Cryosurgery in dermatology

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Cryosurgery in dermatology

  1. 1. Office-Based Cosmetic Procedures Khaled Gharib MD
  2. 2. Office-Based Cosmetic Procedures  Laser and IPL  Chemical peels  Dermabrasion and Micro  Mesotherapy  Botox and fillers  Carboxy therapy  Cryotherapy  Phototherapy as NBUVB  Derma roller and Dermapen  Dermoscope
  3. 3. Office-Based Cosmetic Procedures  Laser and IPL  Chemical peels  Dermabrasion and Micro  Mesotherapy  Botox and fillers  Carboxy therapy  CRYOTHERAPY  Phototherapy as NBUVB  Derma roller and Dermapen  Dermoscope
  4. 4. Objectives  Know indications and techniques for using cryotherapy to treat common dermatologic conditions.  Know side effects of cryotherapy
  5. 5. Cryosurgery  Purpose: For rapid treatment of common skin conditions  Benign lesions: warts, seborrheic keratoses  Premalignant lesions: actinic keratoses  Malignant tumors: Basal cell/squamous cell carcinomas  MUST KNOW THE DIAGNOSIS
  6. 6. Mechanism of Action  Liquid nitrogen, which boils at −196°C, is the most effective cryogen for clinical use. It is particularly useful in the treatment of malignant lesions.  Temperature of −25°C to −50°C can be achieved within 30 seconds if a sufficient amount of liquid nitrogen is applied by spray or probe.  Generally, destruction of benign lesions requires temperatures of −20°C to −30°C. Effective removal of malignant tissue often requires temperatures of −40°C to −50°C.
  7. 7. Irreversible damage in treated tissue occurs because of intracellular ice formation. The degree of damage depends on the rate of cooling and the minimum temperature achieved. Inflammation develops during the 24 hours after treatment, further contributing to destruction of the lesion through immunologically mediated mechanisms.
  8. 8.  Slow thaw times and repeat freeze-thaw cycles produce more tissue injury than a single freeze and thaw.  Usually, several minutes are allowed between repeat freeze-thaw cycles.  Repeat freeze-thaw cycles generally are employed only in the treatment of malignancy.
  9. 9. Liquid Nitrogen  Boiling point -196 C.  Cellular destruction : » ice crystal formation » cellular dehydration » protein and enzymatic denaturization  Destruction more pronounced with: » rapid freeze » slow thaw cycle
  10. 10. Liquid Nitrogen Advantages for clinician  Cheap after set-up costs  Easy to learn  Multiple lesions at one time  Do not need assistant to perform
  11. 11. Liquid Nitrogen Advantages for patient  No local anesthetic needed  Pain tolerable  No sutures  Wound care relatively easy
  12. 12. Liquid Nitrogen Disadvantages for clinician  Start-up costs ?????  Storage facilities  Filling canisters
  13. 13. Cryosurgery  Tissue destruction: -10 to -20 C.  Malignant cell kill: -40 to -50 C.  Chemical refrigerants -70 to -94 C.  Cold cryoprobes -90 C.  Liquid Nitrogen -196 C.
  14. 14. Liquid Nitrogen: Equipment  Liquid nitrogen  Storage tank  2-30 L, filled q 3-4 weeks  Costs: Tanks: Holding time Costs » 2 L 48 hrs ??? » 10 L 6-8 weeks ??? » 20 L 8-12 weeks ??? » 30 L 14-16 weeks ???
  15. 15. Liquid Nitrogen: Equipment Cry-AC Spray/ cryogun (C-tip, mini-gun) 10 oz 16 oz 12 hr 24 hr
  16. 16. Cryosurgery  Frozen areas turn white = “freezeball” or “iceball”  Depth of freeze should be 1 X radius of freeze  Lethal Zone » Tissue temp < -20 C. » 2-3.5 mm inward from outer margin iceball  Freeze 2-3 mm beyond lesion edge
  17. 17. Cryosurgery: Freezeball Time  Freckles/lentigos: 3-5 seconds  Small papules: 5-10 seconds  Seborrheic Keratoses: 30-40 seconds  Actinic keratoses: 40-60 seconds  SCCa/BCCa: 80-90 seconds
  18. 18. Cryosurgery: Freezeball Size  1mm- freckles/lentigos  1-2 mm- most benign skin lesions  2-3 mm- most warts  3-4 mm- most actinic keratoses  4-6 mm- superficial SCCa, BCCa
  19. 19. Cryosurgery  Thermocouple  for temperature monitor and thermocouple needle
  20. 20. cotton-tip applicator, liquid nitrogen spray, cryoprobe
  21. 21. Cryosurgery  Cotton tipped swabs  Informed consent-oral vs written
  22. 22. Cryoprobes  Nitrous oxide cryoguns  Tanks with cart, hand gun, pressure gauge and regulator  Useful if liquid nitrogen not available
  23. 23. Spray Methods  Timed-spot freeze technic  Rotatory or spiral pattern  Paintbrush method American Family Physicians: Cryosurgery for Common Skin Conditions Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina Am Fam Physician. 2004 May 15;69(10):2365-2372.
  24. 24. American Family Physicians: Cryosurgery for Common Skin Conditions Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina Am Fam Physician. 2004 May 15;69(10):2365-2372.
  25. 25.  Use of this technique maximizes the ability to destroy a lesion with minimal morbidity. » Technique: – the nozzle of the spray gun is positioned 1 to 1.5 cm from the skin surface and aimed at the center of the target lesion. – The spray gun trigger is depressed, and liquid nitrogen is sprayed until an ice ball encompasses the lesion and the desired margin. – Margins for most benign lesions can extend as little as 1 to 2 mm beyond the visible pathologic border. Ttimed-spot freeze technic
  26. 26.  These techniques can be useful for treating larger benign lesions.  They are not well standardized for ensuring the temperatures that are required for the destruction of malignant lesions American Family Physicians: Cryosurgery for Common Skin Conditions Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina Am Fam Physician. 2004 May 15;69(10):2365-2372. The rotatory or spiral pattern & Paintbrush method
  27. 27. Cryosurgery: Effectiveness Low  Vascular lesions: e.g. angiomas  Achrochordans
  28. 28. Cryosurgery: Effectiveness Medium  Xanthelasma  Dermatofibroma  Keloid  Molluscum  Prurigo nodularis  Sebaceous hyperplasia
  29. 29. Cryosurgery: Effectiveness Medium-High  Seborrheic keratosis  Verruca  Condyloma acuminata  Lentigo  Freckles
  30. 30. Cryosurgery  Verruca: » Often resistant » Warts on hands » Plantar warts » Flat warts
  31. 31. Cryosurgery: Effectiveness High  Actinic keratosis  Superficial Basal Cell Carcinoma  Superficial Squamous Cell Carcinoma
  32. 32. Cryosurgery: Superficial BCCa/SCCa  Establish pathological diagnosis first  Success rates > 95%
  33. 33. Cryosurgery: Special Populations  Children » In general avoid pain » Use EMLA cream if needed  Useful modality for those on anticoagulants, those with pacemakers and those allergic to anesthetics
  34. 34. Cryosurgery DO NOT FREEZE  If you do not know diagnosis  Recurrent skin cancers  Melanoma or any possibility  Morpheaform BCC  Lip neoplasms  Nasolabial fold cancers  Compromised circulation
  35. 35. Cryosurgery BE CAREFUL ABOUT FREEZING  Lesions on/near the eye  Lesions on the fingers/elbows  Lesions over shins, ears, genitals  Lesions near nails
  36. 36. Cryosurgery BE CAREFUL ABOUT FREEZING  Patients with dark skin  Patients with Raynaud’s disease  Patients on chronic steroids  Patients with diabetes  Patients with cold induced urticaria/cryoglobulinemia
  37. 37. Cryosurgery: Side Effects Short term:  Pain and erythema  Blister formation  Hemorrhage  Infection  Pyogenic granuloma
  38. 38. Cryosurgery: Side Effects Long term  Nerve damage  Pigmentary changes  Hypertrophic scar formation  Permanent nail dystrophy  Recurrence of lesion  Multiple visits may be needed
  39. 39. 1
  40. 40. Electrosurgery  Purpose: » Destroy tissue » Excise tissue » Coagulation  Often done with curettage
  41. 41. Electrosurgery  Electrocautery: Hot electrode (vs cold electrodes)  Electrodessication: Electrode inserted into/on skin (“dries out” skin; “epilation” = fine dessication)  Fulguration: Electrode held away from skin (“fulgur” = lightening; shallow destruction and eschar)  Electrocoagulation: Used for hemostasis  Electrosection: Used to cut tissue  Radiosurgery: Electrosx. with radio frequencies
  42. 42. Electrosurgery  Electricator  Hyfrecator  Bantam Bovie  Ritter Coagulator  Surgitron
  43. 43. Electrosurgery  Advantages: Easy to use, rapid, useful, hemostasis while cutting, less infection  Disadvantages: Electric shocks and burns/fires, hypertrophic scars, “channeling” nerves, viral shedding, delayed bleeding, slower healing, histological distortion  Costs ???????
  44. 44. Electrosurgery Indications Procedure  Cherry angiomas dessication  Achrocordans dessication/fulguration  Telangiectasias dessication  Small verrucae on hands fulguration  Pyogenic granulomas fulguration  Seb Keratoses fulguration  Small BCCa or SCCa fulguration and curettage
  45. 45. My practice decision  Using the spray gun... since it is easy to use and similar technics can be employed to manage benign, premalignant, and malignant lesions.  Using it perpendicular to the warts at a distance of 1-1,5 cm aimed at the center of the target lesion.  Using the the timed-spot freeze technic since it is better known than the rotatory and paintbrush methods and so better standardized.
  46. 46. My practice decision Recommended cryosurgical techniques type technique freeze time (seconds) number of freeze-thaw cycle margins (mm) number of tx sessions intervals (weeks) common wart open spray 10 3 2 3 2 ...and I would do 3 cycles of freeze-thaw for plantar warts.
  47. 47. My practice decision Remember ….. Always best to underfreeze rather than overfreeze
  48. 48. My practice decision Remember ….. Always best to underfreeze rather than overfreeze
  49. 49. Thank youuuu

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