Verruca Pedis: Warts the Best Intervention?


Verruca Pedis the common plantar wart is not just a viral lesion kept to the population of small children and swimmers. The foreign body can appear on any individual regardless of social status, amount of exposure to the viral particles or age. Plantar warts have the ability to spread quickly among those who are immune-suppressed, those under-going radiation therapies, chemotherapy, and transplants of organs or HIV positive.

The interventions used to treat plantar warts vary tremendously, some cause pain, some do not but all seem to have the same aim and duration of treatment regardless of that which is chosen. Within this article we make an overview of the treatments available, what the evidence states and how the plantar warts come to be.

Proliferation at the prickle cell layer is a result of the infected cells of the basal layer undergoing increased mitosis; this eventually leads to an exaggeration of the papillae of the dermo-epidermal junction. This occurrence encourages terminal capillaries to be drawn towards the superficial layers of the skin resulting in the vascularity of the warts. The Vascularity of the warts is often presented as dark pin prick spots within the lesion which may bleed when debrided.
Sonographic imaging of healthy plantar skin has revealed showed a bilaminar parallel hypoechoic structure with a virtual hypoechoic space in between. Blood flow is depicted as thin venous vessels within the subcutaneous tissue (Wortsman, Sazunic, & Jemec, 2009). Alternatively, infected tissues showed an endophytic (invaginating structure) which was hypoechoic and involved both the epidermis and superficial dermis layers. Arterial vessels are present in at the bottom of most lesions.
Post treatment it is not uncommon for warts to reappear following successful treatment. It is often difficult to remove the entirety of the wart leaving a source for further infection in the future (Watkin, 2006).

Verruca Pedis (VP) are the most common dermatological infection. They appear as round keratotic surfaced benign lesions with well defined limits and deep extension into the superficial layers of the skin due to external pressures during gait. VP are a cutaneous presentation of HPV (human papilloma virus) with a prevalence of approximately 5% in children and adolescents, with females at higher risk than males (Nuno Manuel Pinto, 2010). There is a high transference rate of the virus if regular tissue comes in contact with the infection.
Diagnosis is generally a straight forward procedure, however, if the wart has been previously treated, is not responding to intervention or is not clinically relatable then it is important to not discount the following possibilities.
HPV is indirectly linked with epithelial malignancy; these growths tend to be severely painful, red, discoloured and swollen with growth characteristics. Plane warts which can appear on the plantar or dorsal aspects of the foot have the potential to transform into a rare and extremely autosomal recessive disorder known as Epidermodysplasia verruciformis.
Although not common in podiatry circles, plantar warts can be mistaken for corn or callus, alternatively it has been seen that some practitioners have mistaken a corn or callus for a wart and performed similar treatments.

Treatment can be derived as unnecessary due to spontaneous resolution being found in over 50% of cases within 2 years, however if causing pain, irritation or aesthetically displeasing then treatment can be justified. No particular treatment has been found to be 100% effective and therefore the use of a combination of treatments may yield better results (Watkin, 2006).The following are examples of commonly used treatments which have minimum limitations;
Salicylic acid dissolves intercellular cement and therefore desquamation of without affecting the epithelial cells.
Duct tape has a number of theories attached to its use although evidence remains weak at best, however, it is said that the duct tape occludes the wart and activates the immune system of the body to attack the wart. Additionally, the tape then acts as a debriding agent on removal.
Cryotherapy freezes the area using liquid nitrogen on cotton buds or nozzled spray after the area of concern has been debrided via scalpel. This occurs at a minimum of once every three weeks and is disputed about its use on small children given the amount of pain associated with it.
Essential Oils wintergreen, lavender, lemongrass and peppermint have all been mentioned to have a positive outcome on plantar warts during a case study of a immune-suppressed patients who was contraindicated to most other treatments.
Homologous Auto-implantation aims to induced healthy cell mediated immune responses through the use of an 18 gauge needle removing a depth of wart tissue and placing it sub-cutaneously.
Needling Methods can be used to once again spark a strengthened immune response.

All methods have a similar goal in the treatment of plantar warts which is to increase the body’s immune response while additionally removing the superficial layer of the plantar wart. After reading the evidence I have begun to use the following treatment procedure for the Verruca pedis is as follows but can be modified to the clinical presentation and needs of the patient;
Debridement of over lying callus until such time as capillary bleed is achieved.
Donut padding created from 5mm felt which is then filled 60% Salicylic Acid (Upton’s Paste)
Dressed with Hypoallergenic taping and rigid sports taping for better hold
Education is to keep area dry for 2 days before removing and soaking feet nightly for 20min before applying duct tape. This is to be repeated until next consult where the process will be repeated until such time as the Verruca resolves.

Conclusion
In conclusion, the evidence for any particular intervention associated with plantar wart treatment is not strong. Questions remain about how aggressive a treatment should be, the timing between treatments and what constitutes the need for treatment given that such a high percentage of the lesions regress within a two year period.
Nonetheless, given the highly contagious nature of the HPV and the human emotive to have reduced concern for others who may be susceptible to contracting the virus, elimination of existing exposures is important for those who are at risk of spreading the contamination further.

Next month FootNotes Blogging will look at an Overview of Stress Fractures, Part One of our Pain Series and our next athlete interview. Until then, thank you for reading and take care.

Jackson McCosker
Director /Chief Editor

References

Coates, C. M., Boehm, A. P., Leonheart, E. E., & Vlahovic, T. C. (2006). Malignant Transformation of Plantar Verrucae. Advances in Skin and Wound Care , 384 – 385.

Forbes, M. A., & Schmid, M. M. (2006). Use of OTC Essential Oils to Clear Plantar Warts. The Nurse Practitioner , 53- 57.

Longhurst, B., & Bristow, I. (2013). The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases. Journal of Clinical Medicine , 13 – 21.

Murley, G., & Perrin, B. (2011). Dermatology Resource Manual. Bundoora: University Erlangen Department of Dermatology.

Nuno Manuel Pinto. (2010). Treating Plantar Warts: What to do When Patients Take Maters into Their Own Hands. Nursing Times .

Shivakumar, V., Okade, R., & Rajkumar, V. (2009). Autoimplantation Therapy of Multiple Warts. Indian Journal of Dermatol Venereol Leprol , 593 – 595.

Watkin, P. (2006). Identifying and Treating Plantar Warts. Nursing Standard , 50-54.

Wortsman, X., Sazunic, I., & Jemec, G. B. (2009). Sonography of Plantar Warts. Journal of Ultrasound Medicine , 787 – 793.

 

The Adolescent Athlete’s Achillies Heel: Sever’s Disease – An Overview


Calcaneal apophysitis or Sever’s Disease as it is better known, is regularly seen amongst active adolescents experiencing growth advancements between the ages of eight and fourteen. Once thought as an inflammation of the apophysis at the immature athlete’s heel, Sever’s is now regarded as a non articular, non-inflammatory repetitive and chronic injury to the trabecular metaphyseal bone during active remodelling created by traction at the tendo achillies/calcaneal junction- due to the rapid proliferation of growth plates, the apophysis is seen to be more susceptible to injury (Scharfbillig, Jones, & Scuter, 2008).
The young athlete, particularly those who are experiencing both physical and physiological changes in maturity can be at increased risk of sports related injury. Rapid growth has been linked to poor dynamic balance, increase in BMI and a misunderstanding by coaches of how to best work with this period of a young athletes life. Calcaneal apophysitis or Sever’s Disease as it is better known, is regularly seen amongst active adolescents experiencing growth advancements. Once thought as an inflammation of the apophysis at the immature athlete’s heel, Sever’s is now regarded as a non-inflammatory repetitive and chronic injury to the trabecular metaphyseal bone during active remodelling.
The presence of Sever’s in an individual has been shown to decrease the subjective ‘happiness’ levels and reduce physical activity participation when compared to children without symptoms of the condition (James, Williams, & Haines, 2013).

Signs and Symptoms
Pain will usually follow the pathway of non muscular pathology with activity increasing localized pain felt at the insertion of the achilles tendon. Additionally, there may be restricted dorsiflexion range of motion at the ankle and trigger points or tightness within the Tricep Surae, Gastrocnemius or Soleus as muscle growth is thought to lag behind that of bone growth resulting in significant imbalance.
A child wearing poor footwear which does not accommodate their biomechanical needs, overtrains or trains in a way which detrimental to health  or has a foot type which places increased stress on the achilles tendon is at increased risk of developing severs. In a study of 85 patients it was found that most of the subjects were track and field participants with basketball, gymnastics and soccer following closely behind (Scharfbillig, Jones, & Scuter, 2008). Histological and radiographic investigations have failed to show substantial evidence which backs the theory of an increased inflammatory process during suspected severs conditions however increased radiodensity is common (Hussain, Hussain, Hussain, & Hussain, 2013)
Parents of young athletes will commonly comment on a child’s gait including a limp during sport or training and complaints of pain while barefoot.
Of course the best clinical test to perform is the squeeze test or calcaneal compression to illicit painful symtoms.

Differential Diagnosis
Musculoskeletal –
Through the use of imaging and detailed patient history the following conditions may also be obtained as a potential diagnosis.
Achilliobursiitis – Pain due to inflammation associated with the achillies tendon
Tenosynovitis Achilles tenosynovitis is a condition in which there is inflammation and degeneration of the tendon’s outer sheath or layer.
Ankle Sprains –
Layman’s term for inversion or eversion injury to the tendons, ligaments and structures of the foot.
Retrocalcaneal Exostosis –
overgrowth of bone on the back of the heel
Plantarfascitis –
overuse or injury of the plantar fascia of the foot.

Infective – Infective or autoimmune conditions are usually associated with increases in temperature, systemic sickness and night pain.
Rheumatoid Factors – Systemic autoimmune condition which may lead to inflammation within the joints.
Tumors – Abnormal growth of benign or malignant nature
Osteomylitis- Infection of the bone
Tuberculosus- Contagious condition which effects the bones and joints.

Treatment:
Patient load management is most important to be effective in reducing pain at the heel. In the early stages or reactive stages of Severs pain general first aid practices should be completed including; rest, localized icing/cold therapy, compression, elevation and referral to allied health professional such as podiatrist, physiotherapist, chiropractor or paediatrician.
Comparison of treatment modalities in the literature is not something investigated thoroughly but a multi-faceted approach seems to anchor the best results. Reducing sporting activity, offloading through heel lifts or orthotics (if deemed necessary), stretching of the tricep surae and the use of night splints, self massage/ foam rolling and shock absorption padding seem to be the most trialled and tested modalities to combine.
A 2013 Literature review by James, Williams and Haines showed that there was little evidence to support the use of orthotics and heels lifts as a sole modality in children with calcaneal apophysitis pain. Taping and padding was shown to have a positive effect in the reduction of pain in the acute and immediate stages of acknowledgement with a p-value 0.001, however this particular study also included adults with heel pain and should be considered carefully when applying to children (James, Williams, & Haines, 2013).

Prevention:
It is known that injury is a major barrier to sport participation, it is estimated that up to 50% of adolescent sport related injury is preventable. Balanced training has been seen to reduce lower limb injuries as well as multiple intervention approaches with warm up, neuromuscular control strategies and cool down.

Conclusion:
In conclusion, the ability to prevent Sever’s seems to be a difficult issue to address. To try and tell an active child to stop being active before there is anything wrong with them is not the business I want to be in, that’s for sure!
For that matter, reducing structured sporting activity may only be one side of issue. If a child is active it is not only structured activity which needs to be looked at – walking to and from school, PE, morning tea, lunch time and play dates are all time where a child can be increasing the traction over the apophysis.
Once the condition has been identified it’s another story and what is best for the patient should take over any emotional response you have to limiting their activity. I had found being able to monitor a child’s activity levels and keeping them liable for what they are doing to be most effective, additionally, it provides as a good education tool when explaining why the pain is increasing or decreasing. Below is an example of the document I give to patients to monitor their activity levels.

Prescribed Exercises Worst Pain -/10 Best pain   -/10 Other Activity
Tuesday YES 1/10 0/10 Soccer
Wednesday YES 3/10 1/10 PE
Thursday YES 3/10 0/10 Footy
Friday NO 8/10 2/10 Basketball
Saturday NO 8/10 2/10 Basketball
Sunday NO 10/10 5/10 Chasy

Patient Signature………………………………….       Parent Signature…………………………………..

Practitioner Signature……………………………………………………………

An example such as the one above may play out in the clinic such as “ At the start of the week I was really good with only a little bit of pain, but because the pain was gone I stopped icing and doing the stretches and my pain became really bad”.
By having a sheet similar to this available it also allows that the modality you are using to treat severs is effective when being completed and places more responsibility on the patient and their guardian for the outcome of their health.
I hope you have enjoyed reading, in 2weeks we will look at an overview of plantar warts.
If you have any questions please feel free to comment below

Jackson McCosker
Director /Chief Editor

References

Brukner, P. (2013). Bruker and Khan’s Clinical Sports Medicine. North Ryde: McGraw-Hill Education Pty Ltd.

Hussain, S., Hussain, K., Hussain, S., & Hussain, S. (2013). Sever’s Disease: A Common Caause of Paediatric Heel Pain. BMJ CASE REP , 1-2.

James, A. M., Williams, C. M., & Haines, T. P. (2013). Effectiveness of Interventions in Reducing Pain and Maintaining Physical Activity in Children and Adolescents with Calcaneal Apophysitis (Sever’s Disease): A Systematic Review. Journal of Foot and Ankle Research , 6 -16

Michaud, T. (2011). Human Locomotion: the Conservative Management of Gait-Related Disorders. Newton: Newton Biomechanics.

Scharfbillig, R. W., Jones, S., & Scuter, S. D. (2008). Sever’s Disease: What Does the Literature Really Tell Us? Journal of the American Podiatric Medical Association , 212 – 223.

Wiegerinck, J., Yntema, C., Brouwer, H. J., & Struijs, P. A. (2014). Incidence of Calaneal Apophysitis in the General Population. European Journal of Pediatrics , 677 – 679.