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Wishing Away Warts

Common warts (verruca vulgaris) are more of a nuisance than a serious health problem, but they are interesting. There is a whole mythology surrounding their cause (touching toads?) and treatment (everything from banana peels to vitamin C).  Many people believe they can be made to vanish by suggestion or hypnosis. I used to believe that too.

Every doctor has wart stories. Here are some of mine.

  • A patient made an appointment to see me because he had a wart, but when he tried to show me his wart he discovered that it had vanished! Apparently, just making the appointment cured it.
  • Another patient did have obvious warts and I prescribed the “wart medicine” that our pharmacy tech compounded, based on salicylic acid. He was out of one of the ingredients and had to ask my patient to return in a week. When she returned, her warts were already gone. The wart medicine apparently worked so well that you didn’t even have to use it!
  • I worked with a dermatologist who used a colorful laminated card with a picture of a toad to stroke children’s warts, telling them it was a wart remover. In his experience, this would frequently make the wart vanish over the next few days. Was this ethical? Was he lying and deliberately deceiving patients, or could this be excused as playing make-believe to distract the child and improve his attitude about the wart?

He was certainly deceiving himself in thinking that this foolishness was actually effective based on his own uncontrolled observations. Hypnotists claim success in treating warts with direct suggestion: they say that prepubertal children respond almost without exception, although it is less effective in adults.  I was taught that if a patient had multiple warts and you treated just one of them, the others would likely vanish too. This might sort of make sense if the treatment stimulated an immune response, but I haven’t seen any evidence to support it.

What can science tell us about warts?

A new review article in American Family Physician, “Treatment of Nongenital Cutaneous Warts” by Mulhem and Pinelis provides a thorough update of the current evidence.

Cutaneous warts are epidermal proliferations caused by over 100 types of human papillomavirus. They are spread person-to-person or by contact with contaminated objects. They are most common in children. Walking barefoot is a risk factor for plantar warts (warts on the sole of the foot that that have a different appearance due to being under pressure). Nail-biting, meat handling, and immunosuppression are also risk factors. 90% of renal transplant patients develop warts.

Warts are usually self-limited. Half resolve spontaneously in a year, two-thirds within two years. Watchful waiting is an option, but patients often want treatment because of discomfort or social stigma. Two treatments have been clearly proven effective by scientific studies: salicylic acid and freezing with liquid nitrogen. There is limited evidence for silver nitrate, topical fluorouracil, and topical zinc. There is little to no good evidence for cantharidin, dinitrochlorobenzene, oral cimetidine, oral zinc sulfate, podophyllin, propolis ointment, retinoids and topical garlic extract. A few years ago, duct tape was reported to work, but subsequent studies showed that it probably does not. Warts can also be surgically removed, and dermatologists can offer specialized treatments such as intralesional bleomycin and pulse dye laser.

I found it interesting that the AFP review didn’t even bother to mention hypnosis, suggestion, or CAM.

Salicylic acid preparations are available over the counter for self-treatment. They are well tolerated and produce a 73% cure rate in 6 to 12 weeks. Cryotherapy with liquid nitrogen is equally effective but is more expensive, requires multiple office visits, and can cause pain, blistering, pigment changes, and other complications (tendon or nerve damage, scarring), especially if used too aggressively. A combination of cryotherapy and salicylic acid may give the best results. If a treatment caused permanent scarring, that would be worse than the disease.

To take a page from Mark Crislip’s job description, the patient has the mindset “Me have wart. You cure wart. Me go home.” The health care provider can re-frame the issue as “You have wart. Me educate. You think. We discuss.” Since warts are benign and self-limited, the option of not treating should always be on the table.

What about CAM?

Warts provide a fertile field for CAM. Various CAM modalities (chiropractic, acupuncture, homeopathy, energy medicine, etc.) have been claimed to cure warts. Acupuncturists have claimed a 90% success rate in only 1-3 weeks. PubMed lists a recent article about treatment with “sparrow-pecking” moxibustion that sounds intriguing, but no abstract is available. When warts follow their natural history and resolve, CAM is happy to take the credit. When they fail to resolve, CAM can continue treatments and continue to generate income. It’s a cash cow and ideal CAM fodder. Since warts are so common, potential clients are plentiful.

I used to believe that warts could be wished away. Now that I am older and wiser, I think warts vanish because of the natural course of the disease, not because of suggestion. Observers have reached false conclusions due to the post hoc ergo propter hoc (correlation is not causation) fallacy. Warts that went away after suggestion didn’t go away because of suggestion. The many folk remedies, like banana peels, were perpetuated by similar errors in reasoning. No matter how much we wish mind-over-matter worked, warts can’t be wished away: that’s the truth, warts and all.

 

 

Posted in: Science and Medicine

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44 thoughts on “Wishing Away Warts

  1. CC says:

    I’ve heard all kinds of things about warts. Including that they were a fungus, and that they were spread by dropping bits of themselves so that if you walked barefoot then put your foot in a warm moist environment like a shoe it was ideal for any wart picked up to get itself set up in your skin.

    About the only thing I hadn’t heard is that most of them go away on their own!

    I had one on my palm right at the base of the middle finger for years. It would subside for a while and look like a callus with a black dot in it, then flare up and get annoying and sometimes painful, then subside again. Eventually I asked my doctor if it was actually a wart (it was more often a pit than a raised bump when it flared up) and he said it was and froze it on the spot. (liquid nitrogen: ow for a second, then just cold, and disconcerting to hear your flesh hiss)

    It seems to be gone now. At least, I no longer have either the callus or the black dot. And it took one treatment and living with a blood blister on my hand for two weeks, until it fell off on its own.

    (Hitting it with liquid nitrogen is expensive? How much does it cost a doctor to maintain a carboy of LN2? My doc didn’t even ask, he just did it right there in my annual checkup. I guess it’s covered by basic medical in Canada.)

  2. TsuDhoNimh says:

    ” I was taught that if a patient had multiple warts and you treated just one of them, the others would likely vanish too. ”

    As a child, I had a lot of warts. After a bicycle accident ripped several of them partly off my hand the others all vanished.

    Later, when I found out about immunity and antibody production, I assumed that the physical damage and healing process had exposed the wart virus to my immune system.

    Why are they so bloody when you damage them? It would have been a minor scrape, but there was gore everywhere!

  3. alison says:

    You can wait and wish for an awfully long time, with warts. I had them for 20 years. I got one like CC’s, on a middle finger, in 1986; after an unsuccessful attempt to get rid of it with salicylic acid it began to break up and then I had lots of little ones all over both hands. I think the most I had at any one time was 15. Through the early 1990s I spent a lot of time at my doctor’s having them frozen off with liquid nitrogen: it took two sessions to remove each wart, but for a long time I found that new ones arose as fast as the old ones went. Finally I was back down to one large one on my left hand which stayed for ten years – then disappeared within days of our moving house. I haven’t had any since.

    I actually wondered the opposite to TsuDhohNimh – was it perhaps my attempts to get rid of them that stopped my immune system responding to them?

    Interesting, and easy to see why CAM sellers find them such a good source of income.

  4. BillyJoe says:

    I could tell this was going to be a personal anecdote type of commentary, so why not…

    I had a single wart of the back of my left hand throughout most of my childhood. I actually never bothered to find out what it was and found out only much later. It would rise up at times and become inflammed and irritated and then settle down but never quite disappear. Being naturally averse to using any treatments, conventional or unconventional, unless absolutely necessary, I just let the wart do what it wanted. Then, about fifteen years after it appeared, I noticed that it was no longer there.

    Goodbye wart. Friend? Enemy?

    Non-entity.

  5. Ken Hamer says:

    If I had a wart, and the “doctor” suggested some sort of sCAM, I’m absolutely certain the warts would disappear immediately.

    Along with the rest of me.

  6. chaos4zap says:

    Clearly, there are many variety’s of human papillomavirus, but is there any chance that the gadisil vaccine takes care of any of the wart causing variety? It was obviously not developed for this purpose, but it would be interesting if the antibodies did recognize the wart producers because they are similar enough to the other types of HPV.

  7. “The many folk remedies, like banana peels, were perpetuated by similar errors in reasoning.”

    This issue rises here all of the time.

    This is not an error in reasoning.

    If you have a wart, or any other malady, then you intentionally try a putative intervention, and the malady goes away, there are just a handful of conclusions:

    The word “try” gives us our term, “trial.”

    The person trialing the banana peel is conducting a trial.

    We respect this as one aspect of science: the unopposed trial, or open-label trial. You can find this in Pubmed.

    There is no error in a well-reasoned trial.

    The error comes in what comes next. Not in deciding to hold the believe in the banana peel, until something better comes along.

    The wart disappears. Scientifically, there are four conclusions:
    1. gee, it might really work – I should continue to more sophisticated study designs to further rule out competing explanations;
    2. at this point, I will conclude that I obserevd a coincidence, since others scoffed at my idea;
    3. I am a true believer and need no further evidence to accept this as gospel truth. I am gonna open up shop, or patent the banana remedy somehow. (sCAM.)
    4. this putative cause-and-effect hypothesis is so outlandish that I will not consider it anymore. (possibly, science-based medicine.)

    As an everyday person, there are three conclusions:
    1. gee, i will try that next time since it seemed to work;
    2. it seemed to work but i will never try it again;
    3. I am a true believer and need no further evidence to accept this as gospel truth. I will tell all my friends and family.

    For the scientist, only 1 and 4 are proper conclusions. It is a greay area to calculate when 4 will be correct. Some things are just too out-of-this-world (super-dilution of homeopathy, etc.), while there are plenty of stories where most people chose 4, and were wrong (ulcers, etc.).

    For the mom of a child with a wart, 1 is proper. 4 might be in some circumstances. We took a child home post-surgery with Rx meds- powerful opiates – to handle pain when the anesthesia wore off; these particular pain meds did not work for the child, who ended up howling with unmedicated post-surgery pain until we could get Rx phoned to 24-hour drug store at the middle of the night. All of us in that episode now know that we cannot quite accept the doctor’s gospel truth as truth – a pain med might not work for some ppl., and another will be needed.

    The error is: what do you do after you see a possible cause-and-effect event? The error is not in holding some faith in the putative remedy after observing it.

    As an everyday person, holding that theory as a working hypothesis is not a horrible or stupid thing. It is not “wrong.”

  8. Children get rid of warts more easily possibly because their immune systems are more active. From various cuts and scrapes, children heal very quickly, relative to us big people.

    Older adults get less protection from a flu vaccine because the older body has a less-active immune system.

  9. Costner says:

    I had two plantar warts on the bottom of my feet… and I must admit I took a bit of pleasure from watching them slowly be erased by the salicylic acid over several weeks. Unfortunately, the acid also seemed to take a lot of the “good skin” along with it.

    Eventually I cut away the excess dead skin and with it came the remaining wart cells. I’ll admit I was a bit too aggressive however and one of them ended up bleeding what seemed like a lot for such a small thing (much like TsuDhoNimh I was amazed at how much blood could come from one single wart).

    However, with a bandage and a bit of healing time eventually my skin returned to its former glory sans wart. I’ve never had them anywhere else thankfully… because the idea of treating something on my hand or another visible location in the same manner as I treated them on my foot seems much more difficult (and perhaps socially frowned upon).

    On a related note I have had experience with liquid nitrogen but it was to remove a bit of proud flesh from my thumb rather than a wart. I recall it being very cold, but relatively painless, and it did the job well enough even though it did require two treatments. I don’t even have a scar and just now I was trying to remember which of my two thumbs it was.

  10. Scott says:

    “The many folk remedies, like banana peels, were perpetuated by similar errors in reasoning.”
    This issue rises here all of the time.
    This is not an error in reasoning.

    The error in reasoning is that the typical conclusion is not any of those you list, but rather “the banana peel cured the wart.” This is not a justified conclusion.

  11. qetzal says:

    Dr. Hall,

    I’m doubtful that a patient could have “obvious warts” that were completely gone only a week later. I know (from personal experience) that warts can resolve spontaneously, but a week seems much too fast. I don’t think skin and stratum corneum turn over that rapidly.

    If the patient’s “warts” really disappeared in a week, it seems to me that either they weren’t really warts, or else they were already almost fully resolved, and only a superficial callus or blemish was present at the initial visit.

    Am I wrong? Can a “full-fledged” wart really disappear in only a week?

  12. Watcher says:

    Re: The excessively bleeding wart phenomenon

    I had a few plantar warts a long time ago and treated them with salicyclic acid band-aids over a few weeks. At some point, all of them bled … profusely.

    Anyways. If you think about it, these are benign skin tumors created by the HPV virus. As such, you would expect a tumor response of increased vasculature to the rapidly dividing cells in order to feed them. Maybe this is why there’s so much blood involved?

  13. Harriet Hall says:

    quetzal,

    I don’t have any information on the minimum time for warts to disappear. It was a long time ago, and I’m willing to consider that I might have made a misdiagnosis or I may be misremembering. But it sure looked like warts to me, and the diagnosis is usually made on appearance alone.

  14. Deetee says:

    Wot, no Duct Tape??

  15. jpmd says:

    Some “folk remedies” actually have a scientific basis, usually they inflame the wart which produces an immune response which gets rid of it. I think duct tape is thought to work like that, although I am not familiar with the study alluded to that says it may not work.

    I have had warts go away, but usually it is just one of those things that one day you notice is gone, so can’t say how quickly it happened.

  16. Purenoiz says:

    When I was a kid I remember my dad cutting them off with toenail clippers. I have one on my right arm above the elbow, never really thought much about it until I started doing Brazilian Jiu Jitsu, since I have started it has been red an inflamed. My masseuse put duct tape on it because she didn’t want to catch it, when I took the duct tape off the rough cauliflower surface had softened up substantially, that was the only benefit I have noticed. Current treatment is over the counter medicated bandages. Very happy to see this today, glad to know it is a virus and not a fungus.

  17. Mark Crislip says:

    I prefer Huck Finn’s treatment

    “Why, you take your cat and go and get in the graveyard ‘long about midnight when somebody wicked has been buried; and when it’s midnight a devil will come, or maybe two or three . . . and when they’re taking the feller away, you heave your cat after ‘em and say, ‘Devil follow corpse, cat follow devil, warts follow cat, I’m done with ye!’ That’ll fetch any wart.”

    Takes care of two problems…

  18. pmoran says:

    Medvtherapy>The error is: what do you do after you see a possible cause-and-effect event? The error is not in holding some faith in the putative remedy after observing it.
    As an everyday person, holding that theory as a working hypothesis is not a horrible or stupid thing. It is not “wrong.”

    Correct, SBM and its offshoot medical skepticism aspire to a medicine based upon final and absolute truths (or as close as we can get to them). In reality, most of medicine, including a great deal of the mainstream, is carried on at lesser levels of certainty i.e. “best available evidence” or very often in the case of folk medicine and CAM, “what remedy warrants a trial run?”.

    Treatment choices can thus be heavily dependent upon the scientific sophistication and depth of knowledge of the end-user, yet without being entirely irrational at the personal level.

    This might look like an argument for “better education” and “critical thinking skills” but I still say that will help only marginally.

    The skeptical scientific arguments are extremely sophisticated and based upon a formidable breadth of knowledge. Not only that, but they must be instilled to a degree that a person is confident enough in their personal judgment that they will suffer medical complaints in silence, rather than try out risky or expensive methods that others are saying might help them. That is a big ask.

    It is may be better to concentrate on re-building trust, for a start by not shooting ourselves in the foot by allowing ourselves to be so easily portrayed as controlling, close-minded, venal, turf-protecting, slaves to poorly understood protocols, who also have an inflated perception as to the present capabilities of mainstream medicine. We should acknowledge the medical needs that drive people into CAM.

    With respect to regaining trust, it is good that this blog is prepared to condemn the medical and scientific misbehaviour that has contributed to loss of trust.

  19. ryanodine says:

    My cure was burning them off with a metal coat hanger heated up on the stove. Painful but effective.

  20. Harriet Hall says:

    @pmoran,

    “they will suffer medical complaints in silence, rather than try out risky or expensive methods that others are saying might help them. That is a big ask.”

    Straw man. I’m not asking anyone to suffer in silence or not to try whatever they want to try. I’m only asking CAM advocates not to fool them with misleading information.

    If they have reason to distrust science-based doctors, they should have even more reason to distrust CAM practitioners.

    I think you are unfairly insulting our profession by your description of how you think we are portrayed. And I think we do acknowledge the factors that drive people to CAM. You started out sounding like a wise, caring clinician and now you are beginning to sound almost like a troll.

  21. I have recently been looking at superstitions and one folk cure for warts is that you should rub them against an adulterer. I think it was less likely a cure for warts than it was a test for adulterers. :)

    RJB

  22. David Gorski says:

    It is may be better to concentrate on re-building trust, for a start by not shooting ourselves in the foot by allowing ourselves to be so easily portrayed as controlling, close-minded, venal, turf-protecting, slaves to poorly understood protocols, who also have an inflated perception as to the present capabilities of mainstream medicine.

    Jumpin’ Jesus on a pogo stick, Peter! I never expected such utter nonsense from you. Let’s put it this way. No matter what we as supporters of SBM do, the quacks will continue to portray us as “controlling, close-minded, venal, turf-protecting, slaves to poorly understood protocols, who also have an inflated perception as to the present capabilities of mainstream medicine.” They will do so because that is how they sell their wares, and persecution is part of their world view. Lacking sound scientific arguments, ad hominems, distortions of science, testimonials, and mystical beliefs are all they had. Note that I’m talking about the hard-core woo-meisters; the problem is, as we have discussed, is that testimonials and these sorts of logical fallacies and bad arguments are persuasive to people without a background in science, particularly when they appeal to people’s preexisting ideology. The answer to that is education, but that’s a hard, laborious process.

    But, hey, maybe I’m wrong. As I have said so many times before, I’m willing to be taught. I’m willing to learn. Perhaps you would be so kind as to suggest to us specific measures how we can avoid “allowing ourselves to be so easily portrayed as controlling, close-minded, venal, turf-protecting, slaves to poorly understood protocols, who also have an inflated perception as to the present capabilities of mainstream medicine.” Seriously, Peter. How, specifically, do we accomplish this miracle? I really want to know. No vague platitudes, either, which is all your most recent comment offered. I want concrete, specific actions we supporters of SBM can take to prevent this misrepresentation by CAM advocates. Anything less doesn’t help me.

    Are you up to the challenge? Or will you do a bit of handwaving, a bit of condemnation of us “arrogant” doctors, and a bit of appeals to placebo responses, all mixed together in a reply that sounds as though it came from a Andrew Weil or Mehmet Oz?

  23. pmoran “The skeptical scientific arguments are extremely sophisticated and based upon a formidable breadth of knowledge. Not only that, but they must be instilled to a degree that a person is confident enough in their personal judgment that they will suffer medical complaints in silence,”

    Silence? who said anything about silence. I may not be a big fan of unproven remedies, but I figure any ache, pain or illness gives you permission to whine, complain and generally vent…within limits.

    It’s one reason I dislike the alternative health habit. People are constantly interrupting my hard earned whinging to give me advice to take the latest cure-all.

    Back when I was a kid, you took a casserole, a pie or soup to someone who was sick, nowdays people give you supplements and weird microbe impregnated beverages when you’re ill.

    I’ll take a pie over advice to take progesterone supplements any day. A pie might even stop my complaining.

  24. My daughter has a wart we’ve been trying to treat. Have tried the medicated bandages, but it’s hard to keep a bandage on a kid for 12 or more weeks running. Also, it seems to irritate the skin around the medication more than the wart. Might try the liquid next.

    When I googled it the last time the most plausible home remedy I saw was a cotton ball soaks in apple vinegar. Probably cheaper form of acid than the salicylic acid in the OTC remedy.

    I don’t think that I will try MC’s remedy, don’t know of any local evil guy graves and I rather like our cat.

  25. JPZ says:

    @Mark Crislip

    Long laugh from the Mark Twain quote! Thanks. :)

  26. pmoran says:

    “they will suffer medical complaints in silence, rather than try out risky or expensive methods that others are saying might help them. That is a big ask.”

    Straw man. I’m not asking anyone to suffer in silence or not to try whatever they want to try. I’m only asking CAM advocates not to fool them with misleading information.

    Unworthy of you, Harriet. The text you selected referred to part of my explanation of why I think improving clinical thinking skills have no reallstic expectation of success against the forces supporting CAM.

    You have not responded to that reasoned argument. You have simply changed the subject .

    .

  27. pmoran says:

    David, the first step is to thoroughly understand what we are dealing with and to set realistic goals.

    We also desperately need to understand what role, if any, the placebo is playing in the CAM-user’s life.

    Every remark of mine is directed towards those ends.

  28. Harriet Hall says:

    @pmoran,

    “I think improving clinical thinking skills have no reallstic expectation of success against the forces supporting CAM.”

    It sounded like you were talking about patients learning critical thinking skills, but even if you were talking about doctors learning clinical thinking skills, I still don’t see how anything other than thinking skills could possibly have any realistic expectation of success, and you have not responded with any specific proposals as David challenged you to do. “understand the role placebo plays”? Come on!

    “Every remark of mine is directed towards those ends.”

    Every remark of yours seems to be directed towards finding an excuse to condone placebos. Prescribing placebos is unethical.

  29. jerry_sprom says:

    @harriet
    I must admit, I have never heard of chiropractors claiming that chiropractic care can cure warts. Can you point me towards some sites??

  30. WilliamLawrenceUtridge says:

    @ryanodine

    I’m glad I don’t have your doctor :)

    If we’re trading anecdotes, I’ve never had a wart. Whew, catharsis!

  31. Harriet Hall says:

    @jerry_sprom,

    Originally chiropractic didn’t claim to cure anything: it claimed to return the spine to alignment so “Innate” could effect cures. But now some chiropractors make specific claims for warts, for instance Correction Creek Chiropractic Centre claims

    “Chiropractors are able to alleviate the “symptom” of warts by adjusting spinal subluxations in order to return the body’s immune potential, thus alleviating the “cause” of the problem. If you or someone you know struggles with his problem, find a subluxation based chiropractor to get to the cause, and the cure.”

    There is even more silliness. See:
    http://www.facebook.com/note.php?note_id=207685559252379&comments

  32. hyperlalia says:

    @chaos4zap

    Your point about Gardasil and warts is interesting, I remembering reading about a case report related to that a while back and dug up the reference:

    “Recalcitrant cutaneous warts treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, and 18) in a developmentally delayed, 31-year-old white man.”
    http://www.ncbi.nlm.nih.gov/pubmed?term=20479293

    I would imagine it would depend on the strains involved, as Gardasil is only directly protective against the above 4, and non-genital warts are generally caused by other serotypes. That said, I know that the vaccine does induce some cross reactivity with some of the other strains and could theoretically provide a modest benefit.

    Then again, this is a case report, and the top of this thread is full of enough anecdotes about spontaneous wart cures.

  33. pmoran says:

    Harriet: Every remark of yours seems to be directed towards finding an excuse to condone placebos. Prescribing placebos is unethical.

    Well, even though 50% of doctors admit to prescribing placebos, I have never to my recollection explicitly recommended that.

    I do understand the pressures that lead doctors to do so, and they are essentially the same ones that have produced CAM.

    The two matters are linked. If certain complex sham CAM treatments (commonly classified as placebo) can have as strong effects on reported outcomes in some populations as some of the evidence suggests, then either ethical concerns may need to be revisited, or those methods reclassified, perhaps as a “useful bundle of non-specific influences” or something.

    But I am preoccupied with the placebo and existential aspects of CAM for another reason.

    If CAM is truly worthless, even as placebo, and serving no other function for users, then why not attack it in every way we can? Why tolerate it at all, even in our own patients?

    If however it is helping to relieve human sufferings, almost inadvertetly , for reasons quite unrelated to its fanciful understandings of illness, what then?

    When also taking into account that CAM is employed mainly when mainstream methods are deficient, the aggressive discouragement of its safer manifestations is an awful responsibility to take upon ourselves.

    That is why I say we desperately need to better understand both CAM and that complex misture of influences commonly called “the placebo”.

  34. Harriet Hall says:

    @pmoran,

    “those methods reclassified, perhaps as a “useful bundle of non-specific influences” or something.”

    Yes, and we have discussed exactly that. We have also discussed what “useful” means. We understand that patients perceive CAM as useful, and feel that it has relieved their suffering, but we have also talked about how that perception can lead to harm, for instance if an asthma patient “feels” better while his condition is objectively deteriorating.

    You say placebos have “strong effects on reported outcomes” but that is not true: they only have limited effects on subjective outcomes.

    You may not actually recommend placebos, but you sound like you think they are justifiable because they relieve suffering and benefit patients, and you want to be able to recommend things like acupuncture that may only “work” as a “useful bundle of non-specific influences.”

    As I’ve said before, I think as scientists we should have rigorous rules but as humane clinicians we should be willing to break them occasionally under special circumstances and with twinges of conscience.

    Why tolerate CAM? Realism. It’s not going away as long as humans are humans.

  35. pmoran says:

    – but we have also talked about how that perception can lead to harm, for instance if an asthma patient “feels” better while his condition is objectively deteriorating.

    Realistically, how often is that going to happen, especially when the vast majority of CAM use by asthmatic is complementary to mainstream care? Look at the studies. There will be fanatics who risk their life in bizarre ways, but nothing will stop that.

    That discussion was an example of the straw men that we skeptics tend to create for ourselves. Where are all these people who believe that perceptions are better than being really, objectively better? Everyone here was singing away about that, when if you stopped a hundred people in the street it would be hard to find one who believes that, and I would doubt if Moerman himself really believes that as a generally applicable medical rule.

    Thousands of words were said about this non-event while what was not said was the obvious, that objective effect plus placebo is always going to be better than placebo alone (so long as side effects are acceptable), as the NEJM study clearly showed. Once again, the ad hominem compulsion, the urge to demonise those who dare to be critical of us, obscures the truly useful take-home message. (Give me credit for restraining comment at the time)

    WRT the potential helpful effects of placebo, I have posted references that no one has cared to try and directly refute. I am well aware of weaknesses in the clinical evidence, mind you, but that is not the only line of evidence favourable for clinically signifcant placebo influences. There has never been a full consideration of that here despite its importance for CAM policy.

  36. Nescio says:

    Doesn’t every science-based medical treatment come with a free placebo effect? In this context by ‘placebo effect’ I mean the expectation of the treatment making the patient feel better, not non-specific effects like regression to the mean.

    There are many meaningful rituals that surround conventional medical practice; the medical certificate on the wall, the title, the white coat, the stethoscope, the technical language, the referral, the prescription etc.

    These rituals have a practical purpose, but I’m sure they have a psychological effect in addition to that. Don’t they have as great a placebo effect as the meaningless rituals of a CAM practitioner?

    Are there any studies that have looked at this?

  37. Harriet Hall says:

    Subjective effects (from placebo, psychology, or ritual) plus objective results from a proven effective treatment are clearly the most desirable outcome. Prescribing a known placebo or an unproven treatment is not the best route to the best outcome.

    pmoran: ” the urge to demonise those who dare to be critical of us”
    I resent the implication. I don’t think we are trying to demonize anyone. I think we are doing our best to apply science and critical thinking to medicine and to provide accurate information so doctors and patients can make informed decisions.

  38. pmoran says:

    Harriet, did you even post on the NEJM item? You do generally avoid personalities. I didn’t intend that remark to be taken generally and will happily withdraw it if any thinks it is unfair.

  39. pmoran says:

    Nescio: These rituals have a practical purpose, but I’m sure they have a psychological effect in addition to that. Don’t they have as great a placebo effect as the meaningless rituals of a CAM practitioner?

    Are there any studies that have looked at this?

    Many relevant. They suggest that patient-reported outcomes are easily influenced by all these peripheral matters, even by pill colour, and especially the level of confidence expressed by the practitioner and the amount of time devoted.

    There is a catch-22. In order to demonstrate full placebo potential you would have to perform a study maximizing all these influences. There is no question that you would then obtain excellent “results” from placebo when compared to those obtained in the more neutral therapeutic environment of the typical pharmaceutical trial, where placebo responses are a nuisance, to be suppressed where possible.

    But how much of the good results would be due to patients merely saying they are better because they perceive that to be expected result i.e. “reporting bias” or “experimental subordination”?

    We don’t know. It is thus possible to look at the clinical evidence and reach a conclusion that suits personal inclinations. That is not ideal for a science-based forum.

    When taking all lines of evidence into account I am moderately on the side of useful placebo influences, especially within CAM, which is in many ways uniquely suited to producing them. Conventional practitioners work under many constraints.

  40. pmoran says:

    I should add that that may not a good thing from all perspectives and it would be an unreasonable trick for reality to play upon science-based medicine.

    However, if it is permitted by the available science i.e. it is possibly true, we should be prepared to face up to it, and try to find ways of finally resolving the question.

  41. This article was hilarious! Nongenital cutaneous warts are probably so far off the radar of most clinicians and researchers than I’m sure seeing it printed in a journal probably raised a few eyebrows. But with simple, transparent issues like these (of course, the warts go away because the virus runs its course) it speaks volumes about human nature. (that propter hoc thing…ergo whatever. You know what I mean.)

    I have to say though….this bit of the article sort of made ME raise an eyebrow.

    “…the patient has the mindset “Me have wart. You cure wart. Me go home.” The health care provider can re-frame the issue as “You have wart. Me educate. You think. We discuss.””

    I’m an educated patient. Doctors are surprised by me. I can’t tell you how many times I ask a doctor a question and they assume I am asking for a quick answer and a simple explanation. Sure, I’d love if medicine was magic but I know it isn’t. I WISH I could have had more doctors appointments that involved “Me educate, You think. We discuss.” Quite often it is more like “Me sick. Doctor busy and on edge. Doctor doesn’t listen to my question. Doctor pontificates. Me cry. Me go home.”

    I usually have to begin most doctors appointments with a disclaimer about how I don’t expect a quick fix, and that I do understand biomedical mumbo jumbo and the scientific process, and that I do not read the internet for medical advice, and that I do understand that there are no definitive answers, but I do like to understand what is being done to me and why so I can make the best decisions possible. Then, typically, useful interactions can be had.

  42. ImperfectlyInformed says:

    The article says that there is “little to no good evidence for oral zinc”. There have been 3 small RCTs from different research groups which found that oral zinc sulfate led to warts clearing.

    http://www.eblue.org/article/S0190-9622%2808%2901148-1/fulltext

    http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2133.2002.04617.x/abstract;jsessionid=C592022917E8C0F16FF27689F5879891.d03t03

    http://www.scielo.br/scielo.php?pid=S0365-05962009000100003&script=sci_arttext&tlng=en

  43. LovleAnjel says:

    I had TONS of warts as a kid…all over my hands, and this total b!tch of a plantar wart that took over my left arch. It seemed like I had them forever – at least staring in third grade, until fifth grade. In 5th grade I went and looked them up, and read they lasted an average of 7 – 9 months. I thought, holy crap, shouldn’t they be gone by now? A week later they started to clear up. The encyclopedia cured me.

  44. Ali771 says:

    Oh boy wart stories!

    I had a stubborn plantar’s wart and read about fun home remedy of placing a cut garlic clove on the area (after soaking the foot in warm saltwater). The idea was to sleep with this clove of garlic on your foot. The suggestion both tickled my funny bone and got rid of the plantar’s wart. Have studies shown garlic to have anti-viral properties? Perfect minor ailment to subject to fun home remedies.

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