Letters to the Editor

Helpful Hints for Injections of Wrist and Hand Region

TO THE EDITOR: In the article, "Diagnostic and Therapeutic Injection of the Wrist and Hand Region,"¹ the authors describe office procedures for injecting various areas of the wrist and hand region. I would like to add that 27-gauge needles are very effective for these techniques, including injection procedures for digital flexor tenosynovitis (trigger finger), de Quervain's tenosynovitis, first carpometacarpal joint, and carpal tunnel syndrome. These needles hurt less because they are thinner. For de Quervain's, first carpometacarpal joint, or for trigger fingers, the needle should be 0.5 inches long. For carpal tunnel, they should be 1.5 inches long in order to penetrate the carpal tunnel near the site of maximal compression of the nerve. For primary care physicians who are struggling with injecting the first carpometacarpal joint, I would like to add another important clinical note. The superficial branch of the radial nerve can easily be palpated just ulnar to the cephalic vein at the wrist "interns vein" when viewed from the dorsal aspect. If one palpates the cephalic vein and rotates toward the ulnar side of the hand over the radius, one can feel a small spaghetti-sized nerve roll between the fingers. This is the superficial branch of the radial nerve. Before injection of the first carpometacarpal joint, 3.0 to 5.0 mL of 1.0 percent lidocaine (Xylocaine) may be injected around this nerve with a pre-frozen 30-gauge needle,² with caution not to enter the cephalic vein. Freezing of the needle in its sterile package reduces the pain of anesthetic injection. After a few minutes, excellent anesthesia to the dorsal aspect of the thumb, index finger, and carpometacarpal joint is produced. Subsequently, the carpometacarpal joint may be injected, and passageway into this joint is easier because the dorsal aspect of the joint is numb. It is very difficult to cannulate this small joint, even with traction on the thumb, and patients are most grateful that the pain from missed attempts is alleviated. Once the injection does go into the joint, it is still painful, even with local anesthetic added; however, the gain to the physician is peace of mind concerning the patient's pain level until the joint is actually pierced.

KEITH DENKLER, M.D.
275 Magnolia Ave.
Larkspur, CA 94939

REFERENCES

1. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Physician 2003;67:745-50.
2. Denkler K. Pain associated with injection using frozen vs room-temperature needles. JAMA 2001; 286:1578.

IN REPLY: We would like to thank Dr. Denkler for his useful comments. We agree that a 27-gauge needle is useful in many circumstances. The choice of needle gauge and length must be guided by clinical judgment and will vary based on the patient's body habitus. Similarly, Dr. Denkler's technique of identifying the superficial branch of the radial nerve can be difficult depending on variables such as the patient's skin thickness and subcutaneous fat. Nevertheless, we thank him for sharing his comments and experience. Reducing a patient's pain or discomfort is always a worthwhile goal.

ALFRED F. TALLIA, M.D.
DENNIS A. CARDONE, D.O.
Robert Wood Johnson Medical School
1 Robert Wood Johnson Place, MEB288
New Brunswick, NJ 08903

Is Duct Tape Occlusion Therapy an Effective Treatment of Warts?

TO THE EDITOR: We read with interest the recent article "Molluscum Contagiosum and Warts."¹ An adjunctive therapy for the treatment of warts that was not mentioned is duct tape occlusion therapy (DTOT). The hypothesized mechanism of action is stimulation of the host's immune system. There have been anecdotal reports^2,3 of the efficacy of adhesive tape in the treatment of periungual and subungual warts, and one randomized study⁴ has shown that DTOT is significantly more effective than cryotherapy. In this study,⁴ 85 percent of patients undergoing DTOT had complete resolution of the wart compared with only 60 percent of patients treated with cryotherapy. These investigators found no difference in the average time to resolution, but they did not collect data on wart recurrence after completion of the therapy.

The technique for DTOT in this study⁴ involved placing a piece of duct tape on the lesion. Patients were instructed to leave the tape in place for six days. Any duct tape that fell off was replaced with a new piece as soon as possible. After six days, the tape was removed and the wart was soaked in water. A pumice stone or emery board was used to debride the lesions. The next morning, a new piece of duct tape was applied to begin another six-day cycle. These researchers found that the majority (73 percent) of warts that would respond to DTOT (defined as seeing observable signs of resolution within the first two weeks of therapy) completely resolved within 28 days of initiating therapy.

DTOT is purported to be an inexpensive, tolerable, safe, and simple alternative to other forms of therapy to treat warts.⁵ The only reported adverse effects were local irritation and erythema. Also, DTOT may be a cosmetic impracticality on facial warts.⁴ An obvious clinical advantage of DTOT is in the treatment of warts in children, in whom DTOT could be used in lieu of cryotherapy, which can be painful.

Although there are many therapies to treat warts, DTOT is another alternative that should be considered. Larger randomized studies are needed to assess the effectiveness of DTOT on warts in varying anatomic locations, and longer follow-up periods will be necessary to assess the recurrence of warts following treatment with duct tape.⁶ Also, studies comparing DTOT with therapies other than cryotherapy would be useful. Several articles in the mass media have commented on the usefulness of duct tape for treating warts; therefore, physicians should expect that patients might inquire about duct tape during future office visits.

JAMES BRADLEY SUMMERS, M.S., M.D.
Department of Diagnostic Radiology
University of South Alabama
Mobile, AL 36616

JOSEPH KAMINSKI, M.D.
1120 15th St.
Medical College of Georgia
Augusta, GA 30912

REFERENCES

1. Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician 2003;67:1233-40.
2. Litt JZ. Don't excise-exorcise. Treatment for subungual and periungual warts. Cutis 1978;22:673-6.
3. Walbroehl G. Treating periungual warts with adhesive tape. Am Fam Physician 1998;57:226.
4. Focht DR 3d, Spicer C, Fairchok MP. The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris (the common wart). Arch Pediatr Adolesc Med 2002;156:971-4.
5. Lynch TJ. Duct tape removes warts. J Fam Pract 2003;52:111-2.
6. Ringold S, Mendoza JA, Tarini BA, Sox C. Is duct tape occlusion therapy as effective as cryotherapy for the treatment of the common wart? Arch Pediatr Adolesc Med 2002;156:975-7.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.