A Patient Case

[DPMer]

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I treated a patient who was diagnosed with porokeratosis plantaris in my externship last week. I was instructed by the podiatry attending in to anesthetize the patient's plantar foot at the sight of the porokeratosis with lidocaine plus epinephrine prior to debridement and adding cantharidine. The patient did not like the shot. Another podiatry attending who found out said numbing is not necessary.

Which one is correct here? To numb or not to numb?

 

[347932]

I'm not sure I understand. Were you numbing the area to excise it or to do a palliative debridement?

If all you're doing is debriding an IPK why would you consider numbing the area unless the patient requested it due to pain?

Also, why apply the cantharidine? Was it a verruca?

I'm scratching my head a bit, or did I miss something?

 

[DPMer]

I'm not sure I understand. Were you numbing the area to excise it or to do a palliative debridement?

If all you're doing is debriding an IPK why would you consider numbing the area unless the patient requested it due to pain?

Also, why apply the cantharidine? Was it a verruca?

I'm scratching my head a bit, or did I miss something?

I was informed by my podiatry attending and a podiatry PGY-1 intern that cantharidine is a blister medicine used to treat porokeratosis plantaris after excochleation (i.e. debridement of the central white plug). Anesthetizing was done first to numb the area to eliminate pain.

Help me. I feel confused about the treatment of porokeratosis plantaris, even as a 4th year! Hopefully any of you residents and attendings can help me....😕

 

[NatCh]

It depends on how aggro you get with the poro. The shot is unnecessary unless the lesion is severely sensitive or if you're going to remove the entire plug using a biopsy punch. Cantharidin doesn't start to sting until long after the patient has left your office.

 

[DPMer]

It depends on how aggro you get with the poro. The shot is unnecessary unless the lesion is severely sensitive or if you're going to remove the entire plug using a biopsy punch. Cantharidin doesn't start to sting until long after the patient has left your office.

The podiatry attending made me debride deep to remove the plug with a 69 beaver blade. He even told me to not be afraid, just dig in. And there was a hole. Which explains the anesthetic to eliminate pain from the aggressive debridement. That was what the attending pod wanted. He made the finishing touches with debriding with a beaver 69 blade. Then he used a stick end of a sterile cotton applicator to add Cantharone twice and then Tensoplast for occlusion (Cantharone works best under occlusion). Patient was given an analgesic for pain PRN for the stinging from the Cantharone later.

Hmmm? I wonder if a porokeratosis plantaris patient case will show up as a question on the APMLE part 2 boards in March 2012?????

 

[347932]

Forgive me if I'm harping on this, but that just doesn't make any sense to me.

Are you doing a debridement for palliative care or to try to permanently remove the Poro?

We know that trying to remove the poro surgically is often a fruitless endeavor and can lead to other problems, so what's with the chemical destruction attempt?

Debridement, pad off to eliminate the pressure causing the poro/pain, rinse and repeat unless you want to use a custom orthotic to try to offload the area or attempt a metatarsal osteotomy to take the stress off the area.

Or is this just a ploy to get more $$ in that using a local can justify a surgical procedure (billed as such) and using a chemical for destruction thereby billing for chemical destruction of a benign lesion?

Debridement and offloading is the order of the day imho.

 

[DPMer]

Forgive me if I'm harping on this, but that just doesn't make any sense to me.

Are you doing a debridement for palliative care or to try to permanently remove the Poro?

We know that trying to remove the poro surgically is often a fruitless endeavor and can lead to other problems, so what's with the chemical destruction attempt?

Debridement, pad off to eliminate the pressure causing the poro/pain, rinse and repeat unless you want to use a custom orthotic to try to offload the area or attempt a metatarsal osteotomy to take the stress off the area.

Or is this just a ploy to get more $$ in that using a local can justify a surgical procedure (billed as such) and using a chemical for destruction thereby billing for chemical destruction of a benign lesion?

Debridement and offloading is the order of the day imho.

Hi Doctor: I simply do not know anymore. More confused than ever. I am just a mere 4th year obeying my "superiors" on my rotations. I am currently reading up on current literature on line and in journals/manuals/texts on similar cases.

 

[NatCh]

The podiatry attending made me debride deep to remove the plug with a 69 beaver blade. He even told me to not be afraid, just dig in. And there was a hole. Which explains the anesthetic to eliminate pain from the aggressive debridement. That was what the attending pod wanted. He made the finishing touches with debriding with a beaver 69 blade. Then he used a stick end of a sterile cotton applicator to add Cantharone twice and then Tensoplast for occlusion (Cantharone works best under occlusion). Patient was given an analgesic for pain PRN for the stinging from the Cantharone later.

Makes sense. Local anesthetic was one of the greatest inventions ever. Imagine all of the things we couldn't do without causing severe agony had it not been created.

Where was the lesion? How did you approach it? Sometimes if the lesion is on the plantar foot and in a suitable location I'll "sneak" the needle in via a dorsal approach, pass it between the metatarsals, and anesthetize from deep to the lesion. A plantar injection is awfully painful, so avoid it if possible.

As you are seeing with this case, often times "there is more than one way to skin a cat."

 

[347932]

Hi Doctor: I simply do not know anymore. More confused than ever. I am just a mere 4th year obeying my "superiors" on my rotations. I am currently reading up on current literature on line and in journals/manuals/texts on similar cases.

At this point in your career, you need to ask why (politically of course). If you don't understand what you are doing, you need to make a concerted effort to make sure you DO understand and not just "obey" your "superiors".

You are not a "mere" anything. You are the future of our profession. You are clearly confused, but the only person that can begin the understanding process is you. Ask WHY. A lot.

 

[bobdolerson]

At this point in your career, you need to ask why (politically of course). If you don't understand what you are doing, you need to make a concerted effort to make sure you DO understand and not just "obey" your "superiors".

You are not a "mere" anything. You are the future of our profession. You are clearly confused, but the only person that can begin the understanding process is you. Ask WHY. A lot.

👍👍

This attitude is fantastic, thank you for contributing it.

 

[DPMer]

At this point in your career, you need to ask why (politically of course). If you don't understand what you are doing, you need to make a concerted effort to make sure you DO understand and not just "obey" your "superiors".

You are not a "mere" anything. You are the future of our profession. You are clearly confused, but the only person that can begin the understanding process is you. Ask WHY. A lot.

Thanks Doctor. I will embrace this advice.

 

[PADPM]

Forgive me if I'm harping on this, but that just doesn't make any sense to me.

Are you doing a debridement for palliative care or to try to permanently remove the Poro?

We know that trying to remove the poro surgically is often a fruitless endeavor and can lead to other problems, so what's with the chemical destruction attempt?

Debridement, pad off to eliminate the pressure causing the poro/pain, rinse and repeat unless you want to use a custom orthotic to try to offload the area or attempt a metatarsal osteotomy to take the stress off the area.

Or is this just a ploy to get more $$ in that using a local can justify a surgical procedure (billed as such) and using a chemical for destruction thereby billing for chemical destruction of a benign lesion?

Debridement and offloading is the order of the day imho.

Not sure I agree with these comments, but I do agree with NatCH. There are times, regardless of your billing practices where it may be necessary to utilize some local anesthetic to make the patient comfortable while maximizing the amount of the lesion you can remove to also ultimately make them comfortable. It's an attempt to do more than simply shave the surface of the lesion, and often this can be very painful or sensitive.

I also have used the approach NatCH mentioned when possible. I also see no problem utilizing a caustic agent to attempt to further eliminate the problem. It's not always a mechanical/biomechanical problem, and I have seen this method eliminate the problem/erradicate the problem.

I personally have no problem with this approach.

 

[tracheatoedoc]

posterior tibial nerve block...enucleate with a curette

 

[NatCh]

posterior tibial nerve block...enucleate with a curette

If you go this route, first make sure the patient doesn't need that foot to drive home (because he or she won't be able to feel the pedals).

 

[prettypod]

I knew a doc once who used histofreeze on all her callous patients, only spent a month with her but she saw them back q2weeks and related good results, I'm not so sure