Cryosurgery of  verruca vulgaris: What is the technic  to freeze efficiently? to freeze efficiently? to freeze efficiently...
My practice-based clinical question <ul><li>P:  When the patients in the setting of my family medicine practice have a com...
What triggered this question? <ul><li>26 years old men, foreign student from France </li></ul><ul><li>visit in the Derm de...
<ul><li>[Cutaneous cryosurgery in family medicine: dimethyl ether-propane spray versus liquid nitrogen],  [Article in Span...
Physical exam Article ID: ebm00276 (013.030) © Duodecim Medical Publications Ltd
Physical exam Article ID: ebm00276 (013.030) © Duodecim Medical Publications Ltd
Dx <ul><li>Verruca vulgaris </li></ul><ul><ul><li>The diagnosis of a wart is clinically confirmed by point haemorrhages ca...
How I did my research on the net <ul><li>Essential Evidence Plus </li></ul><ul><ul><li>using the word «cryosurgery» </li><...
Papers kept <ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. ...
Br J Dermatol.  2001 May;144(5):1006-9. Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud. Ahmed...
Br J Dermatol.  2001 May;144(5):1006-9. Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud. Ahmed...
Br J Dermatol.  2001 May;144(5):1006-9. Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud. Ahmed...
devices <ul><li>cotton-tip applicator, liquid nitrogen spray, cryoprobe </li></ul><ul><li>the cotton-tipped dipstick metho...
spray methods <ul><li>the timed-spot freeze technic </li></ul><ul><li>the rotatory or spiral pattern </li></ul><ul><li>pai...
<ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D...
The timed-spot freeze technic <ul><li>*allows greater standardization of liquid nitrogen delivery. </li></ul><ul><li>**Use...
The rotatory or spiral pattern & Paintbrush method <ul><li>These techniques can be useful for treating larger benign lesio...
American Family Physicians May 15, 2004 Table of Contents Cryosurgery for Common Skin Conditions Mark D. Andrews, M.D., Wa...
Cryosurgery of Skin Lesions Essential Evidence Last Updated on 2009-05-25 © 2009 John Wiley & Sons, Inc. Last Updated on 2...
Cryosurgery for common skin lesions Treatment in family physicians' offices Stephen J. Wetmore, MD, Msc, ccFP Canadian Fam...
Cryosurgery for common skin lesions Treatment in family physicians' offices Stephen J. Wetmore, MD, Msc, ccFP Canadian Fam...
<ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D...
My practice decision <ul><li>using the spray gun...  since it is easy to use and similar technics can be employed to manag...
My practice decision American Family Physicians May 15, 2004 Table of Contents Cryosurgery for Common Skin Conditions Mark...
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Verucca vulgaris

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Verucca vulgaris

  1. 1. Cryosurgery of verruca vulgaris: What is the technic to freeze efficiently? to freeze efficiently? to freeze efficiently? to freeze efficiently? to freeze efficiently? <ul><li>Pearls Presentation </li></ul><ul><li>Herzl FMPC </li></ul><ul><li>May 25, 2011 </li></ul><ul><li>David St-Sauveur, R1 </li></ul>
  2. 2. My practice-based clinical question <ul><li>P: When the patients in the setting of my family medicine practice have a common wart on their soles or on their hands </li></ul><ul><li>I: what technics of cryosurgery should I use </li></ul><ul><li>C: and what technics should I not use </li></ul><ul><li>O: regarding the best clinical outcome? </li></ul>
  3. 3. What triggered this question? <ul><li>26 years old men, foreign student from France </li></ul><ul><li>visit in the Derm department, May 10, 2011, the first day of my rotation in this department </li></ul><ul><li>coming with multiple verruca vulgaris on hands and soles present X ~ 1 year </li></ul><ul><li>already tried a «spray» in pharmacy from Dr . Scholl's ® that did not help at all (ingredients: Dimethyl Ether and Propane) </li></ul>
  4. 4. <ul><li>[Cutaneous cryosurgery in family medicine: dimethyl ether-propane spray versus liquid nitrogen], [Article in Spanish], Caballero Martínez F , Plaza Nohales C , Pérez Canal C , Lucena Martín MJ , Holgado Catalán M , Olivera Cañadas G . </li></ul><ul><li>Source </li></ul><ul><li>Unidad Docente de Medicina Familiar, Insalud Area 6 de Madrid. </li></ul><ul><li>CONCLUSIONS: </li></ul><ul><li>No clinically relevant differences between the efficacy, tolerance and safety of the two cryogenic agents used in primary care were found. The low freezing of DMEP was sufficient for the cryotherapy of benign lesions. </li></ul>
  5. 5. Physical exam Article ID: ebm00276 (013.030) © Duodecim Medical Publications Ltd
  6. 6. Physical exam Article ID: ebm00276 (013.030) © Duodecim Medical Publications Ltd
  7. 7. Dx <ul><li>Verruca vulgaris </li></ul><ul><ul><li>The diagnosis of a wart is clinically confirmed by point haemorrhages caused by cutting the wart horizontally with a scalpel or paring it. </li></ul></ul>
  8. 8. How I did my research on the net <ul><li>Essential Evidence Plus </li></ul><ul><ul><li>using the word «cryosurgery» </li></ul></ul><ul><li>Pubmed </li></ul><ul><ul><li>using the words «cryosurgery» and «common warts» only with the MeSH search bar. </li></ul></ul><ul><ul><li>and using the words «cryosurgery» , «technique» and «common wart» with the MeSH search bar thereafter. </li></ul></ul>
  9. 9. Papers kept <ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D. , Wake Forest University School of Medicine, Winston-Salem, North Carolina </li></ul><ul><li>Am Fam Physician.  2004 May 15;69(10):2365-2372. </li></ul>Br J Dermatol. 2001 May;144(5):1006-9. Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud. Ahmed I , Agarwal S , Ilchy shyn A , Cha rles-Holmes S , Berth-Jon es J . Source Dep artment of Dermato logy, Univers ity Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Cryosurgery of Skin Lesions Essential Evidence Last Updated on 2009-05-25 © 2009 John Wiley & Sons, Inc. Cryosurgery for common skin lesions Treatment in family physicians' offices Stephen J. Wetmore, MD, Msc, ccFP Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999
  10. 10. Br J Dermatol. 2001 May;144(5):1006-9. Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud. Ahmed I , Agarwal S , Ilchyshyn A , Charles-Holmes S , Berth-Jones J . Source Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. <ul><li>Study design: Prospective study </li></ul><ul><ul><li>on their first visit, the patients had a consultation with the dermatologist and those with a clinical dx of common wart were allocated to have liquid nitrogen applied either by spray or by cotton-wool bud </li></ul></ul><ul><ul><li>the patients were treated every 2 weeks for 3 months in nurse-practitioner-led wart clinics </li></ul></ul><ul><li>Setting: patients referred by general practitioners of U.K. to the dermatology departments of two hospitals </li></ul><ul><li>N = 363 </li></ul><ul><li>Mean age 21 (range 3-75) </li></ul><ul><li>188 males; 175 females </li></ul><ul><li>Mean number of warts: 5 on hands and feet </li></ul><ul><li>Mean duration of warts was 98 weeks (range 2-936 weeks) </li></ul>
  11. 11. Br J Dermatol. 2001 May;144(5):1006-9. Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud. Ahmed I , Agarwal S , Ilchyshyn A , Charles-Holmes S , Berth-Jones J . Source Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. <ul><li>Treatment: </li></ul><ul><ul><li>cryotherapy with the spray gun was done with a «B» nozzle. The spray gun was held perpendicular to the wart at a distance of 1-2 cm. The wart was sprayed until the ice-ball formation had spread from the centre to include the edge of the wart and a 2-mm margin. It was then allowed to thaw. Plantar warts were treated with a double freeze-thaw cycle with complete thawing of the wart between the cycles. </li></ul></ul><ul><ul><li>Liquid nitrogen contained in an open flask was used to treat the warts with a CWB. These buds were made of loosely woven cotton wool on orange sticks. As with the spray method, warts were frozen until ice-ball formation had spread from the centre to include a 2-mm margin around the wart. </li></ul></ul>
  12. 12. Br J Dermatol. 2001 May;144(5):1006-9. Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud. Ahmed I , Agarwal S , Ilchyshyn A , Charles-Holmes S , Berth-Jones J . Source Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K. <ul><li>Results: </li></ul><ul><ul><li>Table 2. Cure rates </li></ul></ul><ul><ul><li>Cryotherapy with liquid nitrogen for hand and foot warts was equally effective when applied with a cotton wool bud or by means of a spray (p = 0,8) </li></ul></ul>Cured Not cured Defaulted CWB group (n à 205) 55 (47%) 63 87 Cryo-spray group (n à 158) 39 (44%) 50 69
  13. 13. devices <ul><li>cotton-tip applicator, liquid nitrogen spray, cryoprobe </li></ul><ul><li>the cotton-tipped dipstick method of liquid nitrogen application has been popular in the management of common benign lesion. However, this method is being supplanted by liquid nitrogen spray techniques, since it is easy to use and similar technics can be employed to manage benign, premalignant, and malignant lesions. </li></ul><ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina </li></ul><ul><li>Am Fam Physician.  2004 May 15;69(10):2365-2372. </li></ul>
  14. 14. spray methods <ul><li>the timed-spot freeze technic </li></ul><ul><li>the rotatory or spiral pattern </li></ul><ul><li>paintbrush method </li></ul><ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina </li></ul><ul><li>Am Fam Physician.  2004 May 15;69(10):2365-2372. </li></ul>
  15. 15. <ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina </li></ul><ul><li>Am Fam Physician.  2004 May 15;69(10):2365-2372. </li></ul>
  16. 16. The timed-spot freeze technic <ul><li>*allows greater standardization of liquid nitrogen delivery. </li></ul><ul><li>**Use of this technique maximizes the ability to destroy a lesion with minimal morbidity. </li></ul><ul><ul><li>technique: </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>The spray gun trigger is depressed, and liquid nitrogen is sprayed until an ice field (or ice ball) encompasses the lesion and the desired margin </li></ul></ul></ul><ul><ul><ul><li>Margins for most benign lesions can extend as little as 1 to 2 mm beyond the visible pathologic border </li></ul></ul></ul><ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina </li></ul><ul><li>Am Fam Physician.  2004 May 15;69(10):2365-2372. </li></ul>
  17. 17. The rotatory or spiral pattern & Paintbrush method <ul><li>These techniques can be useful for treating larger benign lesions. </li></ul><ul><li>They are not well standardized for ensuring the temperatures that are required for the destruction of malignant lesions </li></ul><ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina </li></ul><ul><li>Am Fam Physician.  2004 May 15;69(10):2365-2372. </li></ul>
  18. 18. American Family Physicians May 15, 2004 Table of Contents 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.   2004 May 15;69(10):2365-2372.   2004 May 15;69(10):2365-2372.   2004 May 15;69(10):2365-2372.   2004 May 15;69(10):2365-2372. 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 1 2 3 4
  19. 19. Cryosurgery of Skin Lesions Essential Evidence Last Updated on 2009-05-25 © 2009 John Wiley & Sons, Inc. Last Updated on 2009-05-25 © 2009 John Wiley & Sons, Inc. Last Updated on 2009-05-25 © 2009 John Wiley & Sons, Inc. <ul><li>Cryotherapy with liquid nitrogen spray </li></ul><ul><li>Fill a spray gun with liquid nitrogen and replace the lid to allow pressure to build up. </li></ul><ul><li>Hold the desired tip size of the gun 1 cm to 2 cm from the lesion. </li></ul><ul><li>Depress trigger and freeze the lesion to the desired freeze margin. </li></ul><ul><li>Use a zigzag or rotary motion to limit the depth of freeze for superficial lesions (eg, actinic keratoses, lentigos, or flat warts). </li></ul><ul><li>Repeat after the lesion has thawed. </li></ul><ul><li>Typical freeze margins </li></ul><ul><li>No informations given for the duration on the cryosurgery. </li></ul>typical freeze margins for cryotherapy type of lesion margins in mm warts 2 mm - 3 mm, based on size/thickness
  20. 20. Cryosurgery for common skin lesions Treatment in family physicians' offices Stephen J. Wetmore, MD, Msc, ccFP Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 freeze time for various benign skin lesions Lesions freeze time (seconds) liquid nitrogen nitrous oxide (seconds) comments warts: Non plantar 10-20 up to 60 Plantar 30-60 40 after paring pare plantar warts first; use double freeze-thaw cycle Periungal up to 45
  21. 21. Cryosurgery for common skin lesions Treatment in family physicians' offices Stephen J. Wetmore, MD, Msc, ccFP Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999 <ul><li>«Spray is applied from 1 to 2 cm above the lesion» </li></ul><ul><li>«Successful treatment depends on the lesion's being included in the lethal freeze zone. For this reason, the lateral spread of freeze should extend at least 2 mm beyond the margins of benign lesions and 5mm beyond the margins of malignant lesions.» </li></ul>
  22. 22. <ul><ul><li>American Family Physicians: Cryosurgery for Common Skin Conditions </li></ul></ul><ul><li>Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina </li></ul><ul><li>Am Fam Physician.  2004 May 15;69(10):2365-2372. </li></ul>Cryosurgery in dermatology European Journal of Dermatology. Volume 8, Number 7, 466-74, October - November 1998, Formation Médicale Continue
  23. 23. My practice decision <ul><li>using the spray gun... since it is easy to use and similar technics can be employed to manage benign, premalignant, and malignant lesions. </li></ul><ul><li>Using it perpendicular to the warts at a distance of 1-1,5 cm aimed at the center of the target lesion. </li></ul><ul><li>Using the the timed-spot freeze technic since it is better known than the rotatory and paintbrush methods and so better standardized. </li></ul>
  24. 24. My practice decision American Family Physicians May 15, 2004 Table of Contents 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. ...and I would do 2 cycles of freeze-thaw for plantar warts. 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 1 2 3 4
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