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Clinical Management of Verrucae Pedis

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Paul Bowles

on 21 August 2015

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Transcript of Clinical Management of Verrucae Pedis

WHAT IS A WART?
DNA Virus from papilloma virus family
Over 60+ types
Plantar Warts type: 1,2,4
Infect keratinocytes of the skin or mucous membranes
Majority of known types cause no symptoms in humans
Some types known involvement in cancers of the cervix, vulva, vagina, penis, oropharynx and anus
Recent links to cardiovascular disease (Kuo 2011)
Human Papilloma Virus - Sub Types
HPV1 (single) is notoriously stubborn as it creates a huge amount of vacuolisation - hence the rubbery, macerated texture and has far more disturbance of cell differentiation through the entire thickness of the epidermis than HPV2 & 4

HPV2 (mosaic) produces some vacuolisation in the spiny and granular layers, leading to a honeycomb-like picture on histology as it proliferates. This is probably the most superficial sub-type, so could explain why people observe higher success rates treating them

HPV4 (multiple) causes a thicker granular layer only, but a more compact horny layer
(Longhurst 2013)
HOW DO YOU TREAT WARTS?
Coagulation Treatment
The NEED to treat versus the NECESSITY to treat
Clinical Management of Verrucae Pedis
DISCLAIMER
by Paul Bowles
Cryotherapy
Phenol
Curettage
Duct Tape
Acid Therapy
Injectables
Laser
Falknors Needling Method
Pharmacotheraputic
Self Limiting Nature of Cutaneous Warts
“One-half of primary school children with warts will be free of warts within 1 year” (Bruggink 2013)

“Majority resolves spontaneously and the evidence on treatment of warts is rather poor” (Nordentoft 2013)

“Young age and non-Caucasian skin type enhance resolution” (Bruggink 2013)
What does the Evidence Say?
- Non Genital Warts
“There is a considerable lack of evidence on which to base the rational use of the local treatments for common warts”

“Cure rates with placebo preparations are variable but nevertheless considerable (Gibbs 2001)
“The efficacy of various treatments is inconclusive”
(Watkins 2006)
“Salycylic acid only shows a modest therapeutic effect”

“Trials comparing cryotherapy with placebo showed no significant difference in effectiveness”

“Trials comparing cryotherapy with salicylic acid showed no significant difference in effectiveness”

“Trials of clear duct tape demonstrated no advantage over placebo”
(Kwok 2012)
“Intralesional bleomycin is more effective than cryotherapy in treating warts on hands and feet”
“There was no statistically significant difference in the cure rate between treatment groups (monochloracetic acid 10% with 10% formaldehyde versus formaldehyde alone) The overall cure rate for this population was 61.4%.”
(Adalatkhah 2007)
Formaldehyde
“Pulsed laser treatment is effective and safe in the treatment of recalcitrant viral warts”
(Schellhaas 2008)
“Pulsed laser is an effective treatment for both recalcitrant and simple warts. It is the treatment of choice for these lesions in cosmetically sensitive areas”
(Kenton-Smith 1999)
“Laser is ideally suited for precise and speedy ablation of plantar verrucae with minimal thermal damage to surrounding tissue” (Trelles 2006)
References
THANK YOU
QUESTIONS?
Coagulation or Carbonization?
Carbonization
The longer the pulse duration and shorter the rest times the more heat accumulates in the tissue
COAGULATION
To coagulate means to blanch and kill the tissue without surgical excision or tissue carbonization
CARBONIZATION
Carbonization is an ablative treatment, achieved by applying focused laser radiation to the tissue resulting in burning the tissue
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