PLANTAR WARTS ------------------------------------------------------ The eternal question: Treating a physician with the prototypical plantar wart from hell. It's big, about 2 cm diameter over the head of the third metatarsal. He has failed many cryo Rx's, topical Rx, cimetidine plus cryo, several rounds of IL bleomycin via needle injection and smallpox vaccine needle innoculation, about 7 or 8 rounds of pulsed dye laser at 9.5 J/cm2 (Cynosure) requiring local anesthesia. It's very hyperkeratotic and quite deep I suspect. Surgical curettage is an option, but I worry about scarring given the depth and location. Oops, forgot he also failed DNCB sensitization despite a good initial priming response, a consistent itching response to DNCB application, and several months of weekly application. Ideas? Mark Ling, M.D., Ph.D. ---------------------- If you have not bx'd this lesion ,I would do so. You may be dealing with verrucous carcinoma. Blake Goslen MD --------------- Regarding that "wart from Hell" - I think you should biopsy it to make sure its not a verrucous carcinoma. Dr.Annette Wegman ----------------- Try your local Radiotherapist. As far as I know we have had not one failure after referral to Dr.Ritter at U.W. Hospital. The only complication has been post therapy callous, very very mild, in one patient. A search of the literature proved this to be a common finding in "the old days" of radiotherapy and may occur many years post treatment. Then, again, the homeopathic extract of the thusia berry, Wart Ban, for holoistic patients. Diane Thaler MD --------------- X-ray the feet to be sure there are no spurs causing increased pressure in the area of the wart. If so, a metatarsal bar (or other appropriate measures) might be helpful. Formalin soaks and formaldehyde ointment sometimes work on the tough ones, with regular paring. Sometimes electrocautery and curettage is the only way (might as well get a biopsy to rule out SCC), with frequent followup exams and early retreatment for recurrence so the wart can't get too big again. Perhaps in this case a scar wouldn't be such a bad result. I'm sure disappointed the laser didn't work since I just bought one. Kurt Lofgren MD --------------- 1. Pare it down with your gillette to spot bleeding points, apply Cantharone Plus or whatever your current equivalent is, to the wart and a surrounding 2-3mm to decrease "fairy rings" and cover with duct tape. In 48 hours, if he doesn't sweat it off before pull it off, trim away bullous wart and reapply. Three to four rounds USUALLY works. If sensitive at 48 hours, wait a few days before reapplying. 2. Hot soaks on top of this, preferably in an overly chlorinated hot tub, can also be helpful. 3. If rhus sensitive, paint some fresh poison ivy juice on the wart, if necessary. 4. Be scientific - take a managed care carbonless NCR referral form, fill it out asking to transfer the wart to the recipient, address it to the plan head, rub the wart on the form and mail it off. Daniel Mark Siegel MD, MS ------------------------- X-irradiation will probably work. Is he old enough to assuage your concern about the tiny risk of carcinoma in the distant future? Mark Valentine MD ----------------- I've done intralesional interferon on monsterous plantar warts. It works, but slowly and it hurts. I'd probably cut it out. Guy Webster MD -------------- How about: Biopsy to R/O Veruccous Ca Hot bath treatment? Can't recall temp or duration, though. (I'm not in the office when I type these notes.) Bandaging - occlusion makes them shrink. Simple paring down from time to time and making peace with the thing. Hypnosis Jerry Eisner MD --------------- I would perform an electrodessication and curettage and obtain a piece of the full thickness epidermis to rule out atypia. The pain of recovery is much less in ED&C than in cryodestruction and the tendency to scarring is present but over-rated. I would see the patient back one week later to reassure him that the discomfort is normal (if it is) and review biopsy results. Look at the slide yourself so that you can reassure him that there is no cytologic atypia in a good quality sample. I would see him again after 6 weeks and retreat as necessary. Rhett Drugge, M.D. ------------------ Xray therapy, as practiced 40 years ago? Yelva Lynfield MD ---------------- Re: Temp to kill a wart: 120 degrees F for 20 minutes 3X/wk for supposedly 6 wks or so. This is a difficult temperature to maintain . The two ways I have attempted to implement this therapy are 1} The instant handwarmer packets which are sold for around $1 in sporting goods stores heat to 122 degrees and may be taped onto the foot and 2} Hot wax joint immersion units (foot size) used by physical therapists, and also sold in the Hammacher-Schlemmer (?sp) catalogue I can't say we have had much success, though. Diane Thaler MD ---------------- I have had some success with VIGOROUS paring and Cantharone +. It must be repaeted as soon as the patient can tolerate it, even within 10 days. If there is any delay in reapplication (for whatever reason) continue the assult with Upton's paste. It's not a verrucous CA? I curetted a large (sl > 2.5 cm) lesion off the foot of a microbiologist recently just to get a path diagnosis (plus a bit of desperation!) I was a verruca. I have not seen her back yet. Chris Clay MD -------------