WARTS ----------------------------------------------------------- I would appreciate any novel treatments for multiple periungual warts in a patient on long term cyclosporin for her heart transplantation. Immunomodulators such as interferon, cimetidine, imiquimod, hypnotherapy (?) are contraindicated. LN2 +/- cantharone+, C&D, occlusol HP, etc. are helpful but the VV return and new ones are arising. Bleomycin is a consideration but is not looked favorably upon by the transplant team. Has anyone had experience with bleo in such patients? Brian Berman MD PhD ------------------- How about trying DNCB! Reviva@aol.com -------------- In reply to dr.berman, I would try cimetidine, as there is justification in the literature and in my own personal experience that it can be a useful modality for multiple warts. Steven D. Emmet, M.D. --------------------- I am faced with a similar quandary in a patient with recalcitrant warts who has Multiple Sclerosis. Dare we treat such patients with "immunomodulators" which we are using as non-specific stimulants to their T-cell immunity? I think that contact dermatitis therapy with DNCB or SADBE would fall into that category, although of the two I would favor the SADBE as being safer (no effects of DNA). GenadijS@aol.com ---------------- Having cared for several patients is this situation, I appreciate Dr. Berman's quandary. The renal guys don't want you to use cimetidine because it can cause increased levels of creatinine (spuriously probably, but it effects their monitoring efforts on the cyclosporine and the risks of immunostimulation have been addressed, in addition to the fact it is very hard to sensitize these patients. I have had success in two renal transplant patients having them apply 5FU daily to the wart areas. I have cured none of them, but the numbers of old and new warts are reduced by 50-60%. Local bleo should be ok with the appropriate care around vessels. I am afraid this is another example of one technology outrunning another one, warts aren't exciting enough to get a lot of money spent on them until you have an immunocompromised host and they start posing neoplastic transformation risks. L.J. Gregg ---------- You might combine some of the "traditional" alternative approaches that work some of the time. These include: 1. Hot soaks- water from the tap, as hot as the patient tolerates it, changed as it cools down. Soak for 15-20 minutes at a time, a few times per day. 2. Tape - duct or electrical - applied to the most annoying warts and left in place until the underlying maceration loosens the tape, then replace the tape. 3. Find an overchlorinated pool or hot tub and have the patient soak her hands in that water for a few hours. I have had one patient accidentally do this and a few others intentionally do this with clearing of the warts in a few days! It does not work for everyone. I have not yet tried a pool chlorine tablet in a bucket of water or a dilute Clorox solution (Dakins?) for the same effect but am considering it. 4. A little dab of bathroom silicon applied to warts has the same effect as tape; the acetic acid solvent may enhance whatever the local therapeutic happens to be. 5. A little sap from milkweed or dandelion (dent de lion, pis en lit) applied to the warts can result in destruction of the warts, along with a mild irritant dermatitis, over a fer weeks. 6. Gently sand the warts with some wet-dry sand paper or a pumice stone and then borrow a tiny (and I emphasize tiny: a pinhead size drop to a 4mm wart) bit of zinc chloride paste from your local Mohs surgeon and apply it under occlusion. This gives you the chance to do pathology on the wart when it sloughs. 7. Retin-A liquid, followed in 15-30 minutes by Efudex 5% liquid followed by occlusion b.i.d is also very effective over 4-6 weeks in periungual warts, but i would check with transplantation wallahs before starting this approach. 8. The infrared photocoagulator, the poor mans laser, makes no plume and is also a consideration. I agree with the transplant team about the bleo. If the cyclosporin knocks out the patients kidneys, it will be hard to seperate its effect from the bleo. Good luck. DANIEL M SIEGEL --------------- here is a real witches brew for recalcitrant warts that i have had some successwith (not used by me in immunocompromised patients): high dose vitamin a, 100,000 iu daily, 3 weeks per month, in conjunction with topical acyclovir qid. i warn patients of toxic side effects of oral vit a, especially headaches, hairloss, or peeling of palms and soles, and tell them to lower the dose if any of those are seen. three weeks a month allows a one week wash out period, and i usually treat for 3 months. dncb is another treatment you might consider. William.Liss ------------ The way I treat recalcitrant periungual warts in immunocomprimised hosts: Apply cantharone plus, occlude for 24 hours. Debride the bulla in one week and apply liquid phenol to the base. Repeat evry two weeks. The secret is patience and persistence. One may have to repeat this for months but to date I have had no failures. A note on bleo: it is excreted by the kidneys. Don't ever consider it, even in small doses, in a patient with a high creatinine/low creatinine clearance. I did one time. The patient was unaware she had poor renal function. Her hair fell out after Rx of only one wart. A note on recalcitrant: Re= back. Calcus = heel. It literally means leaning back on one's heels like a mule. Would a wart on the heel be a calcitrant wart? Haines ELy, Grass Valley, Ca. ----------------- From: Haines Ely I have used cantharone plus on such patients alternating with phenol or 5fu at two week intervals. Heres how: Cantharone plus under occlusion for 24hrs. Debride the bulla in one week. Apply a drop of phenol to the raw base (it anesthetizes and cauterizes at the same time) WHen healing has occurred repeat the process. It may take five or ten times in these patients. If phenol is too irritating use 5fu daily during healing of the bulla base, under occlusion. Haines ELy, Grass Valley, Ca. ----------------- I think the rapidly emerging consensus is that pulsed dye laser may be the treatment of choice in this setting. It's simple (though not necessarily cheap, depending upon insurance, provider, etc), not that painful, and appears to approach or exceed other modalities in efficacy. Bleomycin was my Rx of choice for extremely recalcitrant verrucae before getting access to PDL, but I certainly have my list of bleo failures. Mark R Ling ----------- I agree with Haines that H2 antagonists are useful to reduce the chance of recurrence of warts, but I like ranitidine 300 bid better because there are fewer drug interactions and it has a higher H2 affinity. I've sometimes wondered if curettage after electrodessication was useful. Anybody ever tried just electrodessicating the warts then letting it slough off in its own good time? KC Smith MD FRCPC Niagara Falls ON ---------------- I agree that a biopsy is worth seriously considering at this point. If the histology is more consistent with verruca and not squamous cell carcinoma, I would consider giving the patient a "take home" treatment, which I think works better than physician applied therapies in this situation. The virus can remain unexpressed in clinically normal skin, and most of these recurrences are probably due to that. Topical fluorouracil 2% solution applied daily or M-W-F to the affected area until all visible lesions are gone, and then have the patient immediately begin reapplication at the first sign of recurrence. How can the patient visualize the area you may ask. Borrowing a page from femnist self-exam technique, have him place a mirror against the wall at a 30-45 degree angle so that when he lays in front of it with his feet against the wall and straddling the mirror he can comfortably visualize and treat the affected area (a few pillows under the head helps). Persistent and aggressive treatment can and does lead to long-term cures, but the key word is "persistent". It is also very important that he use condoms in his sexual endeavors (particularly his lover) to prevent ping-pong infections. This is also true for heterosexual couples with the same problem. Hope that helps. Mark Naylor, M.D. University of Oklahoma Health Sciences Center ---------------------------------------------- 1. I would biopsy: incidence of HPV-associated SCC significant in this setting. 2. As one easy, though far from reliable option, cimetidine as immunopotentiator? Great in kids, variable in adults, probably not that useful in HIV patients with low CD4 counts but simple and non-toxic. Would of course use it as adjuvant with some destructive modality. If CD4's are low, I'd be pretty pessimistic. Mark Ling, M.D., Ph.D. Emory University Department of Dermatology Clinical Pharmacology Unit Atlanta, GA ----------- Question: do you worry at all about the plume issue? It was certainly a concern with C02 laser with clear demonstration of aerosolization of infectious viral particles. Since electrosurgery would also be predicted to "spatter" potentially infectious materials, and since we typically may not be used to using the same degree of protection with electrodessication that we might with laser (laser mask, smoke evacuator, etc) is this a concern for you? I must admit to holding my breath even when using dye laser for warts (I'm a chicken at heart!). Mark Ling, M.D., Ph.D. Emory University Department of Dermatology Clinical Pharmacology Unit Atlanta, GA ----------- Concerning the patient with intraanal warts, anogenital HPV can theoretically infect all anal squamous epithelia, ie. up to the anal verge (the juncture of squamous epithelia of the anus and columnar epithelia of the colon). The anal verge is not necessarily visible. If some condyloma are "hiding" and shedding infectious viral particles, this may explain the recurrence (or is it reinfection?). What do you think about anoscopy? Marty Okun Bethesda, Maryland ------------------ This is the second time I have seen Ranitidine touted as a substitute for Cimetidine in the treatment of warts on the grounds that it has more H2 affinity. Is there evidence that the purported efficacy of cimetidine in the treatment of warts is due to its H2 blocking effect? Do we know that ranitidine works clinically? -Just curious. - John Uhlemann ------------- Thank you for all your suggestions. However, perhaps I was not clear; this patient does not have perianal warts, he has INTRA-ANAL warts, ie at the internal anal sphincter and rectal mucosal junction. My question still stands, because my colo-rectal surgical colleague is doing a study on the use of intralesional interferon with electrodesiccation. Warren J. Winkelman, M.D., FRCPC -------------------------------- I would agree with the suggestions offered so far for your gay, HIV- negative patient with intractable intra-anal condylomata. I would offer one additional piece of advice: Receptive sex abstinence until clear. T. Keith Vaughan, M.D. Fort Carson, CO --------------- Consider interferon plus an aromatic retinoid, or, a trial of the aromatic retinoid alone (based on clinical resolution of facial flat warts in patients on Accutane). And from the holoistic community pharmacy : Wart Ban. A pill made from the Thusia Berry extract of the Arbor Vitae. I am almost embarrassed to report that 3 of my patients cleared their plantar recalcitrant warts after two to three months of this extract! One had no response. Also, cimetidine may be added as well? Diane Thaler ------------ Ranitidine works better in kids than in adults. At a high enough dose they probably work eqully well. My main reason for preferring ranitidine is less drug interactions and no anti-androgenic effect. KC Smith MD FRCOC Niagara Falls ON ---------------- 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. ---------------------- Try Radiotherapy. 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 --------------- Mark, Xray 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???? Mark1105@aol.com ---------------- 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 -------------- 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. ------------------ 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 ------------- We have a 16 y/o male who we are treating for persistent verruca plana on his nape. We have applied multiple course of 100% TCA followed next by sublesional alpha interferon 2 beta 3 million units 3x a week for several months but they would recur within 2 to 3 months. Electrodessication was also done. Workup done on him showed him to be immunocompromised but HIV (-). T4/T8 ratio decreased .56 (N=1.2-2.4), OKT4 dec 20% (N=35-55), OKT8 N at 36% (N=20-36). IGg, IgA, IgM, C3 all normal. Any suggestions on treating this patient? Jonathan Yu, MD --------------- I have had good luck with a combination of Efudex 5% and Retin A 0.025% cream, equal parts BID... Steven D. Emmet, M.D. --------------------- Have you considered cimetidine, 30mg/kg/day? Article in June "Archives of Dermatology" lends further credence... Dan Mitchell, MD ---------------- I had a patient (a young physician) with persistant (7 yrs, multiple RX), then flat warts. A biopsy of a relatively small neck node showed lympoma (which was probably the basis of her immune defect). Probably worth a look for other causes of immune compromise besides HIV Rick Sharpe ------------ Try either the pulsed dye laser at about 8 J or Intralesional interferon alpha. Both have worked in this situation for me Guy Webster ----------- How about big doses of vitamin A? 500,000 units daily for a month? Jerry Litt ----------- In patients without underlying malignancy we have had great success, especially on the face, with Accutane, 20-40mg/day for 2-5 months. Interestingly, speaking of immune suppression, one of my grad students facial flat warts cleared over vacation in California after a mild sunburn and tan following 3 days of surfing! Diane Thaler ------------- How about Cimetidine, 30-50mg/kg per day for two to three months? Jerry Eisner ------------ Several respondents have suggested cimetidine since an article in the June "Archives of Dermatology" lends further credence. The Archives study was open label. In the June "JAAD", a placebo-controlled, double-blind study concluded that "...cimetidine is no more effective than placebo in the treatment of patients with common warts." (J Am Acad Dermatol 1996;34:1005-7.) Cimetidine, though, is a relatively benign treatment. Anyone have any experience about specific groups in adults where cimetidine was considered helpful? Or is this an example of: "using the medicine while it still works?" Stephen L. Comite, MD --------------------- I started using Tagemet routinely in wart patients about two years ago after an experience with my horse that I reported to this group early on. Although I have not done any controlled studies in my office, it is my gestalt feeling that tagemet has been effective alone in a number of cases and in combination with other modalities, helps to prevent recurrence (I keep patients on tagemet for about 3-4 months after no verruca is visible). This seems to have reduced the recurrences. Jeff Marmelzat, M.D. --------------------- I use a lot of DNCB for intractable warts. Invariably there are patients who cannot be sensitized. If one gives cimetidine 400mg T.I.D. for 2-3 weeks their skin tests become positive. There is absolutely no question cimetidine improves T cell function. I would not rely on it alone for treatment of warts but certainly recommend it as adjunctive therapy along with everything else recommended. Haines ELy ----------- This is anecdotal, but I have had several patients with recalcitrant warts of various types respond to cryo (which I believe enhances the immune response to warts) in conjunction with Tagamet 400 po BID. A cryo study, with & without Tagamet would be useful. Rick Sharpe ----------- For holoistic types try Wart Ban (thusia berry extract, arborvitae evergreen). This is a pill. Manufactured in Wisconsin (we have a lot of arborvitae). I will find out the address if anyone is interested. It is usually available at community pharmacies. Diane Thaler ------------ Have you considered chronic retin-a or 5-FU topical?...or perhaps squaric acid immunotherapy (topical). Jay Barnett ----------- I have had some adults respond to cimetidine, combined with Retin A and/or Efudex. One "wrinkle" (pardon the pun) is that many managed care companies will not pay for it as the low dose form is now OTC and the patients themselves will not pay for it. Daniel Mark Siegel MD ---------------------- I have been very impressed with results of cimetidine for warts in children, and am now trying it in adults with stubborn warts. Results pending. William Liss ------------ Anyone have any qualms about using the high doses of cimetidine which appear to be needed to treat warts from the standpoint of the endocrine problems, or is the short duration of treatment too brief to cause concern? Mark Ling, M.D., Ph.D. ----------------------- Also impotency can be a problem with tagemet even in normal doses for acidity problems. Jeff Marmelzat, M.D. -------------------- Don't know how Tagamet got top billing for warts - Ranidine does not have c-450 or antiandogenic effects, and works fine. I think it also has higher H-2 affinity. And the syrup tastes minty - easy to give to kids. I never Rx Tagamet. Kevin C. Smith MD FRCPC ------------------------- Would you share with us what dosage of ranitidine you use for warts in adults and pediatrics. Thanks. Jere J. Mammino --------------- I use 300 mg bid for adults (same dose for psoriasis), 150 mg bid for 10-13 year olds, and the 15 mg/ml syrup for kids (eg. 5 ml bid for a 3 year old). Same dose for molluscum contagiosa. KC Smith MD FRCPC ----------------- All the studies that I've seen have been with Tagamet, so I assume that's why it has preference over Zantac. Has anyone seen any studies in treatment of wart with Zantac, other than anectdotes? Mychael Luu, M.D. -----------------