Exploring Current Approaches To Plantar Warts

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Continuing Education Course #148 — December 2006

I am pleased to introduce the latest article, “Exploring Current Approaches To Plantar Warts,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Given the challenges of treating plantar warts, Harvey Lemont, DPM, provides an overview of what clinicians should look for and consider when evaluating patients with plantar warts. He also offers an array of insights on treatments including sharp dissection, salicylic acid onitment therapy and intralesional immunotherapy, and underscores the importance of patient education.
At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one contact hour by reading the article on pg. 69 and successfully answering the questions on pg. 74. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Lemont has disclosed that he has no significant financial relationship with any organization that could be perceived as a conflict of interest in the context of the subject of his presentation.
OFF-LABEL/UNAPPROVED USAGE DISCUSSION: This educational activity contains discussion of published and/or investigational uses of agents that are not indicated by the FDA. Neither NACCME nor the manufacturers recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings.
GRADING: A score of 70 percent or above will comprise a passing grade. Within 60 days, you will be advised that you have passed or failed the exam. A certificate will be awarded to participants who successfully complete the exam.
RELEASE DATE: December 2006
EXPIRATION DATE: December 31, 2007
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• assess key factors and considerations when evaluating patients who have plantar warts;
• describe the benefits and drawbacks of salicylic acid;
• review the level of sharp dissection for plantar warts; and
• discuss the use of intralesional immunotherapy for plantar warts.

Sponsored by the North American Center for Continuing Medical Education.

As one can see, a useful sign that the treatment of monochloroacetic acid is over or near its end is the presence of lymphangitis, swelling and pain. This is not an infection but an inflammatory non-infectious aseptic lymphangitis.
Once evacuated, the underlying tissue appears ulcerated, moist and exudative, another good sign that treatment is at its end.
When one uses acid therapy to treat large mosaic warts, the foot will appear to exhibit multiple ulcerative areas as shown above. Although the areas may appear frightening, they will heal nicely in time. The formation of a sterile abscess at that time req
While it is true that warts are only located within the epidermis, mechanical factors stimulate the warty epidermis to grow and extend deep into the reticular dermis to  the level of the superficial fascia.
While in most parts of the body the fascia is composed  primarily of fat, the foot uniquely consists of  white, tough collagenous fibers. Clinically, one can identify the superficial fascia as a white tough membrane that is noted once one has removed all
The superfical fascia is the subcutaneous layer of the loose areolar tissue uniting the corium of the skin to the underlying deep fascia. Under high power, the fascia appears as a dense band of collagen with fibroblasts running parallel to the skin surfac
When it comes to topical contact sensitizers, one may start initial sensitization by placing sensitizing solution on the arm and instruct the patient not to get the area wet. Usually, between 24 and 72 hours will be sufficient time to sensitize.
Here one can see squaric acid 2% sensitization using the foot as the sensitization site
Here one can see Squaric acid 2% applied directly to a group of Mosaic warts  after four weeks of using squaric acid 2%. Warts regress without tissue destruction.
By Harvey Lemont, DPM

      In general, plantar warts are very difficult to treat and pose a certain challenge to physicians and their patients. Both physicians and patients should not be discouraged by an initial poor result. With proper communication between the doctor and patient, one can achieve realistic outcomes.

      Too often, doctors downplay treatment, only to be reproached by a frustrated and angry patient who received unrealistic expectations. For example, the treatment of chemosurgery using acids may take as long as six weeks. If the warts resolve in three weeks, the patient is delighted and may consider the doctor a hero. Podiatric physicians should tell patients what to expect in terms of treatment regimens and outcome before initiating any treatment.

      Before starting treatment, one should also inform patients that there may be recurrence of some of the warts either during or after treatment. Inform the patient this is common and those warts will need to be retreated. Patients should also get realistic estimates of the doctor’s success rate for treating certain kinds of warts. For example, I tell patients that there is an initial 75 percent chance of total cure rate with simple plantar warts but perhaps only 50 percent when dealing with mosaic warts. Other DPMs’ figures may be higher or lower. What matters is that the doctor and the patient are on the same page.

      One should also inform patients of the risk, albeit small, of painful scarring or painful callus formation at the wart site. The use of electrocoagulation or inappropriate use of cutting lasers are more common culprits in this regard. Patients also should be aware there is no panacea for all warts. The modality one selects should be based on the individual patient’s presentation. For example, is the patient a child, a very nervous adult or does he or she have a low pain threshold? Try prescribing over-the-counter acid preparations such as salicylic acid under occlusion. These medications are safe and effective in uncomplicated cases.

      The duration of the warts is also a factor in determining treatment. How long have the warts been present? Has the patient had the warts for two months or two years? Patients who just developed a batch of warts may not be psychologically prepared to undergo certain treatment regimens if they perceive an aggressive or prolonged course of treatment.

      Other factors include the type of warts. Are you looking at mosaic warts or simple plantar warts? Extensive mosaic warts are a challenge quite distinct from other plantar warts. Initial surgical removal of mosaic warts as a rule is not indicated because of the high rate of recurrence within scar tissue. One should first try a more conservative initial approach using oral medications like high dose oral vitamin A and cimetidine, or even placebo therapy. It has been estimated that anywhere from 30 to 70 percent of patients with warts may respond to a placebo.

      Is the patient immunocompromised? Immunocompromised patients with extensive warts are not only particularly predisposed to developing warts but eradicating these warts is also much more difficult. Before initiating treatment, one should tell patients who are on steroids (even those on low dosages), patients with diabetes and patients with hepatitis or AIDS that their treatment may be prolonged, recurrences are common, and the treatment in some cases may not work at all. These patients may do well with contact immunotherapy using squaric acid, dinitrochlorbenzene (DNCB) or Candida albicans antigen injections.

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