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#3 Surg > 47 - Verruca > Flashcards

47 - Verruca Flashcards

1
Q

Characteristics of verruca

A

Caused by the human papilloma virus (HPV), a double stranded DNA virus which is surrounded by an icosohedral capsule (20 sides)

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2
Q

Transmission of verruca

A
  • Actual mode of transmission and infection unknown, but more common in children, adolescents, and young adults-rare over the age of 50 (may spontaneously disappear after 2 years w/o treatment in 40% of children*)
  • May be preceded by break in skin
  • Common in immunosuppressed patients (prolonged steroids)
  • Persistence of disease may be attributable to a lack of Langerhans’ cells at site of lesion, leading to decreased T-cell response
  • Increase in size and distribution and may become more resistant to treatment over time*
  • *Bacelieri R and Marchese-Johnson S. Cutaneous warts: an evidence-based approach to therapy
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3
Q

Incubation period

A
  • Incubation period is 4 to 20 months

- Virus can be found a centimeter away from main lesion

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4
Q

Spreading in pools

A
  • pH of swimming pool (5) is ideal for promoting infection

- Children with treatment-resistant warts may be reservoirs for HPV transmission*

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5
Q

Histology

A

Purely epidermal in its histopathology – ONLY EXISTS IN THE EPIDERMIS, NOT THE DERMIS***

Causes the pathognomonic characteristics of:
o Acanthosis
o Hyperkeratosis
o Interpapillary projections (papillomatosis)

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6
Q

Acanthosis

A

Thickening of stratum spinosum

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7
Q

Hyperkeratosis

A

Thickening of stratum corneum

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8
Q

Papillomatosis

A

o Upward proliferation of epidermis and subepidermal papillae causing surface of epidermis to show irregular undulation

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9
Q

DNA production

A
  • DNA and protein production occur in the SPINOSUS LAYER with final virus assembly occurring in the GRANULAR LAYER
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10
Q

Papillomatosis

A
  • Papillomatosis result in the characteristic “black dots” or “petechia” that are seen clinically within the white, fibrotic base of the wart
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11
Q

Types of HPV

A

Over 75 different forms of HPV

Three most common forms causing plantar warts in humans are:
o HPV-1 (common wart)-occurs most frequently
o HPV-2 (mosaic wart)
o HPV-4 (common wart)
o HPV-10
o (HPV-63 has also been implicated)

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12
Q 
The histological changes that occur with a verruca include:
o	Spongiosis
o	Acanthosis
o	Acantholysis
o	Hyperkeratosis
o	Papillomatosis
o	Papillated
A

Answer: 2, 4, 5

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13
Q

Differential diagnosis

A
  • Verrucae must be distinguished from IPK (intractable plantar keratosis) and porokeratosis
  • After removing overlying hyperkeratosis from a wart, will see a white, fibrotic-like area with presence of “dots” that interrupts the normal skin lines and bleeds easily upon debridement
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14
Q

Clinical presentation – Verruca vs IPK vs porokeratosis

A
  • Often, but not always, a wart will be tender to sideways pressure and not to direct pressure like an IPK (intractable plantar keratosis) will be (NOTE: THIS IS NOT RELIABLE AT ALL – DO NOT USE)
  • IPK’s intractable plantar keratosis) most often confined to weight-bearing areas and covered by thick plug of hyperkeratosis – RELIABLE
  • Porokeratosis found anywhere on plantar surface, similar to verruca – RELIABLE
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15
Q

Porokeratosis

A
  • Porokeratosis is actually a small clonal projection of keratinizing squamous cells
  • Have a coronoid lamellae-columns of parakeratotic keratin that overlie a depression in the surface epithelium-this leads to a prominent rim around the lesion
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16
Q

Squamous cell carcinoma

A
  • Some evidence to suggest that verrucae may undergo transformation to squamous cell carcinoma-very uncommon-consider this possibility if you have a resistant wart that looks more “fleshy” than normal and perform biopsy
  • Should you submit this to the lab every time you treat it? No, that is overkill. Only when you see something that is very resistant to treatment and looks a little more fleshy than normal.
  • Opinion: if it doesn’t look quite normal and has not been responding to treatment for 3 months
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17
Q

Treatment

A
  • Every conceivable treatment exists because there is no single treatment that will eliminate warts each and every time*
  • Doing well if you can eliminate warts 70% of the time
  • One reason that treatment is so ineffective is that the lesion is flattened out on the bottom of the foot, limiting the amount of surface area that is accessible for topical treatment
  • On the hand, they are raised and dome-shaped, on the foot they are flattened out
  • Do as MANY treatments you can in one appt. to achieve the HIGHEST success rate
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18
Q

Chemical ablation with salicylic acid

A
  • Topical salicylic acid is the most common
  • Keratolytic agent (gets tissue to shed as quickly as possible to shed the virus)
  • Applied once or twice daily by patient under occlusion and turns skin white
  • Exists in concentrations of 17% and 40%
  • 17% = NOT EFFECTIVE so don’t bother (Compound W Wart Remover Liquid®, Wart-Off®, Duofilm Liquid®, Occlusal HP®)
  • 40% = (Mediplast®, Duofilm Patch®, Compound W One Step®, Clear Away Wart Removal System®)
  • Cost (once daily of 15-20%): $5 - $7 for entire cost of treatment – CHEAP***
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19
Q

Cantharidin

A
  • Cantharidin [(Cantharone®) derived from the BLISTER BEETLE] or Podophyllin (derived from American mandrake) applied in office under occlusion for 24-48 hours – These are EXTRACTS
  • This is a much higher strength than salicylic acid which causes severe BLISTER
  • Use aperture pad to protect normal skin from agents, this is for OFFICE USE ONLY
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20
Q

STUDY – Cantharidin and Podophyllotoxin

A
  • Application of cantharidin (beetle) and podophyllotoxin (plant) for treatment of plantar warts
  • 1% canth, 5% podo (from Mandrake root), 30% sal acid
  • 87% cure with one treatment, 96% cure with two treatments
  • Applied to surface with q-tip and placed under occlusion-rechecked in 24-48 hours
  • VERY HIGH cure rate – his treatment with just cantharidin is just as high***
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21
Q

Cryosurgery (freezing)

A
  • Liquid nitrogen in spray canister is best; however, can use handmade thick q-tips dipped in liquid N2 solution
  • Histofreezer® and Verruca-Freeze® claim to achieve temp as low as -70° C, but research proves otherwise-this is the temp produced by the modality and not what occurs on the skin
  • Cell death occurs below -20°C
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22
Q

Triple freeze technique

A
  • Administer spray until epidermis freezes (turns white) to an area about 5mm beyond wart circumference-hold freeze for 30 seconds or until patient complains of pain, whichever occurs sooner
  • Wait until tissue regains pink color (45 –60 seconds) and then refreeze
  • Repeat a third time
  • Painful, often not tolerated by children
23
Q

Blister from freezing

A
  • Will form a blister, usually hemorrhagic, often subepidermal, that is left in place
  • Follow in 2 weeks
  • NOTE: Most commonly, a hemorrhagic blister will form, which is usually not painful – This is opposite of the acid, where the treatment is not painful, but the blister is very painful
24
Q

Cost of treatment of freezing

A
  • Cost of 3 to 4 treatments including initial office visit: $420.00
  • Cochrane Review: no more effective than simple topical treatments for nongenital warts
25
Q

STUDY – Cost effectiveness

A
  • Cost-effectiveness of cryotherapy versus salicylic acid for the treatment of plantar warts: economic evaluation alongside a randomised controlled trial (EVerT trial)
  • Cryotherapy is more costly and no more effective than salicylic acid
26
Q

Topical treatments

A
  • Topical corticosteroids
  • Tretinoin (topical vitamin A)
  • 5-FU (inhibits DNA synthesis)
27
Q

Topical corticosteroid

A
  • Topical corticosteroid (Florone®, Diprosone®, Cordran Tape®)
  • Use under occlusion, apply topically BID
  • Inhibits cell division and synthesis of DNA in epidermis
28
Q

Tretinoin

A
  • Topical vitamin A which is applied BID under occlusion
  • Increases differentiation and proliferation of epidermis
  • Cost: $50.00 for 45 gm tube
  • Cochrane: fair evidence to support its topical use
29
Q

5-FU

A
  • 5-fluorouracil [5FU] (Efudex®, Carac® cream)
  • Inhibits DNA synthesis
  • Efudex 10x stronger than Carac, but Carac supplies 5FU over extended period of time
  • Apply BID under occlusion
  • Consider topical preparation of 5FU mixed with 17% sal acid cream (cost: $55.00/month)
30
Q

Oral medication

A
  • Systemic etretinate (Soriatane®)

- Tagamet® (cimetidine)

31
Q

Systemic etretinate (Soriatane®)

A
  • Systemic etretinate (Soriatane®) at dose of 1mg/kg daily for no more than 3 months showed complete clearance of warts in 16/20 children*
  • Systemic retinoid for psoriasis*
  • Cost: $447.00 for 30 day supply
  • Does not use this and would not recommend this – too high of risk
32
Q

Tagamet® (cimetidine)

A
  • Tagamet® (cimetidine), 25-40mg/kg/day in divided doses
  • Interferes with suppressor T-cell function so the inflammatory response against the virus is prolonged
  • 80-85% eradication in children under 16
  • Usually uses this when they have painful or many warts, especially when children have had chemotherapy and then develop many warts
33
Q

Intralesional injection therapy

A
  • Bleomycin (cancer drug diluted down)

- Antigen treatment

34
Q

Bleomycin injection

A
  • 0.1% Bleomycin (15 units dissolved in 15 mLs of sterile water)
  • IV use confined to prickle cell carcinoma and reticular cell sarcoma (cancer treatment)
  • Inhibits DNA synthesis
  • Cost for initial visit with 2 treatments: $500.00
  • 80% cure rate
35
Q

Bleomycin injection protocol

A
  • No more than 0.25cc is injected into the wart (level of injection such that needle can be seen advancing into wart)
  • No more than 1.0 cc administered at any one session (can treat only up to 4 warts per visit)
  • Very painful injection which requires local anesthetic prior to injection
  • Wart will blacken within 2 weeks
  • Do not administer in or near toes (may cause vasospasm)
36
Q

Risks and benefit analysis of bleomycin injection (OPINION)

A
  • Stopped using bleomycin injections for several reasons
  • Very painful , so you first need to inject a local anesthetic in order to be able to do the injection
  • Personally doesn’t think it has anything to do with inhibiting DNA synthesis, it just forms a blister which activates the immune system to get rid of the virus
  • He had one complication of vasospastic disorder to a toe after injecting 3 inches away from it
37
Q

Antigen injection

A
  • An antigen is injected into the site of the verruca to initiate an antigen-antibody response
  • Introduce antigen into base of wart with needle in same concentration as with allergy testing, then puncture wart aggressively
  • Induces immune response
  • Cost: initial visit and one injection followed by 2 follow-up injections is $200.00*
38
Q

STUDY on antigen injections

A
  • STUDY: Intralesional injection of mumps or candida skin test antigen was 74% effective in clearing local and distant warts
39
Q

Immunotherapy topical agents

A 
Theory is to induce a ***delayed cutaneous hypersensitivity reaction*** against the wart by sensitizing the patient with one of three agents
o	Dinitrochlorobenzene (DNCB)
o	Squaric acid dibutylester (SADBE) – ONLY ONE CURRENTLY BEING USED 
o	Diphenylcyclopropenone (DCP)
40
Q

Topical SADBE

A
  • Apply 3% topical SADBE in acetone to lesions (or to normal skin close to wart) under occlusion for 48-72 hours, which causes an allergic reaction
  • Same idea as antigen injection – the topical chemical will cause an immunologic reaction at the site of the verruca, which will also get rid of the virus
  • After 2 weeks, serial dilutions of SADBE (.03%-3%) are applied to the lesions twice a week
  • If no response after 10 weeks, patient is a nonresponder
  • 86% cure rate
  • delayed cutaneous hypersensitivity reaction
41
Q

Imiquimod cream

A
  • Imiquimod (Aldara®) cream
  • Recruits cytokines and interferon-alpha to wart to induce keratinocytes to produce enzymes to block viral replication
  • Apply once daily under occlusion after debriding overlying hyperkeratosis
  • Very successful with condylomas
  • Cost: $180.00 for 12 packet box*
42
Q

Match the treatment with its mechanism of action

Treatment 
o	5-FU
o	Imiquimod 	
o	Salicylic acid	
o	SADBE	
o	Tagamet

MOA
o a. Keratolytic
o b. Inhibits suppressor T-cell response
o c. Recruits cytokines to area
o d. Inhibits DNA synthesis
o e. Initiates delayed hypersensitivity reaction

A

o 5-FU = inhibits DNA synthesis = d
o Imiquimod = recruits cytokines to area = c
o Salicylic acid = keratolytic = a
o SADBE = initiates a delayed hypersensitivity reaction = e
o Tagamet = inhibits suppressor T-cell response = b

43
Q

Surgical ablation

A
  • “Needling” Technique
  • Local anesthetic required
  • Needle is inserted repeatedly into the wart, usually with a reciprocating hand piece
  • Works by destruction of tissue and induction of inflammatory response
44
Q

Curettage

A
  • Requires local anesthetic
  • Margin of wart bluntly dissected with tissue nipper
  • Curette scoops out wart down to superficial fascia
  • Cauterize base with AgNO2 or electrocautery
45
Q

Hyfrecation

A
  • Hyfrecation (also known as electrodessication of fulguration) requires a local anesthetic
  • Uses a current of high voltage and low amperage, using a monoterminal electrode
  • Uses spark-gap technology
  • Tissue dehydration precedes charring and cell death ensues with thrombosis of blood vessels***
46
Q

Procedure for hyfrecation of a verruca

A
  • Surface of wart is hyfrecated (probe does not touch surface of wart) by visible sparking at setting of 50-60 (5-6 watts)
  • Treated wart is resected with tissue nipper
  • Base of wart hyfrecated at lower power at setting of 30 (3 watts)
47
Q

Sharp surgical excision

A
  • Sharp surgical excision (with stitches)
  • Requires local anesthetic
  • High rate of recurrence and scar formation
48
Q

Laser ablation

A
  • Two types of lasers can be utilized: CO2 laser or Pulsed Dye laser
  • LASER-light amplification by stimulated emission of radiation
  • Visible light is altered by passing through different mediums which change the wavelength of the light and give it different tissue absorption properties
  • Absorption
  • Light passed through a CO2 gas chamber is absorbed primarily by water
  • Light passed through DYE is absorbed primarily by red pigment (i.e. hemoglobin)
  • The red beam seen by the operator is a targeting beam created by a helium-neon gas mixture (“hee-nee” beam)
  • Regardless of which laser you use, the outcome is that the laser chars the tissue, just like hyfrecation – no difference in outcome clinically
  • Opinion: pulse dye laser was the BEST treatment option and easiest to use, but cost is too high
49
Q

SUMMARY

A
  • Treatment requires weighing success rate vs. pain induced

- Always use combination treatment

50
Q

Recommendation for children

A
  • Generally, in children under 12, I recommend mixture of 5-FU and 17% sal acid under occlusion with duct tape, followed by imiquimod, then oral Tagamet®, and lastly, pulsed dye laser
  • If you cause pain in a child, you’ll only have that one chance, so make it work
51
Q

Recommendation for adults

A
  • In adults, I would start out with liquid nitrogen (“I changed my mind… I think you should use Cantharidin first”) and once daily application of 5-FU plus 17% sal acid under occlusion with duct tape, followed by Aldara®, followed by pulsed dye laser plus Aldara® if unsuccessful
  • Remember you are dealing with a benign lesion, so “firstly, do no harm”
52
Q

STUDY – Duct Tape vs Cryotherapy

A
  • The efficacy of duct tape vs. cryotherapy in the treatment of verruca vulgaris (the common wart)
  • 85% efficacy for duct tape
53
Q

STUDY – Duct Tape

A
  • Duct tape and moleskin when used separately as sole treatment for common warts in adults
  • Approximately 22% of patients (around 40 in each group) had complete resolution of warts at 2 months in both groups
  • Of those with complete resolution, 75% treated with duct tape and 33% treated with moleskin had recurrence at 6 months
54
Q

Which of the following statements is TRUE?
o The CO2 laser is attracted to hemoglobin
o The pulsed dye laser is attracted to water
o The pH of a chlorinated pool is verruca-cidal
o The verruca virus is a double-stranded RNA HPV
o The verruca virus does not spread into the dermis

A

Answer: 5

#3 Surg (12 decks)

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