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Post by Martin Harvey on Dec 3, 2008 0:34:15 GMT
Whilst agreeing with much of the comments on tissue lysis of VPs by various means (although personally I nuke ‘em with liquid nitrogen) I cannot let the repeated statements about “inflammation not waking up the immune system” pass without comment.
This is because inflammation of any sort IS an immune response from a ‘woken up’ immune system albeit in the case of trauma from mechanical damage a non-specific one (i.e. not initially tied to antigenic mechanisms). The inflammatory response occurs (or should occur) immediately after trauma and prevents pathogenic proliferation, minimises further damage to cells and ultimately stimulates repair.
The stages of inflammation can be summarised (very simply) as: mobilisation of resident macrophages, localised vasodilation, increased vascular permeability, infiltration by leukocytes and remodeling.
Principal amongst the inflammatory progenitors are mast cells which are usually adjacent to blood vessels, including it may be reasonable to assume the neovascularisation of VP tissue. Upon stimulation by trauma, antibodies or plasma protein cascades such as complement, these mast cells initially degranulate histamine particles from their stock of the same (readily visible in the cells under stain in microscopy) in order to stimulate vasodilation and produce leukocyte chemotactics to pull in neutrophils from dilated blood vessels. Subsequently mast cells synthesise some of the eicosanoids (inflammatory mediators manufactured from arachidonic acid) specifically prostaglandins, thromboxanes and leukotrienes. This occurs via a well documented cascade of : phospholipase acting on lipids from cells to produce arachidonic acid which is then acted on by COX 1 and 2 (the elements NSAIDs try to block) and 5-lipoxygenase to synthesise cyclic endoperoxides which are then acted on by prostaglandin and thromboxane synthases to make prostaglandins, thromboxanes and leukotrienes.
These end products then act as further mediators in the inflammatory cascade.
Anyway, just my two ‘pennorth in response to :
I'm sure that both the things quoted above in fact DO stimulate a non-specific immune response, its just that Tumors (albeit usually benign ones such as VPs) probably need a far more aggressive stimulation than they can possibly offer, although on consideration it may be interesting to try some of the POM capsiacin preparations on 'em as 'super rubifacients'
Cheers,
Martin
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Post by chifhpod on Dec 3, 2008 8:17:20 GMT
Not quite sure what is happening here? I posted last night and some of the points in my post have actually been referred to, but I cannot find it this morning. Still feel I need to put things into the debate so have repeated the lost post.
Hi Robert/Blinda,
I don’t need a canon to make a point! Big statement it may be, but the truth IS often writ large. The idea that induced inflammation produced reaction from the immune system died a quiet, natural death. It passed without ceremony and was scattered on the grounds of no grounds. I have observed over a working lifetime that things that work are generally put to use - things that don’t work get lost in the sands of time. It’s hardly worth writing up that something doesn’t work, is it? A bit like good news - not exactly ‘sexy’ and nobody wants to read it.
Silver nitrate is most likely to be limited to the superficial layers of the epidermis, and we all seem to agree that this is due to the reaction with skin proteins and the formation of a limiting layer. So silver nitrate is shallow in its action. I think we might all agree to this much? But if we take off the stratum corneum and lucidum (there are 5 layers in the epidermis of palms and plantar surfaces), we can do it again a week later, week on week. Does the silver nitrate really care which layer it sits on?
Salicylic acid 60% paste penetrates much deeper. By personal observation I have seen that it does not penetrate into the dermis, but certainly breaks down (kills) skin right down to the depth of the dermis. This is postulated (by me with a lifetime of empirical (and therefore of value) experience) to be due to the blood supply present in the dermis and absent from the epidermis. Does the salicylic acid really care which layer it sits on? I observe with they eyes of a trained observer that no inflammation whatever is caused by these applications. The skin with the virus-infected lesion is white, dead, macerated by application of the paste (seven days about). No inflammation above, below, around or imagined! Certainly nothing that could possibly get the immune system excited! A sort of absolute, flat, totally predictable and completely uneventful non-happening really, total entropy!
What each of these preparations does do is to assist with physical removal, silver nitrate by creation of an eshar which will fall off in its own good time (average 7 days), and salicylic acid which destroys nerve endings and macerates the tissue it has killed. Live tissue would resist such maceration. Scoop it out with the verruca tissue embedded. Highly satisfying!
LLLT (low level laser therapy employs red (ruby) light for its photobiological effects. It is said that the light produced at this wavelength stimulates cell division. Rather a red (ruby)-herring in this discussion, don’t you think?
An afterthought…if inflammation wakes up the immune system, why do we not apply rubrefacient preparations to verrucae? Because inflammation does not wake up the immune system!
Thanks for the references David. I can't find these this morning, either!
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Post by dtt on Dec 3, 2008 8:46:48 GMT
Hi Chifhpod I think you are unfamilier with the site ? You have gone onto a new page in the thread. All your posts are still there on page one ( top left corner of the page to toggle) you are now posting on page 2 Great discussion BTW Cheers D
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Post by Admin on Dec 3, 2008 8:49:52 GMT
Not quite sure what is happening here? I posted last night and some of the points in my post have actually been referred to, but I cannot find it this morning. Still feel I need to put things into the debate so have repeated the lost post. Thanks for the references David. I can't find these this morning, either! Post and references are on Page One.
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podmum
Full Member
"There is no dark side of the moon"
Posts: 169
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Post by podmum on Dec 3, 2008 11:09:32 GMT
Quote:Role of Tissue-Type Plasminogen Activator in Salicylic Acid–Induced Sloughing of Human Corn Tissue Ghanshyam D. Heda, PhD* Lee K. Roberts, PhD† JAPMA 2008 www.japmaonline.org/cgi/content/abstract/98/5/345I have a copy if you would like to read it. Yes please Sorry to hijack Bel's post but please could I also have a copy Love the post - very interesting reading. Podmum
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Post by blinda on Dec 3, 2008 12:22:02 GMT
Dave
Thanks for the PDF, I`ll pass it on to Podmum.
Bel
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Post by blinda on Dec 3, 2008 17:59:39 GMT
You know I had a funny feeling that Martin might come in on this one ;D
Cheers, Bel
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Post by Martin Harvey on Dec 3, 2008 19:16:13 GMT
Bel, you psychic Pod you all the best, M
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Post by blinda on Dec 4, 2008 0:02:11 GMT
Absolutley agree that Sal Acid is keratolytic i.e. it disrupts keratinous protein. Cuboidal keratinocytes are formed in the stratum germinativum (basal layer), and develop keratin filaments from the stratum spinosum outwards, where it has been suggested (and I`m so cross that I can`t lay my hands on this ref now ) that the HPV virus sits. So it would be logical as chfhpod said that Sal acid would penetrate down to this bottom basal layer in the epidermis. Interestingly, one of the papers that Dave supplied (Heda & Roberts, 2008) highlighted the fact that whilst Sal acid may disrupt intercellular adhesion structures, the exact mechanism of keratolytic action of sal acid is still poorly defined. It suggested that altered levels of plasminogen activators (a protein involved in the breakdown of blood clots) found in the epidermis contributes to production of hyperkeratotic tissue and that the keratolytic action of Sal acid could be associated with its ability to stimulate proteolysis (degradation of these proteins) a biological processes that is part of the inflammatory process. Soooo, whether the infected tissue can be `scooped out` because the sal acid is strong enough to break down the entire wart virus structure in the basal layer, or whether its because the keratolytic mechanism stimulates inflammation to destroy the virus can still be called into question. This is mainly due to the difficulty in performing ethical robust research in VP tx, therefore the theories still remain just that, theories such as; *the epidermis is avascular *virally infected cells have no surface markers *HPV can locally activate T suppressor cells,etc,etc I just cant buy this. I don`t see how the silver nitrate could possibly `sit on` the stratum spinosum through regular paring(because of its shallow action). Is it ethical to week on week call the pt back to do nothing more than tickle the stratum corneum with a substance that cannot produce enough of a keratolytic action, if indeed it does produce any, to break down the viral structure? Whether we agree or disagree on the mechanics of VP treatment/resolution, I find this statement interesting. You are convinced that this process is effective. This conveyed confidence to the patient plays a major part in their belief that the treatment will work, increasing the (sorry to use the `p` word again ) placebo effect.....but that`s another debate ;D Cheers, Bel
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Post by blinda on Dec 4, 2008 0:13:57 GMT
Oh, forgot to add, karma for chifhpod for raising a good debate!
Goodnight, Bel
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10feet
Junior Member
Posts: 68
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Post by 10feet on Dec 4, 2008 7:49:16 GMT
Guys,
You have really lost me here - again.
I really thought this was a forum (particularly this post) for FHP to ask advice. Maybe I am wrong.
Without the underpinning knowledge of the Human Papilloma Virus - eitiology, pathology, histology et al, you have created a fabulous evidence based debate around the use of silver nitrate and now salicylic acid probably, leaving behind all the FHP's who were hoping for advice.
Remember folks the main of aim of any treatment plan should be safe, legal and effective treatment. Salicylic acid is an unlicensed product in the world of podiatry used legally due to the underpinning knowledge of the degree/diploma trained podiatrist. I am not sure about silver nitrate but if you have not used or been trained to use either chemical during your training process, I would not be inclined to encourage use.
The main aim of any treatment plan regarding HPV is to make sure the patient has a thorough understanding of the condition to the point where they can make their own decision regarding treatment or no treatmemt. It is your duty as a FHP, once all treatment rationale has been explored, to utilise a treatment you are capable of, direct a home treatment (licensed products) or refer to someone with a greater knowledge.
Where are the moderators on this site to move debates to appropriate fora for exploration?
Pete
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Post by Admin on Dec 4, 2008 8:20:12 GMT
I really thought this was a forum (particularly this post) for FHP to ask advice. Maybe I am wrong. Without the underpinning knowledge of the Human Papilloma Virus - eitiology, pathology, histology et al, you have created a fabulous evidence based debate around the use of silver nitrate and now salicylic acid probably, leaving behind all the FHP's who were hoping for advice. Remember folks the main of aim of any treatment plan should be safe, legal and effective treatment. Salicylic acid is an unlicensed product in the world of podiatry used legally due to the underpinning knowledge of the degree/diploma trained podiatrist. I am not sure about silver nitrate but if you have not used or been trained to use either chemical during your training process, I would not be inclined to encourage use. The main aim of any treatment plan regarding HPV is to make sure the patient has a thorough understanding of the condition to the point where they can make their own decision regarding treatment or no treatmemt. It is your duty as a FHP, once all treatment rationale has been explored, to utilise a treatment you are capable of, direct a home treatment (licensed products) or refer to someone with a greater knowledge. Where are the moderators on this site to move debates to appropriate fora for exploration? Hi Pete, I can find nothing in this thread which gives incorrect or misleading advice to FHPs - none of whom asked for advice on HPV etiology, pathology, histology etc. The forum is for Pods, FHPs and others who are active in the UK foothealth industry - as it says in the welcome message at the top of the front page. However I do agree that this thread has now run its course. Anyone wanting to continue the merits of inflammation/immune response (which seems the likeliest spinnoff) or allied topic should start a new thread in on the appropriate board. Due to an oversight I didn't lock this thread down. Due to popular demand its been re-instated! Thanks.
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Post by hurleygirly on Dec 4, 2008 13:27:26 GMT
Shame... Was really enjoying the debate...and managed to follow it despite being FHP. Information was very useful actually...
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Post by dtt on Dec 4, 2008 13:55:34 GMT
Hi Karen You and many other fhp's I suspect. Never mind, you can always look at it on any of the other threads here or podiatry arena and learn from those with perhaps at this stage more knowledge than you , but do keep following and enjoying the debates . Threads have usually run their course when posters stop posting so if there is any continuance of the debate here follow it on the new thread and join in if you wish Karma for thee for advancing your knowledge Cheers Derek
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Post by davidsmith on Dec 4, 2008 14:44:27 GMT
Dave I don't get your rational as to closing the thread because its run its course, presumably because it appears to have gone off topic and or some people cannot follow the debate because of its hibrow, technical content.. Thats not unusual for any topic to evolve into something not quite resembling the OP. However reading back thru this thread it can be summarised like so. OP - Advice on application, use and contra indications of silver nitrate in terms of outcomes and safety to patient and practitioner and as compared to acid treatment. replies - Introduction to pharmocology and pharmocokinetics of medicaments of interest oipinions and counter opinions as to the factual basis of these statements Citations of relevant and recent research to support both arguments. rebuttle of earlier statemnts and more discussion on pharmocology and pharmocokinetics. Complaint that content is to difficut to understand Statement that thread has run its course and should be closed. ? The course of debate appears quite reasonable and entirely relevant to the OP. With regard to the content; Should we dumb down then David? should we only cite data that was put forward by people with scant unreviewed knowledge but that at least use plain language? Should we spend time to explain any difficult terminology or concepts? How would we judge those criteria. Wouldn't it be better for those that do not understand to go and find out, using those terms as key words to research the topic. In fact isn't that the benifit that they will be getting from a well debated discussion??. Its your site and you can lock any thread you wish but I feel that in this case you would be setting a precedent that will detrimentally skew future posting trends. All the best Dave
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