Warts Treatment Continued

Wart treatment continues to develop and newer treatment modalities continue to come out.  Let’s discuss some of the more popular treatments.

The reason why warts persist so long is that they hide from the immune system by living in the thick skin of the plantar skin.  A popular theory now being investigated is injecting something into the wart that will alert the immune system.  Candida albicans, a yeast known for causing oral thrush and yeast infections, has been injected into warts.  The immune system then begins to attack the yeast, and at the same time realizes the presence of the wart and begins to attack it.  This treatment has shown promising results in some, but doesn’t work for everyone.  Talk to your podiatrist if you are interested in attempting this mode of treatment.

Another treatment for warts is called bleomycin.  This may alarm some of you who know that this medication is a chemotherapy agent for those undergoing cancer treatments.  However, when using this medication for wart treatment, bleomycin is diluted down and is only injected into the most superficial part of the skin, similar to how TB tests are done.  Bleomycin stays locally inside the wart and does not get into your circulation.  After one application, the wart will turn black over a 2 week period.  The wart is then debrided using a scalpel.  Often, only one or two treatment is necessary.  If used correctly, this treatment is very effective in only a few office visits.

Another product being used for wart treatment is canthacur.  This is a product that comes from the saliva of an exotic beetle.  It is a very potent chemical that when applied to skin will cause blistering and lifting of the skin, which will cause the wart virus to die.  This is a newer treatment that is slowly gaining favor.  The most commonly seen problem with this treatment is that the chemical, when the foot begins to sweat, will dissolve and not stay over the affected area.  This will obviously decrease the effectiveness of the treatment.

If these conservative measures fail, there are some surgical options that can be pursued.  We’ll discuss these next post.

Warts Treatment

Warts have become so common that health professionals use a myriad of treatments, not to mention home remedies and folk remedies that are shared on personal blogs and websites alike.  We’ll go over some of the more common treatments used by professionals, and mention some of the more popular home recipes.

The best treatment for any condition is prevention.  The best way to prevent picking up the virus is to wear footwear in public areas where water is present.  Be especially careful around locker room showers at health clubs, or at public swimming pools.  If you have an open cut or a break in the skin, be especially cautious.  If you think your shower may be contaminated, a dilute bleach cleaning solution will be sufficient to remove the virus.

A common treatment used by podiatrists is salicylic acid.  This acid works by slowly eating away at the skin infected by wart.  The acid is in a cream form, is applied every week for 5-6 weeks, and is covered with a strong adhesive tape such as duct tape to ensure the acid stays in the correct spot.  After each treatment, the dead skin is shaved away with a scalpel to get to the deeper skin where the wart is hiding.  This is an effective, painless way to get rid of a plantar wart.  The downside is that it requires consistent office visits over a couple weeks.

Another common treatment for warts is cryotherapy, or freezing the warts.  By using a very direct freezing solution, you can induce a local frost bite on the wart, causing the skin and therefore the wart to die.  Similar to salicylic acid, this is a treatment that needs to be applied several times over a couple weeks.  A common mistake when using this treatment is that the cryotherapy is not applied long enough to penetrate the thick skin of the plantar skin.  In order for freezing to work, the therapy must be applied long enough for the treatment to be painful.  For this reason, podiatrists are using this therapy less and less.

We’ve only scratched the surface of wart treatment.  We’ll discuss some more next post.

How did I get this wart?

Summer time is slowly coming to an end, a time of year that many kids spend endless hours at the pool.  It is normal to get a few bumps and scratches along the way, especially on the toes and feet.  Breaks in the skin allow potential viruses to get into the skin and grow.  One of the most common viruses found in this environment is the virus that causes plantar warts.

Verrucae, commonly known as warts, are the result of an infection of a virus, which is part of a family of viruses called the human papilloma virus or HPV.   If that sounds familiar to you, it is because this family of viruses is responsible for cervical cancer and gential warts.  Thankfully, when concerning the manifestation of warts on the feet, they are benign and will disappear on their own without any treatment in a couple of years.

The virus is confined to the thick skin on the soles of the feet, which while it keeps the virus from spreading, it allows the virus to hide from the immune system.  This allows the virus to grow and seed on the plantar skin.

How can we tell a wart from a simple callus or IPK?  When shaved with a small blade, a wart will have small distinct pores that will bleed, a phenomenon termed “pin point bleeding.”  In addition, the skin lines on the soles of the feet will be interrupted by the growth of the wart.  Another way to correctly diagnose a wart will be to squeeze the wart between your fingers.  This will induce exquisite pain, more so than if direct pressure is applied to the surface of the wart.

As you probably know, this is a very common problem among children and young adults.  As such, there is no end to the many treatments that have been attempted, some more successful than others.  We’ll discuss the possible treatments in the upcoming posts.

PTTD Surgical Treatments

Once conservative treatments have failed in treating posterior tibial tendon dysfunction, surgery can be looked at as a potential way to reduce pain and correct the collapsed arch.  There are a wide variety of procedures that have been used.  Some involve repairing tendons or other soft tissues.  Others involve making cuts in bone to shift their position to reestablish their correct position.  If there is cartilage damage or arthritis in the joint, fusing the joints may be beneficial.  We’ll discuss each category of procedures.

Before any surgical decisions are made, an MRI should be ordered and reviewed with your doctor.  With the help of an MRI, the entire length of the posterior tibial tendon can be analyzed and the extent of damage can be determined.  If cartilage damage is present, this will be obvious on the MRI images.  MRI is an important tool that is essential for determination of the best procedure.

If the condition is not too far advanced, a soft tissue procedure can be done to help stop progression of the problem.  This may involve repairing the damaged tendon, or transferring a healthy tendon to take its place.  In some cases, using a tendon graft can help strengthen the tendon.  The nice thing about these procedures is that once the incision is healed (about 2 weeks), you can walk on the foot which was operated on.

If the condition is too far advanced, a soft tissue procedure will not be powerful enough to correct the problem.  In such cases, bone must be cut in order to re-align the foot under the body.  These procedures provide more correction than the soft tissue procedures.  In situations where cartilage damage is present, the surgeon may choose to fuse the damaged joint.  Although these procedures are more definitive and have more potential benefit, the recovery time is much longer.  When bone is cut, the patient should be non-weight bearing for up to 6 weeks to allow the bone to heal in proper position.  Additional non-weight bearing time may be necessary depending on how fast each particular patient heals.  The doctor will want to see you every 2-3 weeks to take xrays to insure proper healing.

PTTD is a difficult condition to treat.  Discuss with your podiatrist which procedure option best suits your situation.  Most patients see dramatic reduction in pain and a foot that allows for normal ambulation.

PTTD Conservative Treatments

Once diagnosed with Posterior Tibial Tendon Dysfunction as evidenced by the “too many toes” sign and the heel rise test, there are some conservative treatments available to help support or slow the progression of the condition.  The best treatment for you will depend on how far advanced you are with the disorder.

If caught far enough in advance, minor modifications can be made to shoe gear to help reduce the amount of pronation.  Custom orthotics made from plaster molds can be fashioned to give support to the arch.  Modifications can be made to the orthotics with time.   If pain persists, a steroid shot can be given to help decrease inflammation.   The decision to go ahead with a shot must be carefully considered as steroids can weaken ligaments and cause the condition to progress faster.  Oral steroids or anti-inflammatory medication may provide some relief, but will not reverse or halt the progression.

In most cases, orthotics will not provide enough relief.  In many instances, orthotics are skipped as a treatment and the doctor will recommend a custom ankle brace as the primary treatment.  Similar to orthotics, you will be casted for the brace, which will then be sent off to a lab for fabrication.  There are many variations to this brace, and they will be fabricated slightly different.  This brace laces up the front, extends up around the ankle, and fits into most shoes.  It helps to give support to the arch and foot.  Movement of the joints in the foot is minimized, thus reducing pain and swelling.  If worn consistently, this brace can be a definitive treatment for some individuals.  However, the brace can be bulky and difficult to wear during the warm summer months.

Despite our best efforts, some patients will eventually exhaust conservative treatments.  At this point, surgical options are explored.  Your doctor will probably order an MRI to get an idea of how degenerated the posterior tibial tendon is.  This will help the doctor to recommend the best surgical option.  We’ll discuss these options next post.

Signs of Flatfoot (PTTD)

We discussed last week the development of flatfoot in adulthood.  There are some diagnostic signs and tests that your podiatrist uses to determine if you have the condition, as well as how far the condition has advanced.

Pain along the course of the posterior tibial tendon is the most important sign when diagnosing PTTD.  The posterior tibialis tendon wraps around the inside of the ankle and inserts on the arch.  This allows the muscle to support the arch.  If there is pain at the tendon’s insertion or pain when the doctor palpates the tendon as it goes up the leg, you may be experiencing PTTD.  If there is no pain, PTTD is unlikely.

Assuming there is pain along the tendon, there are other tests that can be done to help confirm the diagnosis.  The doctor will have the patient stand facing the wall.  The doctor will stand directly behind the patient.  Normally, the doctor can only see the 4^th and 5^th toes, with the leg covering the rest of the toes.  In PTTD, when positioned behind the patient, the doctor will be able to see almost all of toes.  This is known as the “too many toes” sign.

Another test your doctor will use to grade the amount of dysfunction is called the heel rise test.  The doctor will have you stand next to the wall or counter for balance.  You will then be asked to stand on your toes, first each foot individually, then both feet together.  In someone with PTTD, this will illicit large amounts of pain in the arch and up the leg.  In more advanced situations, the patient will not be capable of lifting their heels off the ground at all.  Patients often are surprised that they didn’t notice their inability to lift up on their heels before their appointment.

Lastly, the doctor will watch you walk in the office.  This is called gait analysis.  The “too many toes sign” will be seen as they walk.  The heel bone will not have normal movement, and the person will practically be walking on the inside of the foot, the arch being completely absent.  The doctor will then correlate these findings to the x-rays taken in order to suggest the best treatment options.  We’ll discuss some of those treatment options next week.

How Did My Foot Become So Flat?

It is a normal phenomenon for the foot to get larger over a lifetime of use.  Ligaments lose their tensile strength and tendons can lengthen over time making the shape and size of the foot change.  However, these changes happen over a long period of time, making them unnoticeable from month to month.  The only situation is which noticeable changes happen normally would be in pregnancy, since women have hormones in their body which are meant to make ligaments more flexible to allow for child birth.  But have you noticed that your arch has slowly but noticeably flattened over a period of months?  If so, you may have a condition termed Posterior Tibial Tendon Dysfunction or PTTD.

The posterior tibial muscle is the main muscle that supports the arch of the foot.  The tendon runs on the inside of the leg right behind the inside of the ankle.  It is the main muscle that allows you to turn the sole of one foot in so that it is facing the other foot.  In certain foot types, this muscle can be subject to a significant amount of force, causing over lengthening and breakdown of the tendon.  If the tendon degenerates or loses its strength, the muscle loses its ability to hold the arch up.  With time, the arch slowly loses its height, causing pain and difficulty fitting in shoes.  This process may not produce enough discomfort to push you to see a podiatrist until some irreversible damage has already been done.  There are different stages of PTTD, thus the treatment depends on how degenerated the tendon is.  In most cases, an MRI is needed to assess the current status of the tendon.

There are a couple tests that we can do in the office to assess if PTTD is present, and if so present, how far advanced the condition is.   This helps to determine which conservative or surgical options may help.  We’ll discuss these clinical tests in the next post.