PapersLocal treatments for cutaneous warts: systematic reviewCommentary: Systematic reviewers face challenges from varied study designs
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7362.461 (Published 31 August 2002) Cite this as: BMJ 2002;325:461All rapid responses
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Editor,
I refer to Robert Rudolph's response(1) to the review on local
treatments for cutaneous warts by Gibbs et al(2). In light of Roger
Dobson's recent offering(3) I would like to suggest the following:
If evidence based medicine does continue to offer no support for Dr
Rudolph's treatment, he should adopt an attitude such as 'if life gives
you lemons, make lemonade'. Or, in medicine, 'let the absence of evidence
be no hindrance to making a buck.'
Why not become a quack?
You could employ the following whilst on Oprah:
1. Victim Status
The 'Medical Establishment' (whatever the hell that is) is
suppressing this wonderful, natural treatment in cohorts with multi-
national drug companies, the Government, aliens, communists and JFK’s real
killer.
2. Religiosity
State that Paul Waddling Gait III conducted experiments in his
backyard in 1800 and any speculation since is clearly heresy. This therapy
utilises a 'life energy' (something you modern Doctors can't seem to
grasp) so it shouldn't be subject to evil modern experimentation. Besides,
it cured your hair dresser's cousin's flatmate's dog's former owner's
illness when the Doctors only gave her 3.2 seconds to live, so it must
work.
Mention that it's 'natural' again.
3. The Galileo Argument
Compare yourself to Galileo - since he was supposedly thought wrong
by his contemporaries claim that you must also therefore be right.
Ignore the fact that his ideas were tested and verified by his
scientific colleagues and that it was only the established religious
authorities that insisted on sticking to the existing psuedoscience.
4. Anti-Science
When confronted with inconvenient facts, simply reply:
'Scientists don't know everything!'
Diluting any active ingredient 30 million billion trillion times must
be a good idea for that reason alone.
5. Conspiracies
Claim that the Government is withholding the cure for cancer or any
other bold statement that implies that you are 'in the know'. Don't
suggest that the latest wonder herb is been grown in Area 51 though; you
can take a good thing too far.
6. Supply Pseudo-Proof
Refer to something published in the Lancet. People won't bother
reading the actual article to check if it really supports your argument.
It might, for example, have used only 12 non-randomly selected subjects,
no controls, no blinding of investigators and it may have reached no real
conclusion(4).
Regardless, use statements such as 'it proved conclusively' or say
the study 'rocked the scientific community' etc...
7. Use a Device
Anything with bright lights and dials that supposedly utilises some
poorly understood theory that was discovered by 'the ancients' will do.
Call it a psychophysicoquackometer that will analyse your 'life force',
cure cancer, realign your aura and make a lovely carrot cake all whilst
removing that nasty wart.
In summary, absence of evidence has not deterred many others from
making a mint. So make the most of it.
Sincerely(?),
Tony Floyd
References:
(1) Rudolph R. Why Evidence Based Medicine doesn't seem worth the
room it takes up. BMJ Responses. 2 September 2002
(2) Gibbs G, Harvey I, Sterling J, Stark R and Altman DG. Local
treatments for cutaneous warts: Systematic Review. Commentary: Systematic
reviewers face challenges from varied study designs. BMJ 2002; 325: 461
(3) Dobson R. Doctors fail to see the joke. News. BMJ 2002;325:561
(14 September)
(4) Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular
hyperplasia, non-specific colitis, and pervasive developmental disorder in
children. Lancet 1998; 351: 637-41.
Competing interests: No competing interests
I am surprised by the definitions used for the duration of
cryotherapy.I suspect that most cryotherapy of warts is now done in
general practice in the U.K..In my practice and that of at least one other
practioner in Worcester 10 seconds or less would be considered a placebo,
15 seconds plus would be the minimum time to expect a satisfactory
response and 25 seconds plus 'aggressive'.On this basis I do not believe
cryotherapy has been satisfactorily studied in this article.
Competing interests: No competing interests
I think that Gibbs et al are a bit harsh about the benefits of
fluorouracil in the treatment of warts when they describe it as 'more of
historical interest'. As far as I can tell, the trials they identified
seemed mostly positive about its effects.
I can certainly testify personally to its efficacy. I once endured a
large and painful plantar wart for about 5 years, which resisted copious
amounts of salicylic acid and many excruciatingly painful sessions of
cryotherapy. It disappeared, never to return, within a month of starting
fluorouracil treatment.
I entirely accept the authors conclusions that salicylic acid is a
good treatment for warts, but what about the warts that don't respond to
it? Surely fluorouracil is a reasonable option in those cases?
Competing interests: No competing interests
Many moons ago, I like so many before me, suffered with a rather
large and painful plantar wart. Its discomforts forced upon me were burned
with every second step. I suffer fools badly, and I suffered this very
wart with an even shorter temper.
Not for me the patience demanded of salicylic acid. The anecdotes of
the quick fix drew me into a world of falsehood. In this world the gases
boiled across the earth and transient thick white fogs dissipated with the
speed of ghosts at sunrise. But this devil's world of untruths held me
fast for nigh on twelve months. I could not release myself from the
temptation of the instant cure. And so the liquid nitrogens burned deep
into my sole, and time winced at every step.
Of course, in time I was taken from this mysterious world and forced
to walk upon the hot and scorched earths of the Northern Territory (in the
southern lands). Day in, day out, I walked (and limped) upon the burning
and ash laden earth.
The mechanical stresses upon my dear sole prooved offensive to the
grim and ugly wart. And so the afflicted sole took flight, leaving my soul
to rejoice. No longer would I have to suffer the empty promises of those
boiling cold mists. No longer would I suffer the jests of all those other
merry anecdotes (with bells on). Hoorah, no longer would I pass a week
with a browning, rotting banana skin taped about my wretched foot!
And so to consider the lessons of my trials. The anecdote suggests
all too strongly the ephemeral nature of success with the boiling gases.
The banana skin was quite frankly, little more than slapstick humour at my
expense. But maybe I could seek pleasure in the last laugh.....I could
send people half-way round the world to walk through burning lands, where
not fogs and mists tumble through the air, but thick and blackened smoke
seeks out and chokes the depths of the lungs.
But then that would be to forget the most important lesson. The
tempest may torment the soul, but the temporal heals the sole. And that of
course is why we must suffer the trials and tribulations of evidence based
medicine!
Competing interests: No competing interests
When I was at school in Malawi we used to 'treat' cutaneous warts
by briefly focussing the sun into the base of the lesion with a
magnifying glass. This would produced an itching hyperaemic
reaction after a few days and usually caused the lesion to
disappear within a few weeks without scarring.
Anecdotal perhaps, but certainly a simpler and cheaper solution
than photodynamic therapy or pulsed dye lasers, though it does
require a climate which is sunnier than Britain.
Competing interests: No competing interests
Having treated thousands of patients with plantar verrucae with the
use of topical salicylic acid, I am overjoyed to see a paper published
supporting what I has been clinically evident to me for over 20 years. The
topical use of Sal acid is an effective treatment for plantar verrucae.
Very often a parent will bring in a child for evaluation and
treatment of multiple verrucae. I initially treat them with topical
salicylic acid. In many cases the parents want instant cure. They don't
want to wait one, two or even twelve weeks to assess the efficacy of the
therapy. All too often after the third week of therapy the parent will ask
why I don't surgically remove the warts or initiate, cryotherapy,
hyphrecation, Lazer therapy or some other more invasive way of treating
the warts. In some cases they will even go to a different clinic where a
more aggressive form of therapy will be tried first.
Thanks to the authors, I now can show these patients a well written
and well documented medical paper supporting topical salicylic acid
therapy as a legitimate first line of treatment for pedal warts.
Elliot Udell
Hicksville, New York
Competing interests: No competing interests
A very nice, reasoned response from the good Dr. Mann.
I happen to worship medical science and investigation as much as
anyone, and frequently bend the knee in real astonishment at the altar of
dermatologic research. I truly hope that the investigative energies of
the speciality continues at it's furious speed, and I applaud the advances
made by researchers. My perception and practice of the field constantly
change because of the findings of my investigative colleagues.
What I don't relish reading, however, are articles on EBM. I
personally find that much (most?) EBM material unreadable, unusable, and
unimportant. It's stultification carried to the nth degree.
I learned many years ago, being a staunch cynic, that much of the
medical literature is junk. It's taken me 30 years of continual practice
to hone this skill, and I think I'm still compos mentis enough to realize
what studies are poorly and indifferently done, and to appreciate the
occasional good and important paper.
On the other hand, there is absolutely nothing, in my opinion, which
can equal the "in front of your face" evidence that a particular
therapeutic success gives us physicians. This is, despite the ululations
of the EBM folk, very powerful ammunition for the practice of medicine in
the office, and provides us with many of the arrows in our therapeutic
quiver.
I'll continue, none the less, to flog myself into a stupor trying to
read and digest EBM articles, but I've yet to find one that has really
made me change what I do.
I love science, but I also like anecdote. After all, an anecdote is
often an antidote when science fails.
Competing interests: No competing interests
It is not clear to me why Prof. Rudolph is upset about the EBM
article on wart treatments. The systematic review article does not say
that his personal choice(s) of treatment of warts is quackery. It merely
states that medical studies performed on wart therapy are heterogenous and
inconclusive, and it certainly seems to me that there are many problems
with trial design and trial size in the area of wart therapy research. I
am not therefore not surprised that Prof.Pudolph concludes his animated
response by stating "I'm willing to bet my bottle of port, any
dermatologist anywhere who is going to alter their
therapeutic approach because of it, or be swayed by it." That may be true,
and if that attitude is reflective of the entire dermatology community,
then it would reflect poorly on the quality of scientific medicine
practiced by dermatologists -- if they prefer to practice anecdotal
medicine rather than perform well-designed clinical trials of much larger
size.
Jeff Mann.
Competing interests: No competing interests
After reading the article on the "systematic review of local wart
treatments" I had two responses: the first was to put my fist through the
computer screen. The second was to get up and have myself a dollop of a
really good port.
The article would make me conclude that what I've been doing for
almost 30 years to help patients of all ages get rid of their pesky,
painful, possibly dangerous, and unseemly lesions is buncombe, and
verging on quackery.
Well, my evidence based medicine, based on the accumulated results
from thousands of patients who have been sitting in front of me in my
office, suggests otherwise, and indicates that wart therapies of diverse
types are quite efficacious in a goodly percentage (i.e. almost all) of
patients.
I must say that the article, however, cloaked as it is in the nimbus
of science and written in the current stern fashion, is formidable, and
must have taken a lot of sweating and lucubration. From the my
clinician's standpoint, however, the authors' time could have been much
more productively and better spent: say, tending flowers, going to a nice
restaurant, getting slighty drunk, etc.
This article is the kind of stuff that, in my bumpkin opinion, makes
clinicians sigh and gag at the same time, while making lawyers, on the
other hand, drool with delight: what a splendid tool to use against some
poor shnook dermatologist or other doctor under the legal gun.
All in all, the article might be "scientific" in the extreme but
there is not, I'm willing to bet my bottle of port, any dermatologist
anywhere who is going to alter their therapuetic approach because of it,
or be swayed by it.
Competing interests: No competing interests
Forge Water, Folklore and Warts
I note, from reading both local and international Medical Journals,
that there is no evidence that current treatment of cutaneous warts is
effective 1, 2
This is particularly true for the use of Liquid Nitrogen.
I have been in General Practice for 15 years. I can only concur with
the evidence. I have spent money buying Liquid Nitrogen equipment and
getting supplies of it delivered. I have not found it of much use when
treating cutaneous warts.
Forge water, the water the Black Smith uses to cool hot irons, has
being used by The Irish as a “Wart Cure” for centuries.3, 4, 5
As a boy, I remember dipping my hands in Forge water; my warts went
without trace, within weeks.
I had multiple hand warts for 3 years, several treatments had been tried,
to no avail, from Surgery to Salicylic Acid pastes.
There is a Farrier School in Kildare Town. The Organiser of this
school allowed me access to their forge water. Recently, 5 patients used
the forge water. In 4 out of the five cases, all their warts disappeared
within 3 months.
Needless to say they were pleased with the results since some had had many
warts for years. Forge water was both painless and non destructive
treatment of their warts. It worked for both their plantar and hand warts.
It may be that water, high in iron concentration, is effective.
Who knows?, there may be science in the myth.
If forge water is truly effective, GPs can use their expensive Liquid
Nitrogen containers to store Blacksmiths` “Wart Cure”!
D .Deeny
MRCGP
1. Gibbs S, Harvey I, Cochrane Review 2006, Treatment of Cutaneous
Warts.
2. Dr J Bourke, Treatment of Cutaneous Warts, Modern Medicine
Ireland ,Oct 2006
3. Irish Superstitions , Daithi O Hogan, page 88
4. The Last Blacksmith of Lissmore. P .Vaughan .Page 74
5. Superstitions of the Irish Country People, Padraic O Farrell,
Page 41
Competing interests:
None declared
Competing interests: No competing interests