Cryosurgery of the Skin

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Cryosurgery is a frequently performed ablative procedure used in the treatment of benign, premalignant, and malignant skin growths. Cryosurgery produces controlled destruction of skin lesions by withdrawing heat from the targeted tissue. Historically, physicians have used liquid nitrogen applied with cotton-tipped swabs. Today, most providers generally use a probe tip containing a refrigerant liquid or a device that sprays liquid nitrogen. Human tissue freezes at –2.2°C, with tissue destruction occurring at temperatures at or colder than –10°C. Closed probe systems using nitrous oxide can produce probe tip temperatures in the range of –65°C to –89°C, and liquid nitrogen systems achieve temperatures of –25°C to –50°C. Generally, destruction of benign lesions requires temperatures of –20°C to –30°C. Effective removal of malignant lesions requires temperatures of –40°C to –50°C. 
Cryosurgery is best suited for use in patients with light skin and for treatment of lesions in most non-hair-bearing areas of the body. Skin lesions often can be treated in a single session, although some require several treatments. 
Cryosurgery produces a ball-shaped sphere of ice in the target tissue. The edge of the ice ball only achieves a temperature of 0°C, and this area usually recovers from the effects of the freeze. Cryosurgery should be performed so that the ice ball extends at least 2 to 5 mm beyond the edge of the lesion being destroyed. Because ice ball formation is symmetric in all directions, the lateral extension of the ice ball from the applicator tip gives a good estimation of the depth of ice penetration into the tissue. 
Damage in treated tissue occurs because of intracellular ice formation and electrolyte shifts. 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 tissue destruction. Keratinocytes need to be frozen to –50°C for optimum destruction. Melanocytes only require a temperature of –5°C for destruction. This is the reason that hypopigmentation is a common side effect following cryotherapy on darker-skinned individuals (01412520). 
Figure 1
Figure 1
Although there are multiple ways to determine the length of time to freeze, using the timed spot freeze technique may be the safest and most appropriate method for providers who are learning to perform cryosurgery. The standard freezing times are shown in Table 24-1. The freezing time is adjusted according to the skin thickness, vascularity, tissue type, and lesion characteristics. 
Many clinicians advocate the performance of double freezes when cryosurgery is performed. The main advantage of the freeze-thaw-freeze technique is that greater cell death is achieved in the zone of tissue that has been previously frozen (but would otherwise recover). This advantage can be significant when treating premalignant or malignant lesions or lesions that resist freezing. Caution should be taken during the thaw phase, because vascular lesions may bleed on thawing. Overfreezing once an adequate freeze ball is achieved can result in disruption of the skin collagen matrix and possible scarring. 
Cryosurgery generally produces a burning sensation during the treatment, although the discomfort of injected anesthetic often exceeds the discomfort of the procedure. After the procedure, cryosurgery produces anesthesia in the treated tissues. Frozen tissue reacts with peripheral edema immediately after thawing. Subsequent bulla formation and exudation occur before the area heals in a fine atrophic scar within 4 weeks. The technique produces high cure rates with good cosmetic results. 
Certain medical conditions can produce an exaggerated tissue response to the freezing of the skin (listed in the relative contraindications section). Patients with conditions that produce serum cold-induced antibodies (i.e., cryoglobulins) are at greatest risk for marked skin necrosis. 
 
Table 24-1.
Recommended Cryosurgical Freeze Times for the Standard-Spot Freeze Technique

Equipment

  • Liquid nitrogen sprayer and liquid nitrogen

  • Nitrous oxide tank, regulator, and Cryogun

  • Cotton-tipped applicator, forceps (optional), cotton ball, Dewer flask, polystyrene cup, and liquid nitrogen

Indications

  • Actinic keratosis

  • Leukoplakia

  • Milia

  • Mucocele of the lip

  • Pyogenic granuloma

  • Seborrheic keratosis

  • Sebaceous hyperplasia

  • Superficial basal cell carcinoma

  • Simple lentigo

  • Cherry angioma

  • Verrucae vulgaris

  • Hypertrophic scars

  • Molluscum contagiosum

  • Capillary hemangioma of the newborn

  • Granuloma annulare

  • Solar-induced pigmentation and wrinkling

  • Viral warts

Contraindications

  • Lesion for which tissue pathology is required

  • Lesion located in an area with compromised circulation

  • Melanoma

  • Patient unable to accept possibility of pigmentary changes

  • Proven sensitivity or adverse reaction to cryosurgery

  • Sclerosing basal cell carcinoma or recurrent basal cell or squamous cell carcinoma, particularly when located in a high-risk area (e.g., temple, nasolabial fold)

  • Cold intolerance (relative)

  • Cold-induced urticaria (relative)

  • Collagen disease or autoimmune disease (relative)

  • Concurrent treatment with immunosuppressive drugs (relative)

  • Cryoglobulinemia (relative)

  • Heavily pigmented skin (relative)

  • Lesions located in pretibial areas, eyelid margins, nasolabial fold, ala nasi, and hair-bearing areas (relative)

  • Multiple myeloma (relative)

  • Pyoderma gangrenosum (relative)

  • Raynaud disease (especially for procedures on the digits) (relative)

  • Active, severe ulcerative colitis

The Procedure

Step 1

Pare down thick, hyperkeratotic lesions that resist cryosurgical treatment. Perform paring with a horizontally held no. 15 scalpel blade using a sawing motion or direct pass through the lesion. Achieve topical hemostasis with an agent such as ferric subsulfate (Monsel solution) before cryotherapy. 
  • PITFALL: Blood at the surface of the skin acts like an insulator against cryosurgical destruction. Do not perform cryosurgery on an actively bleeding lesion.

Liquid Nitrogen with a Cotton-Tipped Applicator

Step 2
If using a standard long-handled cotton-tipped applicator, expand the head of the applicator by wrapping wisps of cotton pulled from a cotton ball loosely around it. 
Step 3
Place the liquid nitrogen into a disposable polystyrene cup. Dip the cotton-tipped applicator into liquid nitrogen. 
  • PITFALL: Do not tap the applicator against the lip of the cup (in an attempt to shake off excess liquid nitrogen), because this may remove so much that an adequate freeze will not be possible.

  • PITFALL: Adenovirus is capable of survival in liquid nitrogen. The same source of liquid nitrogen should not be used with different patients.

Step 4
The applicator is then firmly pressed against the lesion for the desired duration. The dipstick applicator method does not achieve the low temperatures of the spray technique; therefore, this method is suitable only for benign lesions. 

Liquid Nitrogen Spray Techniques

Step 2
Position the nozzle of the spray gun 1 to 1.5 cm from the skin surface aimed at the center of the lesion. The spray may be applied directly in a paintbrush fashion or in a rotary pattern. 
  • PEARL: Nozzle sizes B and C are suitable for the treatment of most benign and malignant lesions.

  • PEARL: Pulsing direct spray is useful to avoid an overexpansion of the treatment site.

Step 3
Press the spray gun trigger, and spray the liquid nitrogen until an ice ball encompasses the lesion and the desired margin. 
  • PEARL: Ice ball margins for most benign lesions should extend 1 to 2 mm beyond the visible pathologic border. Premalignant lesions need treatment margins of 2 to 3 mm. Malignant lesions require margins of 5 mm of clinically normal skin to ensure adequate depth of treatment.

  • PEARL: The planned freeze area (with margins) may need to be marked with a skin marker pen before starting the freeze, because freezing may blur the lesion’s margin.

Step 4
Once the ice ball forms, freeze for the appropriate time period as shown in Table 24-1. A freeze-thaw cycle can be repeated. 

Nitrous Oxide or Carbon Dioxide Cryoguns

Step 2
Select a cryosurgical tip for the procedure that approximates the size of the lesion being treated. 
  • PITFALL: Inadequate treatment of warts using a tip that is too small may result in the formation of a ring wart. Formation of a ring wart does not always imply inadequate treatment, because 5% of properly treated warts result in ring wart formation.

  • PITFALL: A large, flat tip applied over a small lesion produces excessive tissue destruction and potential scarring.

Step 3
Apply water-soluble gel to the cryotip, and place the tip on the target tissue at ambient (room) temperature. Activate the Cryogun, causing the gel to turn white. The duration of the freeze depends on the time required to produce a proper-sized ice ball. After an adequate freeze has been obtained, deactivate the Cryogun, and allow the probe tip to defrost before disengaging the tip from the target tissue. 
  • PITFALL: Use the size of the ice ball to guide the duration of the procedure. Physicians often use freeze times to guide therapy. Freeze times vary substantially because of factors such as the pressure (amount of refrigerant) in the tank, skin or lesion temperature, and thickness of the lesion.

  • PITFALL: Do not pull the cryotip off the target tissue before it has defrosted. Withdrawal of applicator tips before defrosting often results in the removal or denuding of the tissue surface.

Step 3

Picture courtesy of Dr. Richard Usatine.

Step 3

Picture courtesy of Dr. Richard Usatine.

Forceps Freeze for Small Pedunculated Lesions

Step 2
Pour liquid nitrogen into a disposable polystyrene cup as described previously. Cover the handle of the forceps with a folded 4- × 4-inch gauze to protect the fingers. Then dip the forceps into the liquid nitrogen until it becomes frosted. Pinch the lesion between the tips of the cold forceps until it turns frosty white. Keep the forceps on for an additional 15 seconds and repeat. 
  • PEARL: Lesions will fall off within 1 week and usually heal without problems.

  • PITFALL: This method is slow and primarily used when few lesions are present.

Step 2

Picture courtesy of Dr. Russell Roberts.

Step 2

Picture courtesy of Dr. Russell Roberts.

Complications

  • Blister formation

  • Edema

  • Headache (after treatment of facial lesions)

  • Pain

  • Syncope (vasovagal; rare)

  • Bleeding

  • Excess granulation tissue formation (rare)

  • Infection (rare)

  • Atrophy (rare)

  • Hypopigmentation

  • Hyperpigmentation

  • Hypertrophic scarring

  • Milia

  • Permanent hair loss

  • Alteration of sensation

  • Temporary, sensory nerve damage (rare)

Pediatric Considerations

This treatment is performed in a similar manner in pediatric populations. Consider a topical or injectable anesthetic for younger children, because they are often less tolerant of mild pain. 

Postprocedure Instructions

Instruct the patient to keep the treated skin clean and to place an antibiotic ointment and bandage on the area after the blister breaks until the wound heals. Because the blister is a sterile bandage that provides moist healing, tell the patient to not open the blister and to allow it to rupture on its own. Have them call your office if the blister becomes painful or drains pus. 

Coding Information and Supply Sources

Specific site treatment codes generally reimburse more than the general codes. Although 17000 and 17003 should be used together when appropriate, 17004 is a stand-alone code for any number beyond 14 lesions and is not use with 17000 or 17003. 
Note the 17110 to 17111 “destruction of flat warts, molluscum, milia” codes were generalized to “benign lesions.” Destruction performed in certain locations such as penis and vulva can be billed using a specific site destruction code. Malignant lesion destruction (17260 to 17286) provides additional reimbursement when cancerous lesions are ablated. 
Office gun applicators, tank units, and hand-held devices can be obtained from these suppliers: 

Bibliography

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