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VPs
Jul 10, 2009 11:30:54 GMT
Post by Admin on Jul 10, 2009 11:30:54 GMT
I've transplanted this from the corns thread as it is a question in its own right
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VPs
Jul 10, 2009 11:32:52 GMT
Post by Admin on Jul 10, 2009 11:32:52 GMT
Sam Replied
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seekerofwisdom
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VPs
Jul 10, 2009 12:09:45 GMT
Post by seekerofwisdom on Jul 10, 2009 12:09:45 GMT
Sam nice start to a exploration of VPs.
Anyone who likes treating them has 'problems'.
However it still comes back to that IMO very difficult question, when is an HD not an HD but a VP?
And how do you solve the dilemma.
There are as far as I know no microbiology 'tests' for HPV, or if there are they are prohibitively expensive, so diagnosis comes down to 'clinical presentation'.
Ok I accept your 'description' of the cauliflower, but in some ways that can be confusing.
My suspicions are always aroused by the 'history taking', especially speed of on come and subsequent failure of treatments.
I do tend to use the 'enucliation experience, ie early pain from debridement of the border, followed by the push pinch test.
The easy ones are obvious, some experts, cannot remember his name but very big in the SCP and dermatology say VPs after 25 are rare, I think he is wrong.
This does not have to be a controversial subject, it's something IMO most practitioners have a problem with.
Treatment ideas can come later?
Still shy.
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VPs
Jul 10, 2009 18:16:22 GMT
Post by billliggins on Jul 10, 2009 18:16:22 GMT
Sam does not mention the one sign which is almost infallible. The skin striae run through a corn (or are not disrupted by it) whilst the skin striae are seen to be disrupted and compressed around a V.P. V.P.s are frequently seen on non-weightbearing areas whilst corns are always noted on areas of pressure. Biopsy and histopathological examination can provide 'certainty' in diagnosis without worrying about microbiological investigation.
All the best
Bill Liggins
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VPs
Jul 10, 2009 20:21:05 GMT
Post by blinda on Jul 10, 2009 20:21:05 GMT
Hi Shy Poster,
Good question, as we all know a wrong diagnosis of any tumour could lead to serious consequences. The usual `ABCDE` approach to any `lump or bump` should be utilised (Asymmetry, Border, Colour, Diameter & Evolution (change)), but for the purpose of this thread, lets stick to the difference between corns and verrucae.
I agree that Sam`s summation of diagnosis is a great start to the discussion. As he suggests; we need to look at the aetiology of both and he started with Heloma Durums (HD`s). I think we can agree that these are circumscribed hyperkeratotic skin lesions that arise at sites of long term mechanical stress. Sam also describes how corns are forced into the skin through pressure, whereas, VPs are endophytic, meaning that they grow (often after a period of remaining dormant within epithelial cells without visible signs) and cannot be elevated above the surrounding skin as a result of direct pressure/lateral squeezing. With VPs, there may also be presence of black dots, that is; thrombosed superficial vessels within the wart tissue (capillary loops). This is why bleeding is often present during debridement of the overlying callus.
Yes, there are microbiology tests which determine whether lesions are VPs and indeed which group of HPV they are from i.e. Plantar HPV type 1, mosaic HPV type 2 and palmoplantar HPV 4 type. As you rightly say, these tests are costly and, in reality, not necessary if a clinical diagnosis can be made.
VPs can be characterized, histologically, as hyperproliferative and poorly differentiated papules or plaques in the epidermis with a greatly thickened immature stratum corneum. This is in accordance with Bill`s statement that clinically VPs can be identified by marked hypertrophy of the horny layer and loss of the defined striae (the pattern of epidermal papillae and dermal rete ridges) as viral replication only takes place in fully differentiated epithelium and the subsequent proliferation results in the clinically evident warty papule or plaque described above, whereas HDs do not interfere with, or change the pattern of the striae. Also as Sam stated, application of pressure laterally, or by pinching the wart, should produce considerable pain, where as for a corn, direct pressure against the underlying bone will cause some distress.
Spot on. VPs appear to develop more rapidly than HDs, especially in the younger population, adolescents and the immunocompromised, whereas corns are more common in the middle aged and older population.
Now THAT is a very interesting statement to make. I happen to empirically agree with you too, but cannot find any EBM to back this observation up.
Cheers, Bel
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seekerofwisdom
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VPs
Jul 11, 2009 4:13:51 GMT
Post by seekerofwisdom on Jul 11, 2009 4:13:51 GMT
Sam does not mention the one sign which is almost infallible. The skin striae run through a corn (or are not disrupted by it) whilst the skin striae are seen to be disrupted and compressed around a V.P. V.P.s are frequently seen on non-weightbearing areas whilst corns are always noted on areas of pressure.
Agreed Bill but I'm really thinking about the situation where none of these appearances are 'clear'. I am sure there are situations where what started off as a corn became infected with virus.
Biopsy and histopathological examination can provide 'certainty' in diagnosis without worrying about microbiological investigation.
Please explain what is involved in performing a biopsy, would parred tissue suffice or do you need to remove the tumour under LA?
Sorry to be anon I know you hate us. Still far too shy.
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VPs
Jul 11, 2009 11:22:43 GMT
Post by billliggins on Jul 11, 2009 11:22:43 GMT
Hello S.O.W. (That is not meant to be rude. I hate Gordon Ramsay!)
Unfortunately pared tissue would not give sufficient material for the histopathologists to have a go at. There are two ways of dealing with the probel:
i) punch biopsy in which a cylindrical section is taken from the lesion
ii) excholiation of the lesion in total.
Both need L.A. and the latter in particular will result in bleeding. However, the technique is frequently used as a treatment for VPs and is anecdotally 75% successful on recalcitrant lesions.
I do hate annonymous postings - already someone else is using your 'handle'. However, I am willing to respond on this site but very rarely on others.
All the best
Bill Liggins
All the best
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seekerofwisdom
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Posts: 180
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VPs
Jul 11, 2009 12:54:34 GMT
Post by seekerofwisdom on Jul 11, 2009 12:54:34 GMT
Hello S.O.W. (That is not meant to be rude. I hate Gordon Ramsay!)
No problem Bill this site takes a bit of getting used to and for trust to build.
Unfortunately pared tissue would not give sufficient material for the histopathologists to have a go at. There are two ways of dealing with the probel:
i) punch biopsy in which a cylindrical section is taken from the lesion
ii) excholiation of the lesion in total.
Both need L.A. and the latter in particular will result in bleeding. However, the technique is frequently used as a treatment for VPs and is anecdotally 75% successful on recalcitrant lesions.
That was my impression, and there in lies the problem?
When operating as a humble PP in a modest clinic it can be difficult to access the full range of services available to the NHS, especially at a cost that can be passed onto a client, so we doubters have to explore ways around this? Convincing patients to undergo anesthesia and in my case 'blunt dissection' and the realistic cost involved when a positive diagnosis has not been confirmed creates problems.
I do hate anonymous postings - already someone else is using your 'handle'. However, I am willing to respond on this site but very rarely on others.
That is good, always enjoyed debating with you.
Shy.
All the best
Bill Liggins
All the best
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