Results of the EVERT 2 needling study of plantar warts – what does it mean?
Paper:
Hashmi F, Fairhurst C, Cockayne S, Cullen M, Bell K, Coleman E, et al. The EVerT2 (Effective Verruca Treatments) Trial: a randomised controlled trial of needling versus nonsurgical debridement for the treatment of plantar verrucae. Br J Dermatol. Early View
The needling of warts/verrucae has seen something of a renaissance in podiatry practice within the UK as a treatment for particularly stubborn lesions. The technique emanated from the United States in 1969 when Dr Falknor (1) published an article in the Journal of the American Podiatric Medicine (JAPMA) outlining a technique he had adopted which used a multiple puncture technique to rid patients on their plantar warts. In that paper, he quoted a very high success rate in 126 patients with only 2 failures. Maybe a little unbelievable?
The technique only in the last decade has made resurgence particularly in the United Kingdom. Probably because of the lack of effective treatments, podiatrists started to look at alternative methods which could be undertaken within the clinic utilising their current skills. Consequently, two clinical papers were published in the UK podiatry literature. Both were retrospective case series of patients who had undergone the treatment. The first paper (2) suggested a 50% cure rate in 14 patients whilst a paper by Longhurst & myself (3) reviewed a cohort of 45 patients who underwent the procedure for plantar warts with a success rate of 69%. Subsequently, a third paper compared cryotherapy to needling (4). Published in JAPMA the paper reported a success of the technique of 64% versus just over 6% in the cryotherapy group.
This month, the research group from Salford University, led by Dr Farina Hashmi, have published the results of a randomised controlled trial comparing needling with simple debridement in the respected British Journal of Dermatology (5). The study had a robust, published protocol and a power analysis was undertaken to ensure that there were sufficient patient numbers within each arm of the study to detect potential differences between the techniques. Thirty adults were recruited into each arm of the study and reviewed after 12 and 24 weeks. The outcome of this study was a little surprising with no overall difference between the groups (each group only having 4 patients [around 16%] clearing their treated wart.
The results may seem on the face of it seem conclusive in suggesting little value in the technique of needling but a closer comparison of the studies may be worthwhile here. The main difference between the Salford study and the others was that it only allowed for a single needling treatment within the protocol. In the both the Longhurst and Cunningham papers multiple needling sessions were permitted, (up to three in the latter study). Looking at the Cunningham study further also, the main differences were that in that study participants were younger adults, had smaller needled lesions and the mean age of the lesion was less than for the Salford study but does this explain the difference?
So where does that leave things? As with all good research it should answer a question but then lead onto further questions. The main one here being are multiple needling sessions required to clear warts as opposed to a one treatment regime? Further work is needed and perhaps time will tell but as many of us know with warts, it is often persistence that pays off rather than the treatment itself.
References
1. Falknor GW. Needling-A new technique in verruca therapy. A case report. J Am Podiatr Med Assoc. 1969;59(2):51-2.
2. Skilton B, Mehar Z. Needling: a treatment option for recalcitrant verrucae pedis. Podiatry Now. 2011;14(5):21-5.
3. Longhurst B, Bristow I. The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases. Journal of Clinical Medicine. 2013;2(2):13-21.
4. Cunningham DJ, Brimage JT, Naraghi RN, Bower VM. Needling Versus Liquid Nitrogen Cryotherapy for the Treatment of Pedal Warts. J Am Podiatr Med Assoc. 2014;104(4):394-401.
5. Hashmi F, Fairhurst C, Cockayne S, Cullen M, Bell K, Coleman E, et al. The EVerT2 (Effective Verruca Treatments) Trial: a randomised controlled trial of needling versus nonsurgical debridement for the treatment of plantar verrucae. Br J Dermatol. [early view]