Haemostasis in Wart Curettage

I have been speaking to a few podiatrists lately about their experiences with wart curettage and I have noted that getting adequate haemostasis (bloodless field) during the procedure is proving difficult. I noted these problems myself when I first began doing these procedures and gradually worked out what needed to be done to achieve a bloodless field. I have outlined the procedure below:

I have also shown the approach I take to doing tibial nerve blocks (which is a common approach by many). The patient is layed prone and I have just recently begun using liquid nitrogen prior to the injection to reduce needle pain (another common trick). Aim for the posterior aspect of the medial malleolus approximately 1-2 cms above the distal aspect of the malleolus. Obviously you do not always have to do a tibial nerve block for wart curettage and indeed I generally lean towards local infiltration to expedite the process of anaesthesia.



The first stage in exanguanating the limb is putting a towel around the leg. This is to reduce the pain of a highly inflated cuff and distributes pressure from the cuff more evenly. The pneumatic cuff is then placed over the towel (mid-calf) but not inflated.



Next a crepe bandage is wrapped around the foot to "milk the blood" from the area.



With the crepe bandage still in place the pneumatic cuff is inflated (I usually just inflate to the maximum pressure of 300 mm/hg) and then the crepe bandage is removed. The cuff will feel tight but this is much better than all the other options you have.

The foot with the crepe bandage removed should then appear white and if you look at SVPFT it should be very slow or non-existent.



I hope that helps a few people.

Matt

Consent Forms

Just noticed there is a good paper in JAPMA on consent forms (March/April edition 2004).

Formalin - Questions from new users

I have been asked by a number of people as to which types of VP I use formalin for. Over the last few years I have changed tact on which ones I do and don't use it for. As I have mentioned earlier it probably has varying effectiveness dependent on wart strain and skin type. Formalin's effectiveness appears to be a partly related also to patient compliance and aggressiveness of application and self debridement.

There is no doubt that mosaic warts are very susceptible to treatment with formalin and it should, I feel, be the treatment of choice for such types. It also highly useful where you have spreading warts with maceration/hyperhidrosis. The moisture appears to be quite important, in my opinion, to viral spread. Hence interdigital spread in teenagers is a problem and where Formalin is quite effective.

I have uploaded my Powerpoint from the Albury conference for anyone who whishes to look through it. Be aware it is about 600kb for those with dial-up access only. Formalin.ppt

[Listening to: Never Coming Home - Sting - Sacred Love DVD (13:48)]

Postlude to Methanol

As a follow-up to the Methanol comments I have since learned that commercial formaldehyde is actually buffered with methanol removing the need to add buffer when diluting with water

Patient advice sheet

Here is a copy of my Formalin advice sheets for patients if you need to use them.

Formalin Patient Advice

Formalin Safety Sheet

More Formalin Ramblings

I have just changed my treatment regime to a more aggressive twice daily application for the treatment of warts. My current theory on resistance to treatment has also evolved. I have a feeling the secret to what warts succeed and fail is determined by viral strain. This I feel determines cell compaction and therefore the penetration of external treatments. I therefore have suggested now to patients that they do superficial fenestration with a needle (of any description) of the area regularly prior to formalin application. This is obviously to increase depth of penetration of the formalin. I have also recommended greater self-debridement with sandpaper. I will be posting my success rates at a later stage.