CutsWithFury

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Feb 2, 2019
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Yes this is a very TFP topic but I was curious to know what guys and gals are currently doing for their wart patients. For me personally I loathe plantar warts. I typically freeze them with liquid nitrogen but I have had some complications with patients blistering if they are too active after treatment (despite patient education). I used to use the laser in residency which I thought was pretty nifty but obviously there is wound management that still needs to be done. Cantharidin is another option but not readily available and can still lead to a lot of patient discomfort.

Recently I have been pushing for excision in the OR and with rotational skin plasty with a Schrudde flap. I have had patients healed after two weeks. Yes they have to be non weight bearing which seems overkill for a plantar wart but honestly I feel it is worth to them rather than struggle with all of the above and still not eradicating the wart. Stretching the treatment over several weeks or even months leading to patient dissatisfaction.

What say you podiatrists.
 
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josebiwasabi

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Dec 6, 2009
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In office we use monochloroacetic acid followed by salicylic acid. For people with numerous/bilateral lesions I have also added oral cimetidine.

Surgical excision for large/deep/recalcitrant ones. I recently did a bilobe flap on a toe for one and the patient healed very well after 3 weeks.

I think rotational/advancement flap is a good idea, as I have seen some follow-ups from patients who had large verruca surgically excised and they have developed painful scar tissue.
 

DYK343

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Jan 7, 2018
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Cantharidin is my go to but I agree... Warts are difficult to treat.

I am too afraid to flap. If it fails then its worse. Not saying its wrong. But I dont have the confidence in my patients to be compliant. Especially since a lot of them are kids.
 
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CutsWithFury

CutsWithFury

I like to cut
Feb 2, 2019
267
293
Podiatry Hell
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Podiatrist
Cantharidin is my go to but I agree... Warts are difficult to treat.

I am too afraid to flap. If it fails then its worse. Not saying its wrong. But I dont have the confidence in my patients to be compliant. Especially since a lot of them are kids.
Good point about kids. I’ve never taken a kid to the OR for this. I’ve only done schrudde flaps on adults with great success.

I have my patients follow up with me in wound care clinic instead of regular clinic. If my frenulum dies or has necrosis I have collagen dressings accessible to expedite wound healing.


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CutsWithFury

CutsWithFury

I like to cut
Feb 2, 2019
267
293
Podiatry Hell
Status
Podiatrist
In office we use monochloroacetic acid followed by salicylic acid. For people with numerous/bilateral lesions I have also added oral cimetidine.

Surgical excision for large/deep/recalcitrant ones. I recently did a bilobe flap on a toe for one and the patient healed very well after 3 weeks.

I think rotational/advancement flap is a good idea, as I have seen some follow-ups from patients who had large verruca surgically excised and they have developed painful scar tissue.
I have issues getting salicylic acid covered by insurance plans therefore I don’t bother ordering it anymore.

What’s your dosing for oral cimetidine and how long are you giving it for? Any contraindications? Giving it to only adults or kids too?


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air bud

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always had pretty good luck with cantharidin and then covered with a compound cream of like 40 something percent salycilic acid and something else I can't remember (last job). Leave on for between 12 and 24 hours depending on age, location etc.

rarely did laser in residency will never do now I don;t know enough about it and have experience that I would trust it. I rarely treat warts anymore (I rarely see patients...) but my protocol is cantharidin and if that doesn't work then cut out in OR and bovie the crap out of it.
 

air bud

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I have issues getting salicylic acid covered by insurance plans therefore I don’t bother ordering it anymore.

What’s your dosing for oral cimetidine and how long are you giving it for? Any contraindications? Giving it to only adults or kids too?


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i also did cimetidine on kids, I dont remember the dosage. I never felt like it actually did anything
 
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CutsWithFury

CutsWithFury

I like to cut
Feb 2, 2019
267
293
Podiatry Hell
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WOW... for a wart? i guess itll be great $ if pt is out of net LOL
I'm hospital employed. RVUs is my language

In all seriousness...it works and its fast and they don't come back. If the patient has any contraindications such as DM2, PVD, nicotine use, etc etc etc I am not doing this. I just wanted to put that out there
 

Scrantonicity

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I just debride, freeze, put them on cimetidine 800mg BID (for adults--I make adjustments for kids according to their weight), and prescribe imiquimod cream. I was never a huge believer in cimetidine until I put someone on it (just to try it) and the patient reported that the warts on their fingers disappeared even though I was only treating the ones on their feet.

I just have them put a dot of the imiquimod cream and some duct tape on the warts every day.

With this combo, I have found that many kids under 12 years old only need 1-2 treatments--I see them back and they are gone, and I'm always amazed.

I do have plenty of adult patients that don't seem to respond to the treatment, or the progress is very slow--I usually end up surgically excising them--haven't tried a flap yet, but I am not usually excising any huge warts. I just have to remind the patient about the likelihood of scarring, and possible keloid, yada yada yada.

If I excise it in the office, I just numb them up and cut a hole in their foot and scoop it out with a curette...cauterize with silver nitrate and phenol, flush it out really well...silvadine dressings every day for about 2 weeks. Warn about recurrence and scarring.
 

DYK343

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Jan 7, 2018
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Its been a few years since I read about it but last I read Cimetidine didnt hold up well against placebo in larger trials. No benefit. I have not used it for this reason since I graduated residency.
 

DYK343

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I have a patient with a wart about the size of a dime or nickel. Very painful and not budging. I might excise and flap...
 
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Scrantonicity

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Its been a few years since I read about it but last I read Cimetidine didnt hold up well against placebo in larger trials. No benefit. I have not used it for this reason since I graduated residency.

Meh, placebo or not--it's probably going to be in my bag of tricks for the foreseeable future. I'm a believer in placebo effects for warts anyways--there have been studies about that as well (the whole mind over matter thing). Anyways, it seems to work for me.
 
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josebiwasabi

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Dec 6, 2009
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I have issues getting salicylic acid covered by insurance plans therefore I don’t bother ordering it anymore.

What’s your dosing for oral cimetidine and how long are you giving it for? Any contraindications? Giving it to only adults or kids too?


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Adults 800mg BID until warts resolve
Kids weight based, up to 40mg/kg/day until warts resolve

Contraindications are renal and hepatic disease
 

dtrack22

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I give patients the option of several essentially painless cantharone treatments (12-14 days apart) with some OTC home salicylic acid products in between, or excision in clinic which is a single treatment that's going to hurt more but the problem is typically resolved in 1 visit.

I've only taken 1 wart to the OR in the last 2-3 years.
 
Jul 9, 2019
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What is highest OTC salicylic acid goes?
Pharmacist here. I think it's 40%. I usually recommend Dr. Scholl products instead of storebrand generics. If the patient has already tried that for a few weeks with no improvement, I will then recommend the freeze away stuff. And if that doesn't work, I recommend seeing one of you or rubbing the area with a banana peel (just kidding).
 
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CutsWithFury

CutsWithFury

I like to cut
Feb 2, 2019
267
293
Podiatry Hell
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Podiatrist
I give patients the option of several essentially painless cantharone treatments (12-14 days apart) with some OTC home salicylic acid products in between, or excision in clinic which is a single treatment that's going to hurt more but the problem is typically resolved in 1 visit.

I've only taken 1 wart to the OR in the last 2-3 years.
I didn’t know you operate still. Get a job you bum


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GeauxT

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I give patients the option of several essentially painless cantharone treatments (12-14 days apart) with some OTC home salicylic acid products in between, or excision in clinic which is a single treatment that's going to hurt more but the problem is typically resolved in 1 visit.

I've only taken 1 wart to the OR in the last 2-3 years.

This our basically our procedure as well. We apply cantherone, then the pt keeps the area covered and dry for 3 days. After that they apply an OTC acid (we use wart stick) daily for the remainder of 2 weeks. I would estimate 80% or more are healed in 2 weeks.
 

heybrother

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Oct 17, 2011
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I'm exploring trying to get cantharidin/a variant for our office. Seems like you can get multi-use vials on line through various labs.

In residency we did cryotherapy (we told the patients it would take 5-7 applications and I definitely saw it take more). They applied salicylic acid + initially 5-FU under duct tape and followed up at 2 weeks for repeat. We eventually switched to Aldara in lieu of 5-FU and I personally thought it had a better effect. Pediatrics got cimetidine. Did excisions for solo/2-3 lesions in clinic infrequently- healed by secondary intention. Large scale (15+) excisions in the OR, again without flaps.

I'll be crass and discuss $. During residency, my presumption is we billed 17110 for the vast majority of wart applications. Medicare values this in my area at about $110. At 7 or more visits that adds up. I believe we billed the size based benign skin lesion excision code for excisions. If experiencedDPM is still reading I strongly suspect he will have something to say about that. I may be looking at this all wrong, but the funny thing to me is that cryo seems ... "overpaid" for its difficulty. If you look at all the things 17110 entails - 30-60 seconds of application of cold spray pays the same as more involved things ie. numbing/cutting

Out of residency my clinic does not have cryotherapy. We do have some sort of historic device that can destroy tissues with soundwave via an application probe. I've never used it. I believe my partner uses it after the excision is already performed.

I offer patients:

(a) medication therapy - go home and put salicylic acid + duct tape + aldara on the lesions. Follow-up 2-3 weeks and I'll redebride down to the lesion and you continue. Most patients who present for pain seem to be alleviated by the first f/u but it takes a long time for resolution - like 2 months of applications. Most of these visits are very quick but unless I'm missing something they are 99212s. I'm not changing the plan/MDM. They are continuing to improve.
(b) go find someone who has cryotherapy
(c) excision

I saw a ton of warts in residency. My current practice really only has them infrequently. If you are doing repeat cryo every 2 weeks even having a handful of patients though is going to generate regular encounters since the patients come back so much. My intention/hope via adding cantharidin is to give my patients something effective/much more rapid as opposed to having to follow-up them for 2 months essentially hoping the problem will resolve. I'm also under the impression I should be able to bill 17110 for this procedure (a online coding site stated this code applies to chemosurgery though that may be out of date information) which would be improvement for the practice over 99212. My office manager claims private insurance will frequently not pay for this code in our area as they view it as cosmetic- perhaps she is wrong or perhaps it is only some plans. Perhaps this makes it an opportunity to offer an effective cash pay service/something that is not already being offered in the area.

I'm open to feedback.
 

air bud

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I think that chemo surgery is for bleomycin and yes pays very well.

3 days seems like a long time to leave cantharidin on. I never left on for more than 24 hours.

Cryo and doing 5 to 7 in this day and age is robbery.
 

heybrother

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Oct 17, 2011
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Cryo and doing 5 to 7 in this day and age is robbery.
This is why I'm always curious to hear what other people have to say. I had no idea what those visits cost in residency. We did something along the lines of 60 seconds of application from cryo-gun - off and on, blanch till the patient says it hurts, stop/dethaw, repeat. I've had some dermatology residents come through my office and their feeling was that if the patient didn't blister like crazy it wasn't going to work. The above regimen inconsistently produces blistering. If you aren't on ...Medicaid the above adds up quickly.

In the spirit of robbery, we dispensed DME at my residency for sprains and fractures and trauma and what not. A $65? brace here. A presumably $200+ CAM boot there. My patient's out of residency have commercial insurance and we don't dispense DME in the office (yet). When patient's hear what the price of the DME at the store is they buy from Amazon. I look back and wonder - was anyone actually paying the cost for those items?
 

air bud

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I love not being able to dispense DME. It is through a 3rd party med supply down the street. I tell people we can go through insurance and I have no idea what will cost, or buy this surgical shoe for 13 bucks on Amazon. Granted it takes longer since I live in the middle of nowhere..... obviously don't do for trauma but stress fracture or tendonitis? Yeah a few days more is fine. Patients love that I give them the option and most importantly makes them think I am not the bad guy when it comes to their bill.
 

heybrother

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Are you so remote your patients can't get a Hoka? Cause that would be bad.
 

G0dFather

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my presumption is we billed 17110 for the vast majority of wart applications. Medicare values this in my area at about $110.

This has and continues to make derms and pods very wealthy, I love it ..... WHAT you should be billing when they come back every 2 weeks for debridement of the lesion is 17110 not 99212 ( your loosing alot of money!) because that is what your doing, even if say on the 3rd visit your evaluating the progression of the wart, it doesnt matter there is an E&M component built into the procedure code ..... YOU ALREADY E&Med it on the visit that they first came in and you dx a wart if you also debirded it on that first visit then you can also tack on the 17110, its within your right ... but when they come back the next 3 visits ( for example) and ALL you are doing is debriding the wart and evaluating it then you should just bill 17110 ONLY .... unless they have something else that is "separately identifiable" then you can bill 99213/12 according to how thorough your EM
 
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dtrack22

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Apr 20, 2008
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I didn’t know you operate still. Get a job you bum


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I’m living my best life. Like @NatCh but with even less work...and unfortunately a little less skiing I’d bet.

Though I got the best of both worlds in CO last weekend. Epic storm that brought a ton of snow (and lift lines even at Mary Jane, thank god I wasn’t at Vail) on Friday and then a bluebird day with great corduroy and a few untouched stashes in the trees on Saturday.
 
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