¶ Intro / Opening
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¶ Introduction to Dr. Stevens and Life Hacks
The Good GP, the education podcast for busy GPs. Today on the podcast is a guest who is well known to listeners. It's Dr. Sean Stevens, who's also a podcaster for The Good GP. Welcome, Sean.
Thanks very much, Tim. Lovely to be here.
So Sean, you know, we were just talking before. You've been on this podcast for it must be three three or more years. Tell us about yourself because perhaps some of the listeners don't know too much about you. You we we all know you're a GP, but tell us about your your background in general practice.
Yeah, so look I've been a GP for about twenty years now, Tim. I was thinking about it. That's uh you know, it's getting on for half my life. I absolutely love being a GP and I love education and you know, I've supervised over thirty GP registrars over the years. Um, and I've just started up a new venture with Dr. Mary Wyatt uh about eight months ago now, and we started our own practice.
um which is really been a lot of fun. I'm also, as you know, uh chair of the WA faculty of the RAC GP and um chair of the GP Business of General Practice for the college So I sort of wear a few hats and um love general practice and love promoting general practice.
And we should also uh shout out to your wife, Julie, and your and your kids, um, who often listen to the podcast. So hello guys, good to good to have you listening today.
Thanks Tim. Yeah. Uh sometimes Connor goes to sleep with it on and he he tells me where When a new episode's been uploaded.
Well, that's great, Sean. So um we've got a really interesting episode. It's very general practice. We're talking about life hacks uh for GPs and specifically in regard to to warts. Um, but perhaps you can explain the concept of a life hack first, Sean.
Yeah, thanks, Tim. Life hack was something my teenage kids introduced me to and I love the term. Basically, uh I had to look it up on Wikipedia as to the exact meaning. Uh and it's any trick, shortcut, skill, or novelty method that increases productivity and efficiency in all walks of life. And I just thought about some of the things that we do in general practice and and a heap of what you learn, you don't learn from a textbook. It's you know life hacks that you pick up from other GPs.
And I had the great benefit of uh being supervised uh by a guy by the name of Peter Wallace, who is an amazing GP and he taught me a number of life hacks. And a couple of them relate to Wart, so I thought I could uh hopefully share them with the next generation of GPs.
Yeah, fantastic. Thanks, Sean. This is fantastic stuff. As you say, it's not found in a textbook. It's just pure knowledge coming from experience in general practice, so that's brilliant. I I guess we're talking specifically about treatment for ward. Um and probably one of the most common treatments that GPs would administer would be cryotherapy. Um so let's talk about cryotherapy and and the role of cryotherapy in treating warts in general practice, Sean.
¶ Cryotherapy for Warts: Tips and Mistakes
Yeah, thanks. So it's interesting. There's a few common mistakes that I find GPs make with treading warts with criotherapy. So one of the most common ones is using cotton buds. And you know, tipping out the liquid nitro into a styrofoam cup and then dipping a a cotton butt into that. That's been shown to be nowhere near as effective as the spray gun cryotherapy.
So the first thing I'd say is if you if you don't have a spray gun, invest in one. Uh the other thing that I s was surprised when I looked into this is that a one off freeze is not enough. Um to get the best cure rate you're best off doing what they call a freeze thaw freeze technique. And that's where you freeze the wart, you let it thaw out completely, and then you give it a shorter second freeze, but where you make sure you you freeze the whole whole lesion itself.
To minimise the damage, one of the life hacks that I read in one of the medical glossies. was to use an otoscope speculum, which is really a great idea because it minimizes the collateral damage of the surrounding skin, it minimizes any blistering, and it just makes sure you get get the ward itself. A couple of tips I would give people just from experience, self-experience, is when you're holding the idoscope.
Make sure you don't hold it with your skin. I've frozen my myself, my own fingers to the um the eidoscope speculum a couple of times. My tip is to grab one of those bits of paper that you rip off the end of a prescription, fold it up a few times, put it around the speculum and hold that and hold it firmly against the wart. Um, you've got to hold the speculum at right angles to the skin.
um because otherwise it'll spray out the side of the hole um where it meets with the skin. And obviously you've got to hold the have it positioned so that the spray gun is held upright so that it the pipe goes to the bottom of the bottle of the the spray gun. Another thing that can happen is if the wart's quite large, the even the larger adult otoscope speculum won't be large enough.
If that happens, get a pair of scissors and just snip the end off it so you make the uh the end of the autoscope that bit larger. The other thing is to warn the patients about blistering. I mean most GPs would be familiar that if you do do a prolonged freeze then the the wart's going to form a blister underneath it and then usually will peel off, but it's always worth
warning the patients about that. The other thing with the speculum, make sure you don't pull it off suddenly because you can actually cause bleeding and and rip some skin off. So let it thaw out and make sure there's no frozen bits on the end of it and then gently peel it off. And if you're in a larger practice or you've got a particularly wealthy boss, inquire about a brimal cryoplate that's spelt B-R-Y-M-I-L-L and then cryoplate.
So that's a clear perspex disc with various sized holes indented in it. And it's similar to using an idoscope speculum. The only real advantage I see is that A, you won't freeze your fingers to it, and B you can see how far your area of freeze has gone because it's clear. Um so yeah, they're basically my tips. I don't know if you had anything else there, Tim, that that you used.
Um no look that they're fantastic tips. I mean the thing I would always say is you know, the the higher the wart, uh the the harder you really need to freeze it. And you know, I think The risk of freezing things more vigorously is the collateral damage, as you say, to the surrounding tissue. Um and that's where I agree the odoscope is a re the speculum's fantastic for protecting the damage, so um Yeah, hundred percent agree with that. That's a fantastic.
Yeah I remember Tim, I mean your dad's a GP, same as mine. My dad was a uh GP surgeon. I remember I had a reasonably large wart as a teenager and he goes, Don't worry, we'll get rid of this and he gave it one prolonged freeze without a speculum. I ended up with a blister from my um metatarsophalangeal joint to the base of my nail. uh on my thumb. Got rid of the wart, but I've never forgotten it. Uh now I always warn people about the blistering.
Mm-hmm.
¶ Effective Treatment for Plantar Warts
Fantastic, Sean. Um now let's talk about that same topic, planter woods. Um they're just a nuisance, aren't they, planter woods? They take a long time to treat. Um and they're just, you know, patients hate'em because they complain that they're uncomfortable to walk on. They really want rid of them as fast as possible.
Yeah, they do. And you know, they have other um issues that can arise too that you've probably seen. You know, you can get infection bacterial infections within them. You know, the the pain is often a big issue. So yeah, pa you know, patients can come in, particularly when they're on weight bearing areas of the foot. and just be completely fed up with it and just want them gone. So I've seen a lot of GPs who try cryotherapy in this area.
And
If you look at the studies, it actually is not a very good treatment. It's painful. Plantar warts are a bit different to warts in other areas of the body. Because you're putting weight through it, the roots are usually a lot deeper. So being able to freeze it um is really quite difficult. So the stuff that works best in my experience is using some Upton's pay.
So Upton's paste is a salicylic acid based paste that's made by pretty much any compounding pharmacist. And what you do I just write on write a handwritten script Upton's paste twenty grams. And then I give'em a sheet. Now I'll run you through the sheet and um if people wanna wanna email our email address I'd be happy to share this with them. So the first thing you do is you get the patient
to paint clear nail polish on the healthy skin surrounding the water. Again to reduce that collateral damage. Then you get a strip of elastoplast. and you cut a a small hole, a a hole in the elastoplast that's the same size as the wart. you put the elastoplast over with the wart poking through that hole. Before you apply the post, you get a nail cuticle, which for anyone who's not familiar with them, they're like a short, reasonably sharp stick.
um that's used to push down the the cuticle on your fingernails. And you sort of dig at it, you dig out as much of the content of the wart as you can without causing too much pain. Then you apply the Upton's paste, and then you apply another strip of elastoplast over the top without any hole in it. So it sort of holds that Upton's paste in direct contact with the ward.
You leave it like that for three days. You get the patient to peel it off. They wash it off. They go about their normal activities for a day. Then they repeat the whole process. um for another three days. And then they take it off the morning that they're going to come in and see you. So that's seven days or a full week after you first saw them. And what you do is that you then get a scalpel and generally pair away in it. So basically
It's like kinda imagine a the biopsy of uh a cervix. Um so doing like a you're sort of coning down and uh removing as much of the water as you can. As soon as it starts to hurt you stop, or if there's any bleeding, you stop. Um and you repeat it. You usually need two, sometimes three lots of treatment.
It was really interesting for myself'cause I got a plan to ward. So I thought I'll give this a go and and see what it's like. And it's actually surprisingly effective and very like it's so relieving when you actually get it out and you get it done. Um so and I've certainly seen a number of patients who've gone through the freezing with people elsewhere and then come and then um had this treatment done and they've you know, they've been really grateful, which is excellent.
Now there used to be a item number for this, which you know only makes sense, but unfortunately in their wisdom the government has removed that item number so that's no longer available.
Mm. And Sean, can I just ask, can the Uptons paste be used on non planter warts? So you know the you know, the external facing warts, for example.
No, it's not recommended. Um the only other area on the body that it is advisable to use is on the palm, again because you've got that thick skin. It's too irritant really for for the thinner skin on the rest of the body, unfortunately.
Great. Yeah, thanks. That's a a really wonderful tip. I think a lot of GPs just struggle with recurrent cryotherapy and pairing of of plant awarts. So that's a a really fantastic hack there.
Now we're gonna
¶ Managing Genital Warts with Podophyllin
Talk about genital warts next, which can also be quite sort of recalcitrant and and tricky. And also, you know, I guess the problem with genital warts is people don't you know, they often don't want to keep coming back in for treatment because they can be quite uncomfortable.
Yeah, look definitely. And I think, you know, because I don't know about you Tim, but I don't see that many genital warts. Uh or at least if I do, if my patients have'em, they don't wanna talk to me about'em. So I think a lot of GPs don't get comfortable with trading genital warts, when actually they're they're pretty straightforward. My advice to patients is to use that nail polish uh approach again. So put uh coat the normal skin around the wart with clear nail polish.
I do a test dose of pedophilin. So I'm I'm talking about that pedophilin paint, um, which, you know, comes as a you know, it's a proprietary prepared preparation and you so you put the the nail polish on, you then put the pedophilin on the wart. I then tell the patient to go straight home and uh wait fifteen minutes from when you've put it on, which is usually about fifteen minutes by the time they get home.
wash it off just to make sure they don't ha they're not one of the few patients who have that really acute severe reaction. Then if they're not, I get them back in a few days and I get them to do the next application in front of me so that they're, you know, make sure they're uh comfortable doing it. And then I get them to apply it to the wart twice a day for three consecutive days. That can be repeated each week for up to a maximum of five weeks.
And you know, that's pretty effective. I usually follow people up. you know, so see them at week two or three, um and just see how it's going. And that's for sort of mild to moderate warts. When you get the really large, you know, sort of cauliflower size uh warts I usually refer them off, but the small to medium ones I think, you know, we can very comfortably manage in general practice.
Yeah, look the um fantastic tips there. I guess the only thing I would add is you're right, you occasionally do see these very not specifically gentle warts, but just general external warts that are very, very large and The tip I would give is that they're often not going to respond readily and easily to to cryotherapy and uh electrocautery seems to be a pretty good option for those ones. I've certainly got um some GP colleagues who
who do electrocautery on them and get really quick results, which is, you know, by the time they're that large, people have sort of been mucking around with them for a fair while and often tried two or three treatments already. Um so I often sort of send them straight on for electro quartery and it does seem to sort of get rid of them fast, often in one go.
Yeah, no, good advice, good advice.
¶ Alternative Wart Treatments and Counseling
Well they're fantastic tips on Warts. Any anything else we can sort of educate the audience about with regard to sort of things to expect for Warts?
There's uh there's a number of sort of immune modulating things that they keep talking about. At one stage for widespread warts they were talking about cemetidine. I don't know if you remember that. Tim was probably fifteen, twenty years ago. Um there was discussion around that.
Yeah, I do. Uh a and you know, there's a actually if you go through the literature there's a whole range of different treatments out there for warts with sort of modest m to moderate benefit. I even understand that hypnotherapy has been tried for warts and and has some evidence
So does placebo.
So yeah, look, you y you know, I think it's about counseling the patient around patients with with warts a lot of the time because you know at the end of the day we're not curing the the viral infection, we're just sort of treating down the manifestations of the infection.
Yeah, absolutely.
Well fantastic talking to you, Sean. That's just been a a brilliant chat and uh really appreciate your time and we'll look forward to perhaps hearing you as a podcaster in the not too distant future.
Fantastic. Thanks, Tim. Pleasure to be on this end of the microscope again.
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