How To Handle Recalcitrant And Recurrent Warts
Dr. Dockery: What do you do when you get that recalcitrant wart? You may have tried everything in your armamentarium and it either persists or spreads or comes back in the same area. At any point, would you refer the patient to another podiatrist, dermatologist or specialty clinic?
Dr. Salk: While there is no set time period, if you have not seen any resolution or a decrease in the size of the wart after three to six months of treatment, I think it is important to look to your colleagues for further advice. It’s rare that we are unable to treat the wart as we have some very innovative treatment modalities. However, there have been a few incidences in which I have sent patients to other podiatrists or dermatologists.
Dr. Chang: As with anything that it is difficult to treat, I agree that a different perspective or a third perspective may be valuable. Dr. Salk and I work together so we can discuss a non-healing wart and look at it differently. I may have the patient see Dr. Salk on a day when I’m not even there.
We have been very excited and have good experience with some of the newer options discussed and these are often the same recommendations from other internists and dermatologists with an interest in verruca. Now we try to utilize those options in our offices. I haven’t referred a patient with a resistant wart recently but I may send a patient to a dermatologist to see if there may be a malignant potential to a lesion that is not healing in the appropriate time.
Dr. Lemont: There are not that many people — and I think we all know it — who really have that much different approaches to warts. The only time I think you end up making the referral is for medical-legal reasons when a patient is really concerned. The only exception to that is if there is a particular modality that you may not have. For example, there may be a certain type of photo laser that you may want to use. I think making the referral is appropriate under those circumstances. However, short of using a particular modality, I would reserve the referral for the most part for medical-legal issues or when patients are showing a lack of confidence in the treatment.
Dr. Dockery: So if the patient starts questioning why there has been no progress in resolving the wart, then it is time to make the referral.
Dr. Lemont: Right. If you get to a point where you feel like you’re stuck and that you have used whatever therapy that you feel comfortable with, I think it’s certainly reasonable to send the patient to another doctor.
Dr. Dockery: I think that’s probably appropriate in any situation with any condition.
Taking A Closer Look At The Recurrence Of Warts
Dr. Dockery: What is the greatest problem with treating warts? Does one single thing stand out?
Dr. Salk: The recurrence rate is a great problem and this is probably related to the incubation period of the wart, which, if you look at the literature, is commonly between four to 20 months. What we see with the naked eye is this lesion that is well encapsulated or a mosaic pattern of warts. There is literature out there that states the virus can be incubating and not be seen by the visible eye within a centimeter or so away from a main lesion. If you destroy and get rid of a wart, there still may be this virus that is incubating. You don’t see it with the naked eye and you have this frustration when this wart comes back.
So I think it’s important to educate the patients and let them know about this incubation period so they can watch their feet to make sure there is no recurrence. We typically will have the patients come back one month after eradication of the wart. I actually encourage the patients to come back three months later. Even though they may not visibly see a problem on their feet, we will often catch it. Of course, if you catch it early, you can treat it effectively with simple modalities.
Dr. Dockery: So you think recurrence is a major issue that you need to address with your patients?
Dr. Salk: Yes. When patients initially present with the human papilloma virus, it is important to let them know in advance that this may be a frustrating treatment course and that they’ll need to be patient over the treatment course. If you don’t tell patients this information, you may be treating this wart over 12 weeks and they may not understand the difficulty of treatment.
They need to understand that this is a DNA virus that has a icosahedral capsule involved with it. What this basically equates to is the fact that this virus is very resistant to treatments. This virus also replicates very quickly so we need to pay attention to the treatment modalities and look at recurrence rates with this.
Dr. Lemont: I think recurrence is also directly related to making sure you treat all the warts that are there, not just the warts that you see. I commonly find podiatrists don’t use enough macro magnification, in general, for the viewing of most warts. I recommend getting as much illuminated magnification as possible to routinely look at the adjacent areas, because you may be missing warts which could only be seen with macro magnification.
What I use is a Dermatoscope with oil on the skin that can actually give you the equivalent of a low power light microscope that’s used under oil. You use it on the skin itself and you actually end up getting down almost to the level of the dermal-epidermal interface. I end up looking at the surrounding tissue.
This way, instead of hoping you removed them all, I thoroughly check the patient to ensure that I’m addressing all the warts that are there.
Based on the histology, plantar warts are almost pushed down to the superficial fascia. I think that accounts for the difficulty of treating plantar warts.
Dr. Dockery: So it appears that recurrence is a major issue in the treatment of warts, whether it’s due to the wart’s resistance to the treatment we have chosen, the inability for us to see the adjacent incubating viral areas, the depth of plantar warts or the patient’s own susceptibility to the wart virus.
