1. Cryosurgery and Electrosurgery Adam O. Goldstein, MD Associate Professor UNC Dept Family Medicine Chapel Hill, NC aog@med.unc.edu

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

3. Cryosurgery l Purpose: For rapid treatment of common skin conditions l Benign lesions: warts, seborrheic keratoses l Premalignant lesions: actinic keratoses l Malignant tumors: Basal cell/squamous cell carcinomas l MUST KNOW THE DIAGNOSIS

4. Cryosurgery l Tissue destruction: -10 to -20 C. l Malignant cell kill:-40 to -50 C. l Chemical refrigerants -70 to -94 C. l Cold cryoprobes -90 C. l Liquid Nitrogen -196 C.

5. Chemical Refrigerants l Verruca-Freeze l Low start-up costs l Useful for satellite offices l Not approved treatment for malignant lesions

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

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

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

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

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

11. Liquid Nitrogen Disadvantages for clinician l Start-up costs $1000 l Storage facilities l Filling canisters

12. Liquid Nitrogen l Boiling point -196 C. l Cellular destruction d/t: »ice crystal formation »cellular dehydration »protein and enzymatic denaturization l Destruction more pronounced with: »rapid freeze »slow thaw cycle

13. Liquid Nitrogen: Equipment l Liquid nitrogen l Storage tank= Dewars l 2-30 L, filled q 3-4 weeks l Costs: Tanks:Holding time Costs »2 L 48 hrs $200 »10 L6-8 weeks $475 »20 L8-12 weeks $535 »30 L14-16 weeks $620

14. Liquid Nitrogen: Equipment l Filling Dewars; pouring, ladles or devices l Devices affixed to dewar: Ladels Valve: $310 Tube: $150

15. Liquid Nitrogen: Equipment l Thermos bottle with hole and cotton tipped swab or l Cry-AC Spray/cryogun (C-tip, mini-gun) 10 oz 16 oz 12 oz $670 $670 $650 12 hr 24 hr 24 hr

16. Cryosurgery l Frozen areas turn white = “freezeball” or “iceball” l Depth of freeze should be 1 X radius of freeze l Lethal Zone »Tissue temp < -20 C. »2-3.5 mm inward from outer margin iceball l Freeze 2-3 mm beyond lesion edge

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

18. Cryosurgery l Cotton tipped swabs l Informed consent-oral vs written

19. Cryosurgery: Freezeball Time l Freckles/lentigos: 3-5 seconds l Small papules: 5-10 seconds l Seborrheic Keratoses:30-40 seconds l Actinic keratoses: 40-60 seconds l SCCa/BCCa: 80-90 seconds

20. Cryosurgery: Freezeball Size l 1mm- freckles/lentigos l 1-2 mm- most benign skin lesions l 2-3 mm- most warts l 3-4 mm- most actinic keratoses l 4-6 mm- superficial SCCa, BCCa

21. Cryosurgery l Thermocouple l $500 for temperature monitor and thermocouple needle

22. Cryosurgery: Effectiveness Low l Vascular lesions: e.g. angiomas l Achrochordans

23. Cryosurgery: Effectiveness Medium l Xanthelasma l Dermatofibroma l Keloid l Molluscum l Prurigo nodularis l Sebaceous hyperplasia

24. Cryosurgery: Effectiveness Medium-High l Seborrheic keratosis l Verruca * l Condyloma acuminata l Lentigo l Freckles

25. Cryosurgery l Verruca: »Often resistant »Warts on hands »Plantar warts »Flat warts

26. Cryosurgery: Effectiveness High l Actinic keratosis l Superficial Basal Cell Carcinoma l Superficial Squamous Cell Carcinoma

27. Cryosurgery: Superficial BCCa/SCCa l Establish pathological diagnosis first l Success rates > 95%

28. Cryosurgery: Special Populations l Children »In general avoid b/c pain »Use EMLA cream if needed l Useful modality for those on anticoagulants, those with pacemakers and those allergic to anesthetics

29. Cryosurgery DO NOT FREEZE l If you do not know diagnosis l Recurrent skin cancers l Melanoma or any possibility l Morpheaform BCCA l Lip neoplasms l Nasolabial fold cancers l Compromised circulation

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

31. Cryosurgery BE CAREFUL ABOUT FREEZING l Patients with dark skin l Patients with Raynaud’s disease l Patients on chronic steroids l Patients with diabetes l Patients with cold induced urticaria/cryoglobulinemia

32. Cryosurgery: Side Effects Short term: l Pain and erythema l Blister formation l Hemorrhage l Infection l Pyogenic granuloma

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

34. Electrosurgery l Purpose: »Destroy tissue »Excise tissue »Coagulation l Often done with curettage

35. Electrosurgery l Electrocautery: Hot electrode (vs cold electrodes) l Electrodessication: Electrode inserted into/on skin (“dries out” skin; “epilation” = fine dessication) l Fulguration: Electrode held away from skin (“fulgur” = lightening; shallow destruction and eschar) l Electrocoagulation: Used for hemostasis l Electrosection: Used to cut tissue l Radiosurgery: Electrosx. with radio frequencies

36. Electrosurgery l Electricator l Hyfrecator l Bantam Bovie l Ritter Coagulator l Surgitron

37. Electrosurgery l Advantages: Easy to use, rapid, useful, hemostasis while cutting, less infection l Disadvantages: Electric shocks and burns/fires, hypertrophic scars, “channeling” nerves, viral shedding, delayed bleeding, slower healing, histological distortion l Costs: $1000-2000

38. Electrosurgery Indications Procedure l Cherry angiomas dessication l Achrocordans dessication/fulguration l Telangiectasias dessication l Small verrucae on hands fulguration l Pyogenic granulomas fulguration l Seb Keratoses fulguration l Small BCCa or SCCa fulguration and curettage

39. Resistant Wart

42. Electrosurgery l Start at low power and increase slowly l Use lowest power needed for tissue destruction/cutting

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

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

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

46. Electrosurgery vs Cryosurgery l Verrucae and AK’s- Cryosurgery l Condyloma- Electrosurgery (Transmission of HPV through vapors)

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

48. Electrosurgery and.... l Pacemakers l Metal pins l Melanoma

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

51. That….that…that….that’s... That’s all folks!!!!!!!!!!!!! THE END