Sunday, November 18, 2007

Uncommon Warts

SRLAMAT DATANG!
Welcome, New Members from the Penang Conference

Early morning, view before we convened for our scientific sessions. Penang is an amazing place to meet new friends, relax and sample a singular culture.

Please look at two interesting cases.

This is the tale of two young patients with warts who were seen back to back on November 17, 2007. Verruca vulgaris (the common wart) is sometimes quite "uncommon."


1. This is a seven year old boy who has had acute lymphocytic leukemia fr three years. He has had recalcitrant warts for the past nine months. At present he has failed liquid nitrogen, TCA and imiquimod. His present medications include methotrexate, 6 mercaptopurine, vincristine and dexamethasone. Each therapy for his warts has resulted in more florid reappearance. This child has suffered a lot over the past few years. Clearing his warts would be a small but pleasant victory for him. Your comments will be appreciated.








2. This is a 12 year old girl who initially had a small wart on her knee. Her physician treated with TCA and then liquid nitrogen over a few months. Each time the wart recurred larger. One can see concentric rings from previous treatments. I'd like to find a treatment that won't cause permanent scarring. In theory, the wart will disappear in a year or two, so the therapy should be benign. I prefen not the use liquid nitrogen or cautery here. Have you had success with warts like these?


10 comments:

  1. For both children, I would consider immunotherapy (intralesional candida antigen or contact sensitization with diphencyprone vs. dinitrochlorobenzene vs. squaric acid dibutyl ester). Immunotherapy would be less likely to be of value in the immunosuppressed boy. After that I would consider intralesional bleomycin diluted in lidocaine given via a combined superficial intralesional injection-scarification technique after informed consent was obtained concerning possible nail matrix damage with periungual bleomycin treatment.

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  2. I agree with Rick. Immunotherapy with DPCP or candida antigen sound reasonable, as is scarification/scoring with bleomycin. Would consider adding oral zinc +/- cimetidine, and may even try cantharone plus. These are always tough. Ben Barankin

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  3. Khalifa SharquieNovember 18, 2007

    Regarding the first case with leukemia, I think better to leave it alone because whatever you give it might fail.

    For the 2nd case I prefer to apply podophylin 25% in benzoin co every 3 days together with topical salacylic acid 30% in vaseline twice a day.

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  4. uresponsive warts may indicate immunosuppresive state from which zinc defficiency is the most relevan, so checking zinc level may help to identify the underlying cause.

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  5. Since warts have been refractory to conventional treatments in both the children, i would suggest to use topical 5- Fluorouracil cream along with topical salicylic acid (12-30%), in case of subungual warts intralesionsal injections of interferon-alpha is another option.
    Oral zinc or levamisol may produce some benefit.

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  6. Matthew H. Mahoney, M.D.November 19, 2007

    I agree that immunotherapy (Candida) on the immunosuppressed patient may not obtain the desired response. I did some training in Chicago with a well-known peds derm there who would treat immunosuppressed children with the following (in the OR): paring, pulsed-dye laser (595nm with cryospray turned OFF), and sometimes cryosurgery after that. This is well tolerated with general anesthesia, and probably allows a more thorough paring and freeze. Often the periungual lesions do not yet involve the matrix. PDL seems to work on the multiple vertically oriented vessels present in verruca vulgaris. Cimetidine or bleomycin are other options.

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  7. Vivek MalhotraNovember 19, 2007

    I wish to say something about the first case. Its periungual warts, which i have seen quite often. I think the best treatment, although a bit mutilating, is the good old electric cautery. I usually do it under LA, trying to do as deep as possible, mostly taking out a good chunk of tissue. It then heals by secondary intention. And believe me the scarring has been quite minimal. The only problem is the painful LA injection, and you may have to repeat it once or twice. But the results are amazing.

    Regarding the second case, I will suggest CO2 laser. If we do multiple sessions we can get rid of the wart with absolutely minimal scarring. If someone has ever done it, its just like removing seborrhoeic keratosis with laser, just scrapping off the layers.
    I will definitely like to have the views of others on this.

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    Replies
    1. I have seen this return after surgical cautery. The local is far from the worst of it for the client. If the client is unable to clear HPV, they return post cautery. To do this to a child is barbaric considering there are virtually painless alternatives.

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  9. Squaric acid immunotherapy protocol. Effective, painless. Dietary supplementation with zinc, vitC, lysine and vitA.

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