brains even now. Thus the passing on of the VP stigma down the generations. Your challenge, as a Podiatrist, is to help patients over come this stigma and if you successfully achieve this, there may be a long term change in the attitude towards VPs.
There are not enough Podiatrists (NHS and Private) in this country (UK) that actually sit down with their patients to communicate a thorough understanding of any foot problem to the patient, whether it be a VP or functional problem. Therefore I see no change in the future management of VPs.
Perhaps our educationalists could be fundamental in changing attitude and perception towards the Human Papilloma Virus?
GB
The Following User Says Thank You to George Brandy For This Useful Post:
Just thought I'd add my view as a private practitioner:
1) Lots of people request treatment for VPs and they just want to get rid of them (usually for cheap!)
2) If they are painful, patients benefit from advice on debridement and pressure-relief
3) When I first see a patient I explain that VPs are a virus and, therefore, treating has extremely variable success rates as it is largely down to their own immune system as there is no anti-viral (unless the cervical cancer vaccine does help)
4) If patients still want localised treatment after I've explained all of the above, I always combine treatment with advice on taking a supplement called 'Perfectil' which is a 'Skin, Hair & Nail' supplement (which is just a multivitamin really) and which has given good results in most people (I am attempting a case study at present!); plus daily filing and application of 25 % urea cream.
However, my overall feeling is that VPs are viral and, therefore, the focus should be on the immune system and not blasting the heck out of the skin, but no matter how much I try to put patients off, the majority still want treatment! Go figure!
Robert, if you view application of caustic etc as treating a verruca then you are definitely missing out on an area of valuable practice. You are shifting the problem straight into the hands of other healthcare professionals in the treatment of verruca. Predominately within my locality the treaters of VP's are now the Practice Nurses - who not only treat VP's with cryo but anything that resembles a VP!
An interesting point not without merit. The plan as it stands is to send refferals for VPs straight back to the GP with a snotty note saying we don't do these no more. So we will do neither education nor intervention. I suspect you are correct in your opinion that this will move the problem to people far less able to deal with it. We too see the occasional HD sitting in a damn great thermal burn care of practice nurses.
Thats how it goes in the NHS these days. If you're foot is'nt about to go black and drop off they're not interested.
The plan as it stands is to send refferals for VPs straight back to the GP with a snotty note saying we don't do these no more. So we will do neither education nor intervention.
Robert,
Whilst I appreciate that the letter will be a little more professional than snotty it doesn't do much for inter professional PR.
Quote:
I know several private pods who have patients back every 4 weeks for debridement and a dab of Silver nitrate, sometimes for years! These patients have been led to beleive that if their lesions are not resolving it's because its a Really tough lesion. I struggle to see this as ethical.
What a shame that it appears you hold such a low opinion of private podiatrists. We are not all like this.
It is also a shame that your PCT, in its policy of not treating verruca, cannot suggest a private practice route to give the VP patient an option.
Oh heck, never mind perhaps the voluntary sector can add another skill to their list and become PCT "approved" VP cutters as well as nail choppers.
I'm sure it'll be a beautifully worded letter. We have some very gifted wordsmiths who will doubtless come up with a dignified, elegant and polite way of saying "sorry, this is yet another thing we won't do, please sod off and stop sending us patients". Fortunatly not my job as i would be tempted to do something along the lines of "due to the new carpets and pot plants at the pct management headquarters, the cost of the legion of administrators and accounts needed to massage the figures to fit the targets and the annual re organisation costs we have no money left in the budget for minor fripperies like treating patients. Therefore we are once again upping the access criteria for the service in line with our 10 year plan to eventually see only those who are either losing toes in the bedclothes or are clinically dead".
I suspect my underlying frustration with the circumscription of our practice has bled through into my language and obfuscated my meaning.
Quote:
What a shame that it appears you hold such a low opinion of private podiatrists. We are not all like this.
If that is the impression you got i can assure you that the appearance is misleading. I hold NO opinion of private pods as a group at all, low or otherwise. Like NHS pods there are some good ones, some ok ones and some not so good. To lump any group together and consider their abilities as a whole would be foolishness.
The inability of the pct to hold a list of "approved alternative suppliers" of podiatry for those patients we are unable to see is indeed somewhat frustrating. I beleive that in order to avoid favoritism we can only recommend that the person seeks the advice of "an HPC registered Chiropodist". I suppose given that most of the pods who work here also do some private work it would be seen as a potential abuse of position to advertise oneself but it is irritating.
I prophecy that within ten years the voluntery sector and the private sector will be all that there is. Were it not political suicide to kill the holy cow the NHS would have been allowed to die, with dignity, of natural causes years ago instead of lurching along from crisis to crisis spending ever increasing amounts on papering over the ever widening cracks.
Sorry. Having a bad day. Toying with the idea of become a snail farmer in Brittany.
Not my cup of tea, but i know that if you look at the Cochrane review, you might as well use a placebo. As I recall they reviewed trials of sal acid versus placebo- no diff and then cryo versus sal acid- no difference. Not sure if this is correct, but it was something like that.
I do recall a paper in "the Chiropodist" (or "shmopodist" as I used to enjoy calling it) some years ago in which intentional haemorrhage was employed "effectively".
I used to freeze mine weekly until I got bored of the pain. Then about two years latter it went away on it's own. n=1.
Personally, I now educate.
If this fails, I rub raw meat on it, bury the meat in my garden, drop a couple of acid tabs and dance naked around it at midnight.
If this fails, I take multiple X-rays and MRI scans as I find the radiation helps.
__________________ Science is the antidote to the poison of enthusiasm and superstition
Fire Walking (Ummu Ti, Tah he, or Nistinaire)
The ceremonial "Fire walk" has its history rooted in antiquity and was certainly known in Biblical times. From available records the ceremony was practised in the Society Islands, the Tonga (or Friendly Islands), New Zealand, Fiji and Hawaii. There are also records of the same practice in Africa, South India, China, Japan, Italy, South America, Spain and Bulgaria. Fire walking appears to have been imported by seafarers into different areas and incorporated into different faiths. The act of fire walking is generally thought to increase religious merit or power (manna) and is intimately connected to the seasonal expulsion of evil influences. Different cultures use different types of fire beds, for example Polynesians use heated stones whilst others use glowing charcoal. In Southern India is an act of faith undertaken to safeguard their cattle and crops from evil doings. Also when a believer suffers an illness they can take a vow in the name of the goddess (Draupadi) and if they are cured they will walk over the fire in gratitude. In Africa it is a test of chastity for priests and priestesses. In most religious fire walking, the walker will fast on the day and pray or meditate with others. Before the walk they bathe their feet in a tank to secure perfect cleanliness. The fire bed is made first from burning a ton of jungle wood to make charcoal, they when it is glowing hot a thin layer is spread to form a walking platform. The great marvel of fire walking is those who walk on red hot embers do not seem to sustain any burns or suffer obvious pain. The whole issue remains a mystery with even firewalkers themselves firmly unaware of why their feet do not burn. Many believe this is an act of faith and the absence of pain and damage is because of divine aid. In truth many fire walkers do experience flesh burns. Devotees believe when these occur the walker is not in tune with the deity. Many scientists and sceptics have tried to disprove the theory including trying to explain the phenomenon. The feet of the firewalkers have thicker skin than normal and many go unshod. As part of the ceremony leading up to fire walking the participants soak their feet in water. This means many are cold damp and dirty from walking barefoot. In the physical world the heat of a fire bed depends on its length, breadth and depth as well as the materials which are alight. The higher the surface the temperature the greater the heat transferred to the feet when they are applied to the fire. According to scientists the reason why fire walkers do not get burns on their feet is because their feet are not in contact with the burning umbers long enough to damage the skin. This is helped by having cold feet which are wet and finally the dirt on the sole of the feet further reduces the conduction of heat. When scientists conducted experiments they showed ordinary people could walk across burning coals without being burnt. Much was dependent on the time of foot contact and the same researchers were able to show severe burning of the skin could occur if the feet were in contact for too long. They believe firewalkers know exactly how long they can make contact. What was interesting about the described experiments was it was possible to cross a charcoal bed, without abstinence from meat, alcohol and sex which kind of debunks the myth of many devotees. However in truth, self denial may strengthen resolve to overcome any adversity.
References
Fonseka C. 1971 Fire-walking: a scientific investigation Ceylon Medical Journal 16:2 104-109.
Mackenzie DA 1996 South seas: Myths and legends London: Senate
Hi Robert
If the vp. is located over a pressure area it will be painfull so why not treat it as a friction/ pressure area and use a silicone pad or advise the patient to purchase one . The leison won't worry them anymore and they will be less inclined to seek a more invaisive form of treatment that will scar and lead to a long term problem.
Tess
The Following User Says Thank You to Tess Bowen For This Useful Post:
Hya,
I don't 'treat' verrucas any more. ( I have over twenty years of experience with these critters!) Now I explain that the pain is caused by callous build up around the edges on vp's on weight bearing areas and pare this down for comfort if required, and then I reccommend rubbing with a pointed end of a mouse shaped pumice while the foot is wet (enough to cause some friction but not enough to cause a heamorrage) the results are impressive. I don't know though whether it's the friction or perhaps a chemical compound in the stone that works but every patient that has followed my advice has had a successful result.
Jane
I would disagree with your explanation simply because the pathology of the skin would support the bloating of the Spinosum layer compresses upon the adjacent nerve ending and causes pain (usually by lateral pressure). The overlying callus is a physiologial protection which is formed to reduce peak forces and rarely is the wart painful on direct pressure. Callus removal will assist in the application of medications and is essential after breakdown to establish drainage. The decision to not treat leaves the body immune response to deal with the infection.
Robert
Caustic labelleing of high solutions of silver nitrate or similar products is a COSH (Health and Safety) requirement, but the action of this caustic is protein precipitation.
To treat or not treat
I have done both with warying degrees of success but as a private practitioner I preferred not to for purel mercinary reason. I was introduced to the herbal prep Kalanchoe and have found this treatment to be 100% successful.
More recently the association with cervical cancer and papova virus has made me a little more interested in the benefits of treating plantar warts early, especially in adolescent populations where unprotected sex is likely. In Australia cervical cancer vacinations have recently been introduced and I will be would be interested to see what effect, if any, this has on the presence of verucca in females.
ToeSlayer
Thanks for the tip on Kalanchoe, ill have to do a some more research on this treatment. Anything that can stop the spread of HPV's is of great help to all pt's and innocent bipedal standers. Leaving HPV's to spontaneously resolve or talking to them for hours on end seems like wishfull thinking. I have recently inherited a pt. with a HPV 10cm in diameter, it completely covers the heel and will grow up to 1cm thick in 10 weeks. If there is a treatment to prevent this i will certainly do al that is in my power to prevent my other pt's from being physically debiliated by this viral growth.
Steve
Have you ever had electrosurgery done?! It is a painful procedure. I had it done 5 years ago (I still have the scar), not only did I have an ulcer for 9 weeks, but the vp multiplied on healing and I developed a further 5! I have never recommended this procedure since undergoing it my self. It is not nice at all!!!!!!
I only treat painful vps, I send others way with the knowledge that banana skins can help as does Thuja. The banana skins appear to take out the pain of these vps and also softens the callous over it.
Only last month I treated my 7 year old nephew and after 3 treatments, his vp had virtually gone, we used sal acid and silver nitrate combo, and it works a treat, I don't find silver nitrate on its own is strong enough!!!
__________________
Tomorrow is promised to no man! My location
I understand that many of the alternative treatments involving herbal or onion family derivatives are likely to work because they contain natural salicylates which breakdown side salt linkages of the keratin and irritate the lesion sufficiently to illicit an epidermal blister (referred to as breakdown).
The synthetic salicylates will have the same effect but this is usually more virulent.
It's not usually adolescent feet that spread the subtypes of HPV associated with cervical cancer! (16 & 18, 30 & 31 are the ones that have been identified as 'high risk') As far as I am aware, the subtypes responsible for verrucae are considered 'low risk' with respect to malignancy developing (although I realise that this can & does occur). The greatest risk is lack of diagnosis and risky behaviour; safer sex may not always offer protection against spread of warts (it depends on where precisely they are located). I am very doubtful that immunisation against these strains of HPV will make any difference to the incidence of plantar warts. (Unless Aussie girls do some things differently from us Pommies!) But that is not say I'd object to being proved wrong!
You are quite correct and the evidence is scant. The risk if it does arise is mainly boys with penal warts engaging in pentrative sex with younger girls. Surveys would suggest this behaviour (apart from natural inquisitiveness) is more far prevalent in young teenage and pre pubescent communities than commonly believed.
The potential for a generation of females immune to the cancer causing virus would be ideal but a downside mght be the lower grade virus becomes more pathological. No evidence but more reason perhaps, to treat warts.
hello fellow feet people,
I put my thread in hoping for some feedback regarding the use of pumice stones on verrucas. Am I the only one to recommend this form of treatment? does anyone know the reason why it works.
Jane
Having been hit recently with some shockers(including every known treatment going) I am having success with Thuja ointment (in a sticky base) . It does not produce a breakdown but reveals the truly distorting damage to the stratum spinosa layer. Invariably it seems to hit the very active teens and after 23 years, I have concluded there is a strong association between this affliction and growth spurts and / or stress which seems to affect the immune system through the glucocorticoid axis.
Therefore anti inflammatory & immune enhancing education is needed, as well as "rest", both global and local ,to the affected part.
robyn
I'm sure it'll be a beautifully worded letter. We have some very gifted wordsmiths who will doubtless come up with a dignified, elegant and polite way of saying "sorry, this is yet another thing we won't do, please sod off and stop sending us patients". Fortunatly not my job as i would be tempted to do something along the lines of "due to the new carpets and pot plants at the pct management headquarters, the cost of the legion of administrators and accounts needed to massage the figures to fit the targets and the annual re organisation costs we have no money left in the budget for minor fripperies like treating patients. Therefore we are once again upping the access criteria for the service in line with our 10 year plan to eventually see only those who are either losing toes in the bedclothes or are clinically dead".
I suspect my underlying frustration with the circumscription of our practice has bled through into my language and obfuscated my meaning.
If that is the impression you got i can assure you that the appearance is misleading. I hold NO opinion of private pods as a group at all, low or otherwise. Like NHS pods there are some good ones, some ok ones and some not so good. To lump any group together and consider their abilities as a whole would be foolishness.
The inability of the pct to hold a list of "approved alternative suppliers" of podiatry for those patients we are unable to see is indeed somewhat frustrating. I beleive that in order to avoid favoritism we can only recommend that the person seeks the advice of "an HPC registered Chiropodist". I suppose given that most of the pods who work here also do some private work it would be seen as a potential abuse of position to advertise oneself but it is irritating.
I prophecy that within ten years the voluntery sector and the private sector will be all that there is. Were it not political suicide to kill the holy cow the NHS would have been allowed to die, with dignity, of natural causes years ago instead of lurching along from crisis to crisis spending ever increasing amounts on papering over the ever widening cracks.
Sorry. Having a bad day. Toying with the idea of become a snail farmer in Brittany.
Regards
Robert
Robert, Snail farming! Is there a vacancy for a vegetarian assistant at your new location in Brittany? I could look after the greens for the lil blighters. I'm also a wizard with a pot noodle so could double up as your housekeeper. Will be delighted to forward my CV if requested. Regards,
__________________
:)
twirly
Mandy Brooks
Brooks Podiatry
S64 0DE
Suffering a fondness for odd things.
Dear all,
Just breezing through the net once again. Paused at this section RE: VPs . Just a quick Q for any who care to respond. Have any of you undergone cryo yourselves?
Not at the provision end of the probe though, I mean as the recipient.
Never had a verruca myself but a few years ago I developed a small wart (called percy) on my peter pointer finger. Local GP offered to freeze it for me. Following a 20 second blast I went back to my clinic to complete my afternoons work. GP called in to see how I was doing & asked if it was stinging a little. Stinging, no. ABSOLUTE AGONY!! yes. I lost 3 nights sleep & wanted the damned thing amputated.
However I am pleased to tell you that Percy, (the wart) is no more. Since this happened I have been far more cautious when advising patients to seek cryotherapy (particularly for weight bearing areas). My usual advice is if it aint hurtin' leave the thing alone.
A private patient was quite upset though when I advised her that the non-painful VP on her 3 year olds sons 5th toe was best left alone. I had printed her copies of advice from the Societys web site. The little chap was not bothered by the verruca until his mum insisted on filing it until it bled & tried to apply bazooka to his tiny foot.
Pondering ringing child line.
__________________
:)
twirly
Mandy Brooks
Brooks Podiatry
S64 0DE
Suffering a fondness for odd things.
Twirly, I have had cryo about 9 times, I have had the sal acid and silver nitrate combo and electrosurgery.
I too would agree, if it isnt sore dont touch!! I had a vp for years and when I did Podiatry decided it would be good to see what treatments were like (I even had a pna). Well I coped with the cryo, but yes it throbs and keeps you awake, gives you sore knees and hips as you try to adjust your walking. But nothing and I mean nothing compares to electrosurgery. I will never ever send a patient for that. I had an ulcer for 9 weeks (I am relatively young and healthy!), it got infected and I needed abs and I had to pad it up to walk it was over my 3rd mpj.
My standard treatments for vps now are, either banana skin, tea tree and lemon oil or the thuja tincture.
Tea tree and lemon oil seems to work, I had a colleague(SP) that used it on a sty on her eye and thought she was going to loose all sight due to the burning sensations!! On your foot though it is not painful.
__________________
Tomorrow is promised to no man! My location
VPs. To treat or not to treat.
Re: VPs. To treat or not to treat.
and thought she was going to loose all sight due to the burning sensations!! On your foot though it is not painful.
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