Key Insights On Wart Treatment

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Case Study: When An Excisional Biopsy Makes A Difference

About five months ago, a 47-year-old male came to my office complaining of pain below his left fifth metatarsal head. He stated that he had this wart on his foot for as long as he could remember. He had prior treatments but it never really seemed to go away. The patient also stated a history of basal cell carcinoma.

I decided to perform an excisional biopsy in my office. This was not so much because I thought it might be cancer but because it was a deep, intractable, hard piece of skin. I felt no other treatment would really be ideal for this and I was not really sure it was a wart. The thicker the wart, the more likely I am to remove it surgically.

I performed the biopsy and then got a call the next week from the pathologist, who just happens to specialize in verrucous carcinoma. He told me it was most likely a low grade carcinoma and needed a wide excision. I called the patient, gave him the bad news and referred him to a surgical oncologist. Sure, I could have performed the wide excision myself but I felt that he would be better served by someone who deals with this a lot more than I do.

I think we can all learn from this situation and biopsy more than we presently do because you just never know. This is why it is important to get a history and be sure to review any prior treatments as well as any disease processes that might cause an immunocompromised state or reveal a history of cancer.

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Author(s): 
Peter Bregman, DPM

Step-By-Step Insights On The Excisional Biopsy

Surgical excisional biopsy is a very effective (about 85 percent in my experience) procedure and also confirms that it is in fact a wart. It is important to obtain patient consent for this procedure, preferably a signed consent form. At the very least, one should document a verbal consent. This is just good practice and can save you any problems should any complication arise from this simple procedure.

   If necessary, you can prescribe an anti-anxiety medication such as lorazepam (Ativan) preoperatively. If appropriate, a local anesthetic block with epinephrine is ideal as long as it is not for a toe. I utilize a V block with a 27-gauge needle. Ensure standard sterile prep to the surgical area.

   Circumscribe the lesion using a skin scribe and create a 3 mm border. Then excise the lesion down to the basement membrane. I use a combination of a 15 blade and a dermal curette. Be careful not to enter the subcutaneous layer as this can cause scarring.

   I like to cauterize the area with 80% monochloroacetic acid with just two to three seconds of application. Send the specimen off to the lab. Depending on the size of the lesion, you can dress this with a topical antibiotic of choice and small sterile bandage. Have the patient provide local wound care and follow up as you see fit. If I see any sign of recurrence during the recovery period, I will often use the pulsed dye laser, which can stave off any recurrence.

In Conclusion

I am sure many people reading this likely manage their verruca in a different manner. However, just as I prefer to perform a Scarf procedure for my bunionectomies, there is more than one way to skin a fish. I hope I was able to provide you with some pearls about how to treat warts effectively while keeping practice management in mind.

   Dr. Bregman is the President of the Association of Extremity Nerve Surgeons. He is a Fellow of the American College of Foot and Ankle Surgeons, and a Fellow of the American Society of Podiatric Surgeons. He is in private practice at Barrett Foot and Ankle Center in Las Vegas.

References

1. Androphy AJ, Lowly DR. Warts. In Wolff K, et al. (eds.): Fitzpatrick’s Dermatology in General Medicine. McGraw-Hill Medical, New York, 7th ed., vol. 2, pp. 1914-1923, 2008.
2. Silverberg NB. Human papillomavirus infections in children. Curr Opin Pediatr. 2004;16(4):402-9.
3. Personal communication with Harvey Lemont, DPM.

   For further reading, see “Current Concepts In Managing Plantar Warts” in the December 2010 issue of Podiatry Today.

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