INTRODUCTION
Warts and Verrucae (plantar warts – are a common nuisance. These are skin lesions that are caused by the ubiquitous Human Papilloma Virus (HPV). Once present they are hard to get rid of. In fact, caution is advised with repeated attempts with filing and salicylic acid and treatments that macerate the surrounding skin can cause them to spread.
These days there is little that can be done on the NHS for warts as they are classified as a cosmetic issue. Treatment will only be performed if there is an issue that prevents normal functioning of an individual.
Much confusion exists over the numerous methods of treatments of warts. So many methods are proposed but many methods are ineffective. The main reason for failure to clear warts is that if you leave behind residual wart tissue and fail to clear it fully there is a high likelihood of recurrence.
Most methods are incomplete due to failure to use anaesthetic. If maximal chance of clearance is do be obtained the tissue to be treated will have to be injected with local anaesthetic. Removal of the lesion to a deep enough level will be sore and not tolerated by an individual who has not had anaesthetic.
This is why methods such as physical paring followed by silver nitrate application and strong salicylic acid application (which are often used by chiropodists and podiatrists) are valid methods but unfortunately have a high failure rate. Numerous repeat treatments are required and most times despite repeat treatment failure to clear is commonplace.
Summary of methods with high failure rate
Veruccae have the highest rate of treatment failure and this is directly related to the extent of thickness of lesions and failure of complete clearance. I have discussed commonplace treatment modalities below and why most of them fail. Mosaic warts/veruccae are ones that are large in size due to the superficial spread of the lesions. These are more difficult to clear due to their size. Sometimes Dr Hussein will treat part of mosaic wart/verucca on the foot in order to make sure the ensuing wound is not to large and heals quickly without wound complications.
Periungual warts (warts that affect the nail edges) also have a high fail rate. This is more to do with the fact that because the wart affected tissue wraps tightly around the nail fold and under the nail. As a result, it is very hard to clear it completely without temporarily or sometimes permanently causing some form of nail growth deformity. Sometime growth of warts around the nail have already caused some form of nail growth deformity before treatment.
Silver Nitrate/Salicylic Acid (50% strength)
Paring followed by silver nitrate application and strong salicylic acid application (which are often used by chiropodists and podiatrists) are valid methods but unfortunately have a high failure rate. Numerous repeat treatments are required and most times despite repeat treatment failure to clear is commonplace. This because silver nitrate and strong salicylic preparations penetrate the top millimetre or so of a lesion that can be potentially up to 5mm plus in thickness. This leaves the majority of the lesion still present. As a result, it would be evident from the start that the treatment was doomed to fail.
Cryotherapy (Liquid Nitrogen – freeze therapy)
This is a more effective treatment but still has a high failure rate. It is used by GPs and Dermatologists. Liquid nitrogen is relatively inexpensive and readily available within the NHS. However, these treatments are now not reimbursed by the NHS to GPs and dermatology departments. As a result, it is rare to find a GP surgery that offers this treatment on a non fee-paying basis.
Freezing the wart with liquid nitrogen is painful. However it is an effective way of killing wart tissue. The problem is that local anaesthetic is not used during freezing. This is because the local anaesthetic solution can freeze itself and the doctor uses pain as an indication as to how far he can safely freeze.
Unfortunately, the treatment often fails on the soles of the feet due to wart thickness. Before the full thickness can be treated the patient finds the treatment too painful and will not tolerate enough freezing. If a pulsed application of the freezing spray is used the freezing will not be deep enough as the tissue warms up again between each pulse.
It is impossible for the doctor to tell whether or not the wart has been frozen to an appropriate depth and also usually the patient would find a deep enough freeze too painful.
Despite many repeat freezing attempts recurrence or regrowth of the wart is common.
Needling
This is a method that has gained popularity over the past few years. It is designed to push wart affected tissue deeper into the skin with small needle punctures. The theory behind it is that by doing this the skin’s own immune defence system is triggered and will fight off the wart spontaneously. Even though this seems like a good idea the reality is that the rate of failure of this treatment is high. There is not much clinical evidence to support its use.
DR HUSSEIN CASE GALLERY
PROCEDURE DETAILS
Dr Hussein has developed considerable expertise in the treatment of these lesions as he uses a wide array of laser surgical and conventional skin surgical techniques. He treats well over a hundred of these lesions every year. His access to state-of-the-art equipment such as NdYAG and CO2 lasers allows him to perform treatments that are not available to most dematologists and doctors. His expertise in cutaneous laser surgery and skin surgery allow him to offer the most effective solutions for the treatment of these stubborn lesions. Success rates of treatment with Dr Hussein are in the order of 70%-80% with the first treatment depending on lesion type. This is well above the average of most doctors using conventional techniques.
Pulsed Dye Laser
Pulsed Dye laser is a very useful technique for treatment for warts that are located on areas other than the soles of feet and around the nails. Caution should be exercised if it is to be used on the face due to too much collateral damage to normal tissue. It has a high rate of failure on areas such as the feet and around the nails due to insufficient depth of penetration of this type of laser. Dr Hussein uses this method for non-facial and non-feet/nail lesions. This method is a little sore but local anaesthetic is rarely used as it is used only for superficial lesions.
NdYAG laser
This is the most effective tool for the treatment of small (less than 1cm diameter) veruccae on the soles of the feet. These lesions are thick and as such a deeper penetrating laser is required. The treatment is performed in two stages. This treatment must be performed under local anaesthetic as the laser penetrates deeply through the full thickness of the lesion. Once treated the lesion will be left for one week. The dead tissue containing the wart will be removed a week later. Contrary to most patient’s expectations the removal of this dead tissue is usually pain free.
CO2 laser
This is Dr Hussein’s method of choice for more complex mosaic warts. It is also his method of choice for warts around the nails. Multiple veruccae on the soles of the feet can also be treated with this method. The advantage of this laser is that it allows for precise destruction of diseased tissue under direct vision. It is also bleed free as the laser cauterises as it removes tissue. As a result, the treatment can be ceased as soon as normal tissue is encountered. This allows for no more wounding than is necessary and faster healing time as a result. This treatment if required will usually be carried out at the sk:n Epsom branch as that is where the special laser for this treatment (Lumenis Ultrapulse CO2) is located.
Cautery & curettage
This is a simple method that is an easy solution for treatment of superficial small lesions on and off the face. It involves a small amount of local anaesthetic to numb the area to be treated. The lesion is then destroyed with an electrosurgical tool and then scraped off the normal underlying skin. It is a much less suitable method for warts around the nail and on the soles of the foot.
Surgical Excision
In certain cases Dr Hussein may decide to perform a surgical excision of warts and verrucae under local anaesthetic. Given the multiple other methods available it is rarely necessary. Sometimes a patient will feel that excisional surgery is the only way to remove the wart completely and without recurrence. This is an incorrect assumption as recurrence is possible even in excisional surgery.
AFTERCARE
Once the wart/verruca has been removed there will be a wound which may take a few weeks to heal completely. Healing on the foot can be compromised as the area is constantly under pressure and prone to infection (due to heat, dirt and sweat). It is therefore essential to wear loose and cushioned footwear during the healing process.
Good wound care is essential. It is important to wash the wound separately with a antiseptic soap called Hibiscrub. Colloid dressings such as CompeedTM dressings provide for a moist wound healing environment and cushioning that aids a swifter recovery. Both the dressings and the antiseptic soap can be easily sourced at your local pharmacy.