Slide 1

Cryosurgery and Electrosurgery

Adam O. Goldstein, MD
Associate Professor
UNC Dept Family Medicine
Chapel Hill, NC
[email protected]


Slide 2

Objectives
Know indications and techniques for
using cryotherapy to treat common
dermatologic conditions
 Know indications and techniques for
using electrocautery to treat common
dermatologic conditions
 Know side effects of cryotherapy and
electrosurgery



Slide 3

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



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Cryosurgery
Tissue destruction:
 Malignant cell kill:


-10 to -20 C.
-40 to -50 C.

Chemical refrigerants -70 to -94 C.
 Cold cryoprobes
-90 C.
 Liquid Nitrogen
-196 C.



Slide 5

Chemical Refrigerants
Verruca-Freeze
 Low start-up costs
 Useful for satellite
 Not approved treatment
for malignant lesions


offices


Slide 6

Verruca Freeze








Speculum size (2-12 mm) that encompasses
lesion
1 “freeze” cycle =
» Fill speculum with spray 1/8- 1/4 inch (3-6
seconds)
» Allow fluid to evaporate (20-25 sec.)
130 “freezes” per cannister
$200 start-up costs
Long shelf life- 4-5 years


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Cryoprobes
Nitrous oxide cryoguns
 Tanks with cart, hand gun, pressure
gauge and regulator
 Useful if liquid nitrogen not available



Slide 8

Nitrous Oxide
Put water soluble gel to lesion
 Select probe size
 Apply activated cryogun probe tip to skin



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Liquid Nitrogen
Advantages for clinician
 Cheap after set-up costs
 Easy to learn
 Multiple lesions at one time
 Do not need assistant to perform


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Liquid Nitrogen
Advantages for patient
 No local anesthetic needed
 Pain tolerable
 No sutures
 Wound care relatively easy


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Liquid Nitrogen
Disadvantages for clinician
 Start-up costs
$1000
 Storage facilities
 Filling canisters


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Liquid Nitrogen
Boiling point -196 C.
 Cellular destruction d/t:


» ice crystal formation
» cellular dehydration
» protein and enzymatic denaturization


Destruction more pronounced with:
» rapid freeze
» slow thaw cycle


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Liquid Nitrogen: Equipment
Liquid nitrogen
 Storage tank= Dewars
 2-30 L, filled q 3-4 weeks
 Costs:


Tanks:
» 2L
» 10 L
» 20 L
» 30 L

Holding time
48 hrs
6-8 weeks
8-12 weeks
14-16 weeks

Costs
$200
$475
$535
$620


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Liquid Nitrogen: Equipment



Filling Dewars; pouring, ladles or devices
Devices affixed to dewar:
Ladels
Valve: $310
Tube: $150


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Liquid Nitrogen: Equipment
Thermos

bottle with hole and cotton tipped swab or
Cry-AC Spray/cryogun (C-tip, mini-gun)
10 oz
$670
12 hr

16 oz
$670
24 hr

12 oz
$650
24 hr


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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


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Cryosurgery
Remember …..
 Always best to underfreeze rather than
overfreeze
 Hold canister perpendicular to skin
 Usually 2-3 freeze/thaw cycles


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Cryosurgery


Cotton tipped swabs



Informed consent-oral vs written


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Cryosurgery: Freezeball Time
Freckles/lentigos:
 Small papules:
 Seborrheic Keratoses:
 Actinic keratoses:
 SCCa/BCCa:


3-5 seconds
5-10 seconds
30-40 seconds
40-60 seconds
80-90 seconds


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Cryosurgery: Freezeball Size
1mm 1-2 mm 2-3 mm 3-4 mm 4-6 mm

freckles/lentigos
most benign skin lesions
most warts
most actinic keratoses
superficial SCCa, BCCa


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Cryosurgery


Thermocouple



$500 for temperature
monitor and thermocouple
needle


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Cryosurgery: Effectiveness
Low
 Vascular lesions: e.g. angiomas
 Achrochordans


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Cryosurgery: Effectiveness
Medium
 Xanthelasma
 Dermatofibroma
 Keloid
 Molluscum
 Prurigo nodularis
 Sebaceous hyperplasia


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Cryosurgery: Effectiveness
Medium-High
 Seborrheic keratosis
 Verruca *
 Condyloma acuminata
 Lentigo
 Freckles


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Cryosurgery


Verruca:
» Often resistant
» Warts on hands
» Plantar warts
» Flat warts


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Cryosurgery: Effectiveness
High
 Actinic keratosis
 Superficial Basal Cell Carcinoma
 Superficial Squamous Cell Carcinoma


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Cryosurgery: Superficial BCCa/SCCa
Establish pathological diagnosis first
 Success rates > 95%



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Cryosurgery: Special Populations


Children
» In general avoid b/c pain
» Use EMLA cream if needed



Useful modality for those on
anticoagulants, those with pacemakers
and those allergic to anesthetics


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Cryosurgery
DO NOT FREEZE










If you do not know diagnosis
Recurrent skin cancers
Melanoma or any possibility
Morpheaform BCCA
Lip neoplasms
Nasolabial fold cancers
Compromised circulation


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Cryosurgery
BE CAREFUL ABOUT FREEZING
 Lesions on/near the eye
 Lesions on the fingers/elbows
 Lesions over shins, ears, genitals
 Lesions near nails


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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


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Cryosurgery: Side Effects
Short term:
 Pain and erythema
 Blister formation
 Hemorrhage
 Infection
 Pyogenic granuloma


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Cryosurgery: Side Effects
Long term
 Nerve damage
 Pigmentary changes
 Hypertrophic scar formation
 Permanent nail dystrophy
 Recurrence of lesion
 Multiple visits may be needed


Slide 34

Electrosurgery


Purpose:
» Destroy tissue
» Excise tissue
» Coagulation



Often done with curettage


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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


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Electrosurgery
Electricator
 Hyfrecator
 Bantam Bovie
 Ritter Coagulator
 Surgitron



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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: $1000-2000



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Electrosurgery
Indications









Cherry angiomas
Achrocordans
Telangiectasias
Small verrucae on hands
Pyogenic granulomas
Seb Keratoses
Small BCCa or SCCa

Procedure
dessication
dessication/fulguration
dessication
fulguration
fulguration
fulguration
fulguration and curettage


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Resistant Wart


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Slide 42

Electrosurgery



Start at low power and increase slowly
Use lowest power needed for tissue
destruction/cutting


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Electrosurgery






Local anesthesia: EMLA, lidocaine
Avoid ethyl chloride, alcohol wipes, and
oxygen
Keep field dry (Aluminum chloride)
Mask and ventilation
Fire extinguisher


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Electrosurgery and Curettage (C&D)
Useful for small BCCa or SCCa
 Local anesthetic
 Sharp 2 mm, 3 mm curettes
 Scrape in different directions until “firm”



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Electrosurgery and Curettage (C&D)
Electrodessicate base and 2 mm skin
 Repeat total of three times
 Control bleeding with Monsel’s solution
 Wound instructions and saucerization



Slide 46

Electrosurgery vs Cryosurgery
Verrucae and AK’s Condyloma

Cryosurgery
Electrosurgery

(Transmission of HPV through vapors)


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Electrosurgery vs Excision
Excision preferred for histology and to
minimize tissue destruction
 Electrosurgical excision acceptable at
times
 Avoid both on feet if at all possible



Slide 48

Electrosurgery and ....
Pacemakers
 Metal pins
 Melanoma



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Conclusions
Cryosurgery and elctrosurgery are safe,
effective and can be done quickly
 Know the diagnosis first
 Perform patient education before the
procedure



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THE END

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