I’m sure I don’t see as many patients with common skin warts as my family practice or dermatology colleagues, but these patients still make it to my office. Sometimes it’s the primary complaint, sometimes it’s an afterthought. In reviewing the topic, it occurred to me that most patients don’t need to see any of us for this problem. They mostly need to accept the fact that the treatment takes TIME. So if you will persist, then you will often be successful without the expense of seeing a doctor. (photo credit)
Common warts (Verruca vulgaris) are caused by the human papillomavirus (HPV). Warts on the hands or feet do not carry the same clinical consequences of HPV infection in the genital area. It is estimated about 10% of children and adolescents have warts at any given time. As many as 22% of children will contract warts during childhood.
Common warts can occur anywhere on the body, but 70% occur on the hand. Often they will disappear on their own within a year. Even with treatment, warts can take up to a year to go away.
Before heading to the doctor, there are treatments you can try at home: salicylic acid or duct tape.
When using the 17% salicylic acid gel (one brand name: Compound W), it must be applied every day until the wart is gone. Only apply to the wart, not the skin around the wart. This treatment is enhanced by covering the wart with an occlusive water-proof band-aid or duct tape after applying the acid. It can also be enhanced by gently filing the wart with an emery board daily to remove the dead cells prior to applying the salicylic acid. Treatment can take weeks to months. Don’t give up early.
Duct Tape can take weeks or months to be effective. Apply the duct tape to the wart and keep it in place for six days. After removing the tape, soak the wart, and pare it down with a filing (emery) board. Repeat the above until the wart disappears. Once again, don’t give up early.
The two treatments (salicylic acid and duct tape) can be combined. Apply the salicylic acid liquid to the wart before bedtime. After letting it air dry for a minute or so, then apply the duct tape over the wart, completely covering the area. Remove the duct tape the following morning. Each time you remove the tape, you will be debriding some of the wart tissue. Repeat the application each night, until there is no remaining wart tissue. As with using only one treatment, don’t give up early.
If the above don’t work or you just don’t want to take the time, then you may wish to see your physician for removal. He can use cryotherapy to destroy the wart. This method may involve repeated treatment over several weeks. You can do the following to “get the wart ready for removal” and make the cryotherapy more effective:
Every night for 2 weeks, clean the wart with soap and water and put 17% salicylic acid gel (one brand name: Compound W) on it.
After putting on the gel, cover the wart with a piece of 40% salicylic acid pad (one brand name: Mediplast). Cut the pad so that it is a little bit bigger than the wart. The pad has a sticky backing that will help it stay on the wart.
Leave the pad on the wart for 24 hours. If the area becomes very sore or red, stop using the gel and pad and call your doctor’s office.
After you take the pad off, clean the area with soap and water, put more gel on the wart and put on another pad. If you are very active during the day and the pad moves off the wart, you can leave the area uncovered during the day and only wear the pad at night.
If none of the above work, then your wart may need to be removed surgically. Remember the above all take time, so give them time to work. Even if the wart disappears with any of the above treatments, it may recur later.
Sources
Treatment of Warts; Medscape Article, May 27, 2005: W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD
This past week I was once again asked about suture allergy. It has prompted me to revisit the issue which I have posted about twice now. (photo credit).
Sutures by their very nature of being foreign material will cause a reaction in the tissue. This tissue reactivity is NOT necessarily a suture allergy.
Many factors may contribute to suture reactivity.
The length of time the sutures remain. The longer the sutures are in, the more reactivity occurs.
The size of the sutures used. The larger the caliber of the suture, the more reactivity. The increase of one suture size results in a 2- to 3-fold increase in tissue reactivity.
The type of suture material used. Synthetic or wire sutures are much less reactive than natural sutures (eg, silk, cotton, catgut). Monofilament suture is less reactive than a braided suture.
The region of the body the suture is used affects tissue reactivity. The chest, back, extremities, and sebaceous areas of the face are more reactive.
In general, accepted time intervals for superficial suture removal vary by body site, 5-7 days for the face and the neck, 7-10 days for the scalp, 7-14 days for the trunk, and 14 days for the extremities and the buttocks. The deeper placed sutures will never be removed.
Sutures meant to dissolve (ie vicryl sutures) placed too high in the dermis (which happens often when the dermis is thin) can “spit” several weeks to several months after surgery. This is a reactive process, NOT a suture allergy. It usually presents as a noninflammatory papule (looks very much like a pimple) and progresses with extrusion of the suture through the skin. The suture material may be trimmed or removed if loose, and it is not needed for maintaining wound strength. Rarely does this affect the scar outcome.
The remaining portion is a “repost” about suture allergies:
Allergic reactions to suture materials are rare and have been specifically associated with chromic gut. However, Johnson and Johnson mention known triclosan allergy as a contraindication for use of certain sutures (see below). Contact allergy to triclosan is uncommon.
Surgical gut suture (Plain and Chromic) is contraindicated in patients with known sensitivities or allergies to collagen or chromium, as gut is a collagen based material, and chromic gut is treated with chromic salt solutions.
PDS Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).
VICRYL*suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan). [In rechecking facts, I found that only Vicryl Plus has the triclosan, so simple vicryl or coated vicryl should be okay.]
Surgical Stainless Steel Suture may elicit an allergic response in patients with known sensitivities to 316L stainless steel, or constituent metals such as chromium and nickel. Skin staples are surgical steel so should be used with the same precautions.
Dermabond — Tissue glues should not be used in patients with a known hypersensitivity to cyanoacrylate or formaldehyde.
SO WHAT IS LEFT TO USE
So what is left to use in a patient who may have or has a proven allergy to suture or closure material?
Silk, Dexon, Nylon (monofilament or braided), Prolene, INSORB (absorbable staples), and any of the above listed (in the allergy section) to which the patient in question doesn’t react negatively.
The choice of a particular suture material will have to based further on the wound, tissue characteristics, and anatomic location. Understanding the various characteristics of available suture materials will be even more important to make an educated selection.
The amount of suture placed in a wound, particularly with respect to the knot volume, affects inflammation. The suture size contributes more to knot volume than the number of throws. The volume of square knots is less than that of sliding knots, and knots of monofilament sutures are smaller than those of multifilament sutures.
REFERENCES
Allergic Suture Material Contact Dermatitis Induced by Ethylene Oxide: G. Dagregorio, G. Guillet; Allergy Net Article
Materials for Wound Closure by Margaret Terhune, MD; eMedicine Article
Product Allergy Watch: Triclosan; MedScape Article by Lauren Campbell; Matthew J. Zirwas
New References
Surgical Complications; eMedicine Article, May 29, 2009; Natalie L Semchyshyn, MD, Roberta D Sengelmann, MD
Engler RJ, Weber CB, Turnicky R. Hypersensitivity to chromated catgut sutures: a case report and review of the literature. Ann Allergy. Apr 1986;56(4):317-20. [Medline].
Two nice articles in the June edition of the Journal of Plastic and Reconstructive Surgery. Full references are given for both below.
There are many techniques used for nipple reconstruction which should tell you that none is perfect. One of the main issues is loss of nipple projection over time. So if it is safe to spare the nipple when doing a mastectomy so no nipple reconstruction is needed – perfect!
The first article below looks at when it can be safely spared in prophylactic mastectomy (risk-reduction mastectomy) and therapeutic mastectomy clinical scenarios. Spear and colleagues did a literature review and came to the following conclusion:
It is clear from a review of the literature of the past 15 years that the subject of nipple-sparing mastectomy is complex and evolving. The subject is properly divided into two parts: risk prevention and therapeutic mastectomy.
There now seems little doubt that nipple-sparing mastectomy is an oncologically safe approach to prophylactic mastectomy. For that purpose, proper patient selection and technique remain open questions. ……….
Nipple-sparing mastectomy at the time of therapeutic mastectomy remains more controversial. There is developing consensus by those interested in nipple-sparing mastectomy as a possibility with therapeutic mastectomy that it is best suited for women who meet certain criteria. …….
The collective data suggest that, using the above below criteria, the risk of occult tumor in the nipple should be 5 to 15 percent; that frozen section of the base of the nipple will identify many if not most of those occult tumors; and that the risk of occult tumor still being present in patients screened as above with frozen section-negative findings is as low as 4 percent.
The tumor criteria listed include:
The tumor should be 3 cm in diameter or less
The tumor should be 2 cm away from center of the nipple
Clinically negative axillae or sentinel node negative
No skin involvement, and no inflammatory breast cancer.
If possible, they should undergo preoperative magnetic resonance imaging of the breast to further exclude nipple involvement.
When the nipple can be spared then there is no need for nipple reconstruction. When it can’t be, then the nipple sharing technique can be useful. As with the above, the cancer risk is addressed:
Fears of cancer in the transplanted nipple and concerns for surveillance are thus far unfounded. This occurrence has never been described in the literature. Furthermore, as more liberal use of nipple-sparing mastectomy occurs, a large cohort of patients with retained nipples will be able to be followed over time to see whether we even need to be concerned. For now, simple self-examination as performed by these patients is appropriate.
The article gives a good description of two different ways to perform the nipple sharing depending on the shape of the donor nipple.
Both articles are worth your time to read.
REFERENCES
Nipple-Sparing Mastectomy; Plast & Recontr Surg 123(6):1665-1673, June 2009; Spear, Scott L.; Hannan, Catherine M.; Willey, Shawna C.; Cocilovo, Costanza
Many of the surgeries I do are elective. They can and should be scheduled to be convenient. It happens – God laughs at our plans or life interrupts or …..
Last week was such a time for one patient. She called, very apologetic, “Dr Bates, I need to reschedule my surgery. My father is having tests done. He hasn’t been feeling well.”
I quickly assure her that no apology is necessary. Her family comes first. I suggest we simply cancel the surgery for now until the “dust settles.” She can call me back when she is sure things are okay with her family. We’ll reschedule then.
She is still worried. “The surgery center called me today. Do I need to call them? Will I need to pay them or anesthesia or you for the canceled time?”
Again I reassure her, “No, I’ll call them and take care of canceling the surgery. No, we don’t charge you for surgery we don’t do. It happens. It’s okay to cancel surgery for whatever reason – another family member gets sick, an accident happens, you just get scared.”
It happens on both sides. Sometimes (as for me earlier this year when my mother had surgery) it’s the doctor who has to cancel or reschedule. Sometimes it’s the patient. I once had a patient not show up for surgery, only to find out later she had been in a motor vehicle accident the evening before her scheduled surgery. She turned out to be okay, but it really cemented how I fell about patients who call to cancel or reschedule. It’s okay. No need to apologize. Thank you for letting me know.
After surgery I am often asked, “When can I get back in the tanning bed?” I say something like, “I would rather you not use a tanning bed. You need to protect you new scar from the sun, that includes tanning beds, for at least 6 months.”
“But, if I cover up the scar, when can I get back in the tanning bed?” is the usual response.
I then counter with, “IF you feel you must, then yes cover the scars. Please, limit or reduce the time you spend in the tanning bed. I would rather you not use a tanning bed.”
Most see “no harm” in using a tanning bed. After all, it’s not like laying out in the sun for hours. Too many see tanning beds as a “safe” way to get a tan. It isn’t.
These same experts have moved tanning beds and ultraviolet radiation into the top cancer risk category, deeming both to be as deadly as arsenic and mustard gas. The new classification also puts them in the list of definite causes of cancer, alongside tobacco, the hepatitis B virus and chimney sweeping, among others.
I would not mind tanning bed extinction. Regular use increased the risk of melanoma. It is much better to have a “peaches and cream” complexion or to use self-tanning creams. Skin cancer is no fun.
It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…
I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…
I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…
When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…
I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…
