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CRYOSURGERY: A SAFE AND EFFECTIVE SKIN TREATMENT
- 1. CRYOSURGERY Dr MANASA S J PG RESIDENT CHAF B
- 2. INTRODUCTION • Controlled and targeted destruction of diseased tissue by the use of extreme cold temperature
- 3. ADVANTAGES • Safe, inexpensive, simple • Short preparation time • Sutureless • Anesthesia not required • Suitable for all age groups, pregnancy • High healing rates • Good cosmetic results(if performed appropriately)
- 5. Cryogen Rapid transfer of heat Extracellular ice formation Inc in osmotic gradient Fluid shift Dehydration and cell damage Membrane damage
- 6. Intracellular ice Damages mitochondria and endoplasmic reticulum Severe vasoconstriction and endothelial damage Platelet aggregation, microthrombi formation Ischemic necrosis Inflammation in response to cell death
- 9. FACTORS AFFECTING TISSUE DESTRUCTION • Rate of freezing • Coldest temperature reached • Freeze time • Rate of thawing Maximum damage- rapid freezing and slow thawing Repeating freeze–thaw cyclegreater tissue damage
- 10. CRYOGENS Cryogen Boiling point Liquid nitrogen (most commonly used) –196°C Nitrous oxide –89°C Solidified CO2 (Dry ice, CO2 snow) –78°C Chlorodifluoromethane –41°C Dimethyl ether and propane –24°C, –42°C
- 11. TISSUE TARGET CELL DEATH TEMPERATURES Cell Temperature(° C) Melanocytes –4 to –7 Keratinocytes –20 to –30 Fibroblasts –30 to –35
- 12. CRYOSURGERY EQUIPMENTS • Cryogen storage container • Cryogen • Cryosurgical delivery unit
- 13. CRYOSURGERY EQUIPMENTS • Cryogen storage container • Cryogen • Cryosurgical delivery unit
- 14. CRYOSURGERY EQUIPMENTS • Cryogen storage container • Cryogen • Cryosurgical delivery unit
- 15. TECHNIQUES • Open spray- paint brush, spiral, confined/cone • Closed spray- cryoprobe • Dipstick • Histofreezer • Intralesional cryotherapy
- 17. OPEN SPRAY • Nozzle- 1cm from skin surface • Lateral freeze- 2mm in benign 3mm in malignant
- 22. CRYOPROBE • Lesion gets attached to the probe
- 23. DIPSTICK METHOD • Size of the bud should be smaller than the lesion
- 24. HISTOFREEZER • Commonly used for warts • Liquid-gas mixture of dimethyl ether and propane in an aerosol spray can
- 25. PATIENT SELECTION • Lesion selection- Diagnosis, type, size, thickness, depth, location • Patient skin type
- 26. INDICATIONS • Acne cysts • Acne keloidalis nuchae • Acne vulgaris • Acquired perforating disorder • Angiofibroma • Angiokeratomas, including of fordyce • Cherry angioma • Chondrodermatitis nodularis helicis • Chromoblastomycosis • Clear cell acanthoma • Condyloma acuminatum • Dermatofibroma
- 27. INDICATIONS • Discoid lupus erythematosus • Eccrine poroma • Elastosis perforans serpiginosa • Epidermal nevus • Erosive adenomatosis of the nipple • Folliculitis keloidalis • Lichen sclerosus (of vulva) • Granuloma annulare • Granuloma faciale • Hemangioma • Herpes simplex • Keloid • Leishmaniasis • Lentigo
- 28. INDICATIONS • Lymphangioma • Cutaneous lymphoid hyperplasia (lymphocytoma cutis) • Molluscum contagiosum • Mucocele • Myxoid cyst • Nevoid hyperkeratosis of the nipple • Orf • Pearly penile papules • Porokeratosis • Prurigo nodularis • Pyogenic granuloma • Rhinophyma • Rosacea • Sarcoidosis
- 29. INDICATIONS • Sebaceous hyperplasia • Seborrheic keratosis • Syringocystadenoma papilliferum • Syringoma • Trichiasis • Trichoepithelioma • Venous lake • Verruca vulgaris • Xanthoma
- 30. CONTRAINDICATIONS Absolute • Lesions that require histopathology • Recurrent nonmelanoma skin cancers Relative • Cold urticaria • Abnormal cold intolerance • Cryoglobulinemia • Cryofibrinogenemia • Tumors with indistinct borders • Darkly pigmented melanotic
- 31. APPLICATIONS
- 32. Lesion Technique Freeze time (seconds) Number freeze- thaw cycles Number of treatment sessions Dermatosis papulosa nigra OS/Cp Ice formation 1 Several Xanthelasma OS 5 1 2-3 Keloids OS/Cp 15-30 1 5-10 Acne scars OS-Paint brush 5-face 15-back 1 Monthly Common warts OS/D 10 30-60- plantar 1 2 10-13, weekly Genital warts OS 10 1 1-3 Freckles Cp Ice formation 1 1
- 33. Lesion Technique Freeze time (seconds) Number freeze- thaw cycles Number of treatment sessions Hemangiomas Cp 5-30 1-2 2-4 at 2m interval Benign tumors OS/Cp 5-30 1-2 1-2 Oral leukoplakia OS/Cp 45-60 2 Actinic keratosis/cheil itis, LSA OS/Cp 20-30 1 Several Bowens disease OS/Cp 20-30 2 BCC, Superficial OS-Fractional/ Segmental 30 2(1-80% Cure rate and 2-
- 34. POST OPERATIVE CARE • Immediate- supfcl. – Left open Deep- covered with gauze for 48hrs • After 24-48hrs- wash with soap & water Edema and blisters appear • After 48hrs- weepy wounds- dressing with antibiotic
- 36. COMPLICATIONS Acute •Pain, edema, blistering •Syncope, headache Subacute •Hemorrhagic necrosis, wound infection, subcut. emphysema •Delayed healing Protracted •Pigment. Change, scar, milia, alopecia, hypoesthesia •Cartilage damage, neuroma, granuloma
- 37. PLANE WART
- 38. LENTIGO MALIGNA
- 40. SCC SCC before treatment SCC after treatment :inflammationSCC after treatment : clearance
- 41. BCC
- 42. REFERENCES 1.SHARMA VK, KHANDPUR S. GUIDELINES FOR CRYOTHERAPY. INDIAN J DERMATOL VENEREOL LEPROL 2009;75(SUPPL 2):90-100. 2. PASQUALI P. CRYOSURGERY. IN: NOURI K, EDITOR. DERMATOLOGIC SURGERY-STEP BY STEP. 1ST ED. WILEY-BLACKWELL; P. 51–7. 3. VUJEVICH J, GOLDSMITH LA. CRYOSURGERY AND ELECTROSURGERY. IN: FITZPATRICK’S DERMATOLOGY IN GENERAL MEDICINE. 8TH ED. UK: MCGRAW-HILL MEDICAL; P. 2968–72. 4. GRIFFITHS CEM, BARKER J, BLEIKER T, CHALMERS RJG, CREAMER D, ROOK GA, EDITORS. ROOK’S TEXTBOOK OF DERMATOLOGY. NINTH EDITION. CHICHESTER, WEST SUSSEX HOBOKEN, NJ: JOHN WILEY & SONS INC; 2016. 1 P.
- 43. THANK YOU
Editor's Notes
- Tissue destruction occurs as a result of rapid heat transfer from the tissue causing tissue injury, vascular stasis and occlusion and inflammation. On spraying the cryogen, there is rapid transfer of heat from the tissue to the cryogen with ice formation in the extracellular compartment. The extracellular solutes are concentrated, setting up an osmotic gradient with movement of fluid extracellularly and concentration of solutes within the cell leading to cell damage. The ice crystals also damage the cell membrane mechanically. Moreover, intracellular ice formation occurs damaging the organelles like mitochondria and endoplasmic reticulum. There is severe vasoconstriction and endothelial damage due to cold temperature leading to platelet aggregation and microthrombi formation producing ischemic necrosis of the tissue. There is inflammation in response to cell death causing further destruction. Necrosis occurs at the centre of the treated area, when temperature reaches around -40°C. However, away from the centre, where temperature is higher, only partial destruction but sufficient to cause cell death by apoptosis, occurs. These temperatures can be measured by using a thermocouple and thereby achieve precision in management. There
- Repeating the freeze–thaw cycle produces much greater tissue Damage than a single freeze because the greater conductivity of the Previously frozen skin and the already impaired circulation both Allow a greater and faster depth of cold penetration. It is suggested That a temperature of −30°C is required to produce cell death.