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Verrucae: Why we don’t need to treat them


A couple of years ago, I gave a lecture about treating verrucae - in particular, using needling to treat them. When I gave the lecture, I did a quick poll of the audience and they quite nicely split into about 3 different groups:

  1. Those who actively avoid treating them

  2. Those who will treat them if the reasons are good enough

  3. Those who will treat every verruca that comes through because that's how they'll buy a Ferrari!

Group 1 are those who have spent a while treating verrucae and found them to be too frustrating for them or their patients - shocking, right? Verrucae are hard to treat, who'd've thunk it?


What are verrucae?


Verruca are a benign form of the Human Papilloma Virus. They are a type of wart and specifically occur on the foot… although for those who like to pick, they could end up anywhere!


The majority of verrucae are very small and cause no pain whatsoever. This being said, their presence can cause upset for their “owner” (or in some cases, their owner’s parents or significant others!) and can also be unsightly or painful. The pain that they cause is not specifically because of the verruca but because of the hard skin that builds up as a result of the verruca.


When a verruca occurs, it infects one of the deeper layers of the skin cells. This results in a disruption in normal growth and as a result, a change in the texture of the skin. This disruption of the skin cells can cause increased friction when walking and the body responds to this by producing callus. This happens all over the body where those areas exposed to larger amounts of friction develop more hard skin, which when on the foot can be a particularly frustrating protective mechanism. On other parts of the body, such as the hands for builders and those who train in the gym a lot, the calluses can mean that their skin is protected.

The presence of a verruca is not really a good enough reason enough for treatment - certainly not in young children

Trust me, if I could treat every verruca that walked through my door, I would… I’d be driving a really nice car by now! Sadly, however, I can’t justify it, and hopefully you will understand why as this article progresses.


So, if a verruca is not painful and doesn’t really bother the person it's attached to, then I strongly recommend not treating it. There is however a “but”...

Should I see someone for my verrucae?


Well, yes, but only because not all verruca are verruca.


A verruca is one type of skin lesion out of a multitude of skin lesions. Some skin lesions on the feet can simply be corns or callus, which can be resolved with:

  • routine foot care

  • padding, strapping & cushioning

  • insoles

  • stretching/strengthening of the feet

  • and surgery.

Equally, there are a few nastier skin lesions and significantly more contagious (and embarrassing) conditions than verrucae that can occur on the feet, and so it is always worth getting them diagnosed, because then you can make an informed decision about treatment.


How are verrucae diagnosed?


There are lots of different ideas about how to identify and diagnose a verruca. The most common misconception is that verrucae have black dots. This technically isn't wrong, but it also isn't right.


Verruca alter the growth of skin cells in the basal cell layer. This means that the skin lines (dermatoglyphics) are then interrupted. It is the absence or disorganization of the skin lines that is diagnostic of a verruca.



It doesn't take much to make a big change to a system. This art installation by Jorge Méndez Blake was meant to be a metaphor for the power of a single book to disrupt a system.

The metaphor applies to how a very small change in the growth of skin cells can be enough to change the function of the skin. (If you want to read more about the art, please click here, which is where I stole this picture from!)


Verrucae are often mistaken as corns, or vice versa. Below are some pictures of warts that are available at an excellent resource about skin, which is a website called: DermNet NZ. The pages can be found by clicking on either Corns or Verrucae.


How do you treat a verruca?


Verrucae live in the basal layer of the skin, meaning that there is no real blood supply supplying them and there is no medication that will be able to get to, and thus kill, the virus inside of the cells. As a result, we have to tell the body that the verruca is there so that the body can start an immune response.


"How do you create an immune response", I hear you ask. Well...

To create an immune response, we have to create an 'insult' to the body that the body then investigates, which we can do by injuring the area. This then means that the body creates inflammation to try to heal the injury and also to bring white blood cells to the area to attack anything that shouldn't be there. It sounds easy, right?


Well... it is. However...

the verrucae release anti-inflammatory proteins meaning that all of the white blood cells that would start to attack the verrucae, are basically told to turn around and leave through some clever tactics.

and this is why verrucae do not always respond to treatment.


Methods to treat a verruca, broadly speaking, are either:

  • Palliative - managing the symptoms or appearance without aiming for cure

  • "Curative" - stimulating the required response to get rid of the verruca.

Specifically looking at each of the main treatments offered:

Treatment

Palliative

Curative

What is involved?

Doing nothing

​-

Removing hard skin

Using a blade to remove the hard skin. Do not file

Covering with tape

Apply tape to the area. This traps water, makes the verruca softer and helps to remove the top layer of skin.

Acid therapy

This is helpful for reducing the size and thickness of the verruca as well as stimulating an inflammatory response.

Cryosurgery

By creating a cold burn, and potentially causing a blister, cryosurgery stimulates an inflammatory response. It can also help to shrink the verruca.

Swift microwave therapy

By creating a heat burn, and potentially causing a blister, swift microwave therapy stimulates an inflammatory response. It can also help to shrink the verruca.

Electrosurgery

This involves removing the top layer of skin and then burning the deeper layers with an electric current. This is repeated several times and assists in stimulating an inflammatory response.

Needling

Using local anaesthetic to numb the foot or a region around it, a needle is pushed into the verruca multiple times. This breaks up the structure, pushes it deeper into the body to introduce it to the immune system and develops a strong inflammatory response. It is also helpful for shrinking the verruca.

Curettage

Using local anaesthetic to numb the foot or a region around it, a sharp spoon is used to scrape out the verruca. This gets rid of the infected cells and also stimulates a strong inflammatory response.

Excision

The verruca is cut out having used local anaesthetic to numb the foot and stitches are then used to close the wound. This gets rid of the infected cells and also stimulates a strong inflammatory response.


What's the difference in the treatments?


Each treatment has it's merits and disadvantages. As you move down the list, the treatments become either more invasive or more painful. In terms of causing an inflammatory response, this is perfect, but for those who are:

  • Busy, and therefore cannot take time off

  • Pain averse

  • Very active with sports, work or school

  • Immune compromised

Trying the more invasive routes may be inconvenient, dangerous, or an expensive waste of time.


The success rate for verruca treatments is good, sort of. But it isn't perfect.


We also cannot guarantee how many treatments you might need. It could be one, three, five, ten or more than you (or your wallet!) care to think about!


With kids, I usually try to avoid continuing the stigma that exists around verrucae and try to avoid inducing a fear of health professionals in them. With adults, well, you're old enough to decide things for yourselves... but I certainly would recommend avoiding treating your kid for your own sake.


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